Understanding reasons for and outcomes of patients lost to follow-up in antiretroviral therapy programs in Africa through a sampling-based approach.
OBJECTIVE
Losses to follow-up after initiation of antiretroviral therapy (ART) are common in Africa and are a considerable obstacle to understanding the effectiveness of nascent treatment programs. We sought to characterize, through a sampling-based approach, reasons for and outcomes of patients who become lost to follow-up.


METHODS
Cohort study.


METHODS
We searched for and interviewed a representative sample of lost patients or close informants in the community to determine reasons for and outcomes among lost patients.


RESULTS
Three thousand six hundred twenty-eight HIV-infected adults initiated ART between January 1, 2004 and September 30, 2007 in Mbarara, Uganda. Eight hundred twenty-nine became lost to follow-up (cumulative incidence at 1, 2, and 3 years of 16%, 30%, and 39%). We sought a representative sample of 128 lost patients in the community and ascertained vital status in 111 (87%). Top reasons for loss included lack of transportation or money and work/child care responsibilities. Among the 111 lost patients who had their vital status ascertained through tracking, 32 deaths occurred (cumulative 1-year incidence 36%); mortality was highest shortly after the last clinic visit. Lower pre-ART CD4 T-cell count, older age, low blood pressure, and a central nervous system syndrome at the last clinic visit predicted deaths. Of patients directly interviewed, 83% were in care at another clinic and 71% were still using ART.


CONCLUSIONS
Sociostructural factors are the primary reasons for loss to follow-up. Outcomes among the lost are heterogeneous: both deaths and transfers to other clinics were common. Tracking a sample of lost patients is an efficient means for programs to understand site-specific reasons for and outcomes among patients lost to follow-up.
Geng
Elvin H
EH
Division of HIV/AIDS at San Francisco General Hospital, 995 Potrero Avenue, Building 80, San Francisco, CA 94110, USA. genge@php.ucsf.edu
Bangsberg
David R
DR
Musinguzi
Nicolas
N
Emenyonu
Nneka
N
Bwana
Mwebesa Bosco
MB
Yiannoutsos
Constantin T
CT
Glidden
David V
DV
Deeks
Steven G
SG
Martin
Jeffrey N
JN
D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D014454:Uganda; D016903:Drug Monitoring
D019380:Anti-HIV Agents