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.
Médecins sans Frontières, Medical Department (Operational Research), Brussels Operational Center, 68 Rue de Gasperich, L-1617, Luxembourg.
Katie
K
Tayler-Smith
Rony
R
Zachariah
Moses
M
Massaquoi
Marcel
M
Manzi
Olesi
O
Pasulani
Thomas
T
van den Akker
Marielle
M
Bemelmans
Ariane
A
Bauernfeind
Beatrice
B
Mwagomba
Anthony D
AD
Harries
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