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Cumulative incidence plot of the outcomes in patients lost to follow-up (LTFU), including death, stop of combination antiretroviral therapy (cART), transfer to another clinic, and retention on cART. Cumulative probabilities, together with 95% confidence intervals, are given for each tracing outcome at 1-4 years since the last clinic visit.
Source publication
Background:
Low retention on combination antiretroviral therapy (cART) has emerged as a threat to the Joint United Nations Programme on human immunodeficiency virus (HIV)/AIDS (UNAIDS) 90-90-90 targets. We examined outcomes of patients who started cART but were subsequently lost to follow-up (LTFU) in African treatment programs.
Methods:
This wa...
Citations
... 9 Mortality and undocumented transfers were substantial among LTFU patients in sub-Saharan Africa. 10 During the test and treatment era, the risk of loss to follow-up increased with time and was higher among patients who started ART within seven days of HIV diagnosis. 11 Loss to follow-up is a term used to categorize patients no longer being seen in a chronic HIV care treatment program. ...
Background
Antiretroviral Treatment (ART) reduces morbidity and mortality in patients with human immunodeficiency virus (HIV). However, clients loss to follow-up (LTFU) from the treatment poses a paramount problem to the public, healthcare, and patient outcome. Thus, this study identified determinants of loss to follow-up to ART among adult clients in West Wollega hospitals, Oromia, Ethiopia, in 2021.
Methods
An unmatched case-control study was conducted and a systematic random sampling technique was used. Data were collected from patient charts by three BSC nurses and three card reporters using a structured checklist. Then, it was entered into Epi-data version 3.1 and analyzed using SPSS version 21. Descriptive statistics (frequency and percentage) were used to present the results. Bivariate and multivariable logistic regression analyses were performed using the backward stepwise method. Adjusted odds ratio (AOR) and p-values <0.05 were used to declare significant association with loss to follow-up. Model fitness was checked using Hosmer-Lemeshow goodness-of-fit.
Results
A total of 399 (133 patients and 266 controls) participated in this study. Rural residents (AOR:3.46, 95% CI:1.65, 7.25), male patient (AOR: 2.65 95% CI 1.54,4.55), lack of formal education (AOR: 4.35, 95% CI 1.53, 12.41), base line CD4 ≤350 (AOR: 5.25, 95% CI 1.93,14.24), poor functional status (AOR: 4.298, 95% CI 5.33,34.62) and WHO stages III & IV (AOR: 2.65, 95% CI 1.68,4.19), and tuberculosis co-infection (AOR: 2.82, 95% CI 1.11,7.45) were determinant factors of loss to follow up.
Conclusion
Rural residence, male sex, daily laborer, no formal education, baseline CD4 count <350 cells/mm3, baseline advanced WHO clinical stage, and TB co-infection were determinants of LTFU. Therefore, emphasis should be given to the identified factors along with awareness creation and health education sessions. Regular TB screening, optimal adherence regardless of their stay on ART, and follow-up study are recommended.
... If PWH become disengaged from care, they may have poor ART adherence and high viral load (VL), resulting in an increased risk of mortality [19]. Systematic reviews of tracing studies across Sub-Saharan Africa reported a wide range between 9-87% of LTFU PWH had actually died [19][20][21]. Understanding the factors associated with LTFU can help program implementers identify better strategies to facilitate retention. Accounting for LTFU may improve assessments of mortality and other health outcomes, which are necessary to inform improved programs and policies. ...
... Optimum adherence to antiretroviral therapy (ART) (i.e., taking ≥ 95% of prescribed medication) is essential to achieve viral suppression, increase survival rates in people living with HIV (PLWH), and to prevent onward transmission [1][2][3]. Sub-optimal adherence can also cause drug-resistance which leads to increased use of costly second line drugs [4][5][6]. Prisoners are among key populations that bear a disproportionate burden of HIV epidemic and have a greater potential of transmitting to others during and after incarceration [3,7]. The burden is much higher in prison populations that are associated with resource-limited countries [3,8]. ...
Background
Optimal adherence is crucial for ensuring both therapeutic and preventative benefits of antiretroviral therapy (ART). Sub-optimal adherence is common in prisoners and little information is available about its predisposing circumstances in resource-limited settings. We explored lived experiences of inmates living with HIV (ILWH) and experiential accounts of service providers in South Ethiopia to identify barriers to and facilitators of HIV care use in the prison context.
Methods
We conducted qualitative in-depth interviewing with eleven ILWH and eleven service providers. Audio recorded interview data were transcribed verbatim in Amharic language, translated into English and coded based on emerging concepts. We employed a descriptive phenomenological approach to abstract meaning attributed to the prisoners’ lived experiences in relation to HIV care use and service providers’ experiential account regarding care provision as presented to our consciousness.
Findings
Several concepts emerged as barriers to HIV care use amongst ILWH in South Ethiopia including: limited access to standard care, insufficient health staff support, uncooperative security system, loss of patient privacy, a lack of status disclosure due to social stigma, and food supply insufficiency. In addition to a unique opportunity offered by an imprisonment for some ILWH to refrain from health damaging behaviours, the presence of social support in the prison system facilitated care use.
Conclusions
This study identified important structural and social contexts that can both hinder and enhance HIV care use amongst ILWH in South Ethiopia. Given the disproportionate burden of HIV in prisoners and the potential of transmission to others during and after incarceration, development of contextually-responsive strategies is required to address the barriers and to also strengthen the enablers.
... Antiretroviral therapy (ART) has demonstrated remarkable e cacy in mitigating HIV/AIDS-related morbidity and mortality, particularly in resource-limited settings [1,2]. However, the full realization of its bene ts has been impeded by the high loss to follow-up (LTFU) [3], especially within the rst year of ART [4]. Newly initiated ART clients are particularly vulnerable to treatment interruptions due to a multitude of factors, including the severity of their illness, di culties in disclosing their HIV status, and adaptation to life with HIV and ART [5,6]. ...
Introduction
Antiretroviral therapy (ART) improves the health of people living with HIV (PLHIV). However, a high loss to follow-up, particularly in the first year after ART initiation, is problematic. The financial expenses related to client retention in low- and middle-income countries (LMICs) in sub-Saharan Africa are not well understood. This study aimed to comprehensively assess and quantify the financial costs associated with routine ART retention care at Lighthouse Trust’s (LT) Martin Preuss Centre (MPC), a large, public ART clinic in Lilongwe, Malawi.
Methods
We performed activity-based microcosting using routine data to assess the expenses related to routine ART retention services at the MPC for 12 months, January-December 2021. MPC provides an “ART Buddy” from ART initiation to 12 months. The MPC’s Back-to-Care (B2C) program traces clients who miss ART visits at any time. Clients may be traced and return to care multiple times per year. We assessed client retention costs for the first 12 months of treatment with ART and conducted a sensitivity analysis.
Results
The total annual cost of ART retention interventions at the MPC was $237,564. The proactive Buddy phase incurred $108,504; personnel costs contributed $97,764. In the reactive B2C phase, the total cost was $129,060, with personnel expenses remaining substantial at $73,778. The Buddy unit cost was $34 per client. The reactive B2C intervention was $17 per tracing event. On average, the unit cost for ART retention in the first year of ART averaged $22 per client.
Conclusion
This study sheds light on the financial dimensions of ART retention interventions at the MPC of LTs. ART retention is both costly and critical for helping clients adhere to visits and remain in care. Continued investment in the human resources needed for both proactive and reactive retention efforts is critical to engaging and retaining patients on lifetime ART.
... The majority (95%) of individuals who had undergone non-retention were LTFU. In a meta-analysis of data to determine outcome of patients LTFU from Africa, the majority (54%) were either known to have died or could not be found (presumed dead) [35]. The decline in non-retention over calendar period in our findings may, therefore, be attributed to a decline in HIV-related mortality. ...
Background
The COVID-19 pandemic adversely disrupted global health service delivery. We aimed to assess impact of the pandemic on same-day HIV diagnosis/ART initiation, six-months non-retention and initial virologic non-suppression (VnS) among individuals starting antiretroviral therapy (ART) in Kenya.
Methods
Individual-level longitudinal service delivery data were analysed. Random sampling of individuals aged >15 years starting ART between April 2018 –March 2021 was done. Date of ART initiation was stratified into pre-COVID-19 (April 2018 –March 2019 and April 2019 –March 2020) and COVID-19 (April 2020 –March 2021) periods. Mixed effects generalised linear, survival and logistic regression models were used to determine the effect of COVID-19 pandemic on same-day HIV diagnosis/ART initiation, six-months non-retention and VnS, respectively.
Results
Of 7,046 individuals sampled, 35.5%, 36.0% and 28.4% started ART during April 2018 –March 2019, April 2019 –March 2020 and April 2020 –March 2021, respectively. Compared to the pre-COVID-19 period, the COVID-19 period had higher same-day HIV diagnosis/ART initiation (adjusted risk ratio [95% CI]: 1.09 [1.04–1.13], p<0.001) and lower six-months non-retention (adjusted hazard ratio [95% CI]: 0.66 [0.58–0.74], p<0.001). Of those sampled, 3,296 (46.8%) had a viral load test done at a median 6.2 (IQR, 5.3–7.3) months after ART initiation. Compared to the pre-COVID-19 period, there was no significant difference in VnS during the COVID-19 period (adjusted odds ratio [95% CI]: 0.79 [95%% CI: 0.52–1.20], p = 0.264).
Conclusions
In the short term, the COVID-19 pandemic did not have an adverse impact on HIV care and treatment outcomes in Kenya. Timely, strategic and sustained COVID-19 response may have played a critical role in mitigating adverse effects of the pandemic and point towards maturity, versatility and resilience of the HIV program in Kenya. Continued monitoring to assess long-term impact of the COVID-19 pandemic on HIV care and treatment program in Kenya is warranted.
... healthcare workers (HCW) shortages) and macro-level factors (e.g., COVID-19; global funding priorities) [1,[5][6][7]. However, once patients miss visits or have treatment interruptions, early retention efforts are most likely to successfully return patients to care [8]. ...
Background:
Early retention of people living with HIV (PLHIV) in antiretroviral therapy (ART) programs is critical to improve individual clinical outcomes and viral load suppression. Although many mobile health (mHealth) interventions aim to improve retention in care, there is still lack of evidence on mHealth success or failure, including from patient's perspectives. We describe the human-centered design (HCD) process and assess patient usability and acceptability of a two-way texting (2wT) intervention to improve early retention among new ART initiates at Lighthouse Trust clinic in Lilongwe, Malawi.
Methods:
An iterative HCD approach focused on patient and provider users' needs, incorporating feedback from multidisciplinary teams to adapt 2wT for the local, public clinic context. We present mixed-methods usability and acceptability results from 100 participants, 50 at 3-months and 50 at 6-months, post 2wT enrollment, and observations of these same patients completing core tasks of the 2wT system.
Results:
Among the 100 usability respondents, 95% were satisfied with visit reminders, and 88% would recommend reminders and motivational messages to friends; however, 17% were worried about confidentiality. In observation of participant task completion, 94% were able to successfully confirm visit attendance and 73% could request appointment date change. More participants in 4-6 months group completed tasks correctly compared to 1-3 months group, although not significantly different (78% vs. 66%, p = 0.181). Qualitative results were overwhelmingly positive, but patients did note confusion with transfer reporting and concern that 2wT would not reach patients without mobile phones or with lower literacy.
Conclusion:
The 2wT app for early ART retention appears highly usable and acceptable, hopefully creating a solid foundation for lifelong engagement in care. The HCD approach put the local team central in this process, ensuring that both patients' and Lighthouse's priorities, policies, and practices were forefront in 2wT optimization, raising the likelihood of 2wT success in other routine program contexts.
... 3 The overestimation of disengagement or the oversimplification of the complex cycle of entry and re-entry into care contribute to the misclassifications of engagement. [4][5][6][7][8][9] The implications of misclassifying engagement include failing to detect immunosuppression, inaccurately prioritizing interventions targeting viral suppression and retention in care, and failing to recognize disengagement from individuals who remain at a care facility. 10 Furthermore, engagement often implies a moral framework of what constitutes a "good" patient compared to a "bad" patient. ...
Introduction:
Engagement in the HIV care cascade is required for people living with HIV (PLWH) to achieve an undetectable viral load. However, varying definitions of engagement exist, contributing to heterogeneity in research regarding how many individuals are actively participating and benefitting from care. A standardized definition is needed to enhance comparability and pooling of data from engagement studies.
Objectives:
The objective of this paper was to describe the various definitions for engagement used in HIV clinical trials.
Methods:
Articles were retrieved from CASCADE, a database of 298 clinical trials conducted to improve the HIV care cascade (https://hivcarecascade.com/), curated by income level, vulnerable population, who delivered the intervention, the setting in which it was delivered, the intervention type, and the level of pragmatism of the intervention. Studies with engagement listed as an outcome were selected from this database.
Results:
13 studies were eligible, of which five did not provide an explicit definition for engagement. The remaining studies used one or more of the following: appointment adherence (n=6), laboratory testing (n=2), adherence to antiretroviral therapy (n=2), time specification (n=5), intervention adherence (n=5), and quality of interaction (n=1).
Conclusion:
This paper highlights the existing diversity in definitions for engagement in the HIV care cascade and categorize these definitions into appointment adherence, laboratory testing, adherence to antiretroviral therapy, time specification, intervention adherence, and quality of interaction. We recommend consensus on how to describe and measure engagement.
... Our LTFU rate is likely over-estimated as studies from other contexts at a similar stage of scaling up ART have estimated that over 20% of patients LTFU patients had in fact died [10]. Furthermore, undocumented transfers to another clinic lead to an overestimate of the number of PLHIV who have ever initiated ART, and under-estimates of retention in care rates but would lead to over-estimates of the number of PLHIV on ART as well as under-estimates of retention in care rates [37][38][39][40]. Similarly, we were unable to estimate mortality outcomes and so we could not distinguish between patients who had defaulted but remained alive, and those who had died. ...
Few studies have investigated retention in HIV care in West Africa. We measured retention in antiretroviral therapy (ART) programmes among people living with HIV and re-engagement in care among those lost to follow up (LTFU) in Guinea and identified associated risk factors using survival analysis. Patient-level data were analysed from 73 ART sites. Treatment interruptions and LTFU were defined as missing a ART refill appointment by over 30 days and by over 90 days respectively. A total of 26,290 patients initiating ART between January 2018 and September 2020 were included in the analysis. The mean age at ART initiation was of 36.2 years, with women accounting for 67% of the cohort. Retention 12 months after ART initiation was 48.7% (95%CI 48.1-49.4%). The LTFU rate was 54.5 per 1000 person-months (95% CI 53.6-55.4), with the peak hazards of LTFU occurring after the first visit and decreasing steadily over time. In an adjusted analysis, the hazards of LTFU were higher among men compared to women (aHR = 1.10; 95%CI 1.08-1.12), being aged 13-25 years old versus older patients (aHR = 1.07; 95%CI = 1.03-1.13), and among those initating ART in smaller health facilities (aHR = 1.52; 95%CI 1.45-1.60). Among 14,683 patients with an LTFU event, 4,896 (33.3%) re-engaged in care, of whom 76% did so within six months from LTFU. The re-engagement rate was 27.1 per 1000 person-months (95%CI 26.3-27.9). Treatment interruptions were correlated with rainfall patterns and end of year mobility patterns. Rates of retention and re-engagement in care are very low in Guinea, undermining the effectiveness and durability of first-line ART regimens. Tracing interventions and differentiated service delivery of ART, including multi-month dispensing may improve care engagement, especially in rural areas. Further research should investigate social and health systems barriers to retention in care.
... In our study, the risk of unsuppressed viremia (>1000 copies/ml) was higher in pregnant women, in PLHIV with AHD and in patients treated with a NVP-based or EFV-based regimens compared to DTG-based regimens, confirming the results of several studies in SSA (17)(18)(19)(20)(21). Careful follow-up should be proposed to groups at higher risk of treatment failure and lower adherence to therapy to ensure the individual and population benefits of ART. ...
Introduction
ART expansion and viral load as a treatment monitoring approach have increased the demand for viral load testing. Many hurdles affect the coverage, quality and use of viral load results. Estimates of viral load monitoring and viral suppression rates are needed to assess the performance of ART programs and improve HIV management outcomes.
Methods
PLHIV viral load monitoring data were routinely collected in 84 health facilities in Kinshasa, DRC, between 2013 and 2020. The number of PLHIV under ART, the number of participants with at least one viral load test result, the rate of viral suppression (defined as ≤1,000 HIV RNA copies per mL), and the mean turnaround time from sample collection to release of viral load test results were collected together with clinical data.
Results
14,057 PLHIV were included in the analysis. PLHIV were mainly enrolled after the “test and treat” implementation. The patients were followed for a median period of 27 months. The proportion of PLHIV with at least one available viral load largely increased in recent years. The delay from sample collection to release of viral load test results decreased overtime, from 35 days in 2018 to 16 days in 2020. Pregnancy and advanced HIV disease were associated with a lower chance of viral suppression.
Conclusions
There has been considerable success in increasing viral load access for all PLHIV under therapy in DRC. Nevertheless, viral load testing should be intensified with a particular effort to be made in groups at higher risk of viral failure.
... The immediate initiation of ART may contribute to missed clinic visit and loss to follow-up due to insufficient time for psychosocial readiness and informed decision-making to initiate ART thus unsuppressed viral load and treatment failure. [4][5][6] Previous studies examining adherence to clinic visit among adults with HIV infection reported a substantial proportion of missed clinic visit, with rates ranging from, 26% to 59%. [7][8][9] Other studies also documented the factors influencing adherence to general clinic visit such as stigma and discrimination, patients' self-efficacy, patient load, waiting time, distance to healthcare facility, and social support. ...
Background:
The "test-and-treat" policy may adversely affect adherence to clinic visits of clients newly diagnosed with HIV due to unpreparedness to commence treatment. However, few studies have examined the factors influencing the status of adherence to second clinic visit among clients newly diagnosed with HIV. We examined the factors influencing the status of adherence to second clinic visit among clients newly diagnosed with HIV in Apac District, northern Uganda.
Methods:
This was a mixed-methods study conducted among 292 systematically sampled clients newly diagnosed with HIV for the survey and 15 purposively sampled clients for the in-depth interview from July to August 2020. Quantitative data were collected using a structured questionnaire, while qualitative data were collected using an interview guide. Quantitative data were analyzed descriptively while qualitative data were analyzed thematically.
Results:
The mean age of the study participants were 39.5±11 years and their age ranged from 18 to 72 years. Close to three-quarters of study participants adhered to their second clinic visit 74% (214/292). Factors that influenced participants' adherence to the second clinic visit were the adequate HIV pre/post-test counseling positive attitude of clients towards HIV-positive diagnosis, family support, and long waiting time.
Conclusion:
More than two-thirds of clients newly diagnosed with HIV in Apac District, northern Uganda adhered to their second clinic visit. HIV/AIDS service providers should strengthen HIV pre/post-test counselling, social support systems for persons living with HIV/AIDS, and reduce clients' waiting time to improve adherence to second clinic visit among clients newly diagnosed with HIV.
