Unacceptable attrition among WHO stages 1 and 2 patients in a hospital-based setting in rural Malawi: can we retain such patients within the general health system?
A study conducted among HIV-positive adults in WHO clinical stages 1 and 2 was followed up at Thyolo District Hospital (rural Malawi) to report on: (1) retention and attrition before and while on antiretroviral treatment (ART); and (2) the criteria used for initiating ART. Between June 2008 and January 2009, 1633 adults in WHO stages 1 and 2 were followed up for a total of 282 person-years. Retention in care at 1, 2, 3 and 6 months for those not on ART (n=1078) was 25, 18, 11 and 4% vs. 99, 97, 95 and 90% for patients who started ART (n=555, P=0.001). Attrition rates were 31 times higher among patients not started on ART compared with those started on ART (adjusted hazard ratio, 31.0, 95% CI 22-44). Ninety-two patients in WHO stage 1 or 2 were started on ART without the guidance of a CD4 count, and 11 were incorrectly started on ART with CD4 count > or = 250 cells/mm(3). In a rural district hospital setting in Malawi, attrition of individuals in WHO stages 1 and 2 is unacceptably high, and specific operational strategies need to be considered to retain such patients in the health system.
Tayler-Smith
Katie
K
Médecins sans Frontières, Medical Department (Operational Research), Brussels Operational Center, 68 Rue de Gasperich, L-1617, Luxembourg.
Zachariah
Rony
R
Massaquoi
Moses
M
Manzi
Marcel
M
Pasulani
Olesi
O
van den Akker
Thomas
T
Bemelmans
Marielle
M
Bauernfeind
Ariane
A
Mwagomba
Beatrice
B
Harries
Anthony D
AD
D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000145:classification / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D008295:Malawi; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D012423:Rural Health; D014944:World Health Organization; D055815:Young Adult; D016903:Drug Monitoring