title: Retention in care and connection to care among HIV-infected patients on antiretroviral therapy in Africa: estimation via a sampling-based approach.
abstract: BACKGROUND
  Current estimates of retention among HIV-infected patients on antiretroviral therapy (ART) in Africa consider patients who are lost to follow-up (LTF) as well as those who die shortly after their last clinic visit to be no longer in care and to represent limitations in access to care. Yet many lost patients may have "silently" transferred and deaths shortly after the last clinic visit more likely represent limitations in clinical care rather than access to care after initial linkage.
  
  
  METHODS
  We evaluated HIV-infected adults initiating ART from 1/1/2004 to 9/30/2007 at a clinic in rural Uganda. A representative sample of lost patients was tracked in the community to obtain updated information about care at other ART sites. Updated outcomes were incorporated with probability weights to obtain "corrected" estimates of retention for the entire clinic population. We used the competing risks approach to estimate "connection to care"--the percentage of patients accessing care over time (including those who died while in care).
  
  
  RESULTS
  Among 3,628 patients, 829 became lost, 128 were tracked and in 111, updated information was obtained. Of 111, 79 (71%) were alive and 35/48 (73%) of patients interviewed in person were in care and on ART. Patient retention for the clinic population assuming lost patients were not in care was 82.3%, 68.9%, and 60.1% at 1, 2 and 3 years. Incorporating updated care information from the sample of lost patients increased estimates of patient retention to 85.8% to 90.9%, 78.9% to 86.2% and 75.8% to 84.7% at the same time points.
  
  
  CONCLUSIONS
  Accounting for "silent transfers" and early deaths increased estimates of patient retention and connection to care substantially. Deaths soon after the last clinic visit (potentially reflecting limitations in clinical effectiveness) and disconnection from care among patient who were alive each accounted for approximately half of failures of retention.
authors.affiliation: Division of HIV/AIDS at San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America. genge@php.ucsf.edu
authors.forename: Elvin H
authors.initials: EH
authors.lastname: Geng
authors.forename: David V
authors.initials: DV
authors.lastname: Glidden
authors.forename: Mwebesa Bosco
authors.initials: MB
authors.lastname: Bwana
authors.forename: Nicolas
authors.initials: N
authors.lastname: Musinguzi
authors.forename: Nneka
authors.initials: N
authors.lastname: Emenyonu
authors.forename: Winnie
authors.initials: W
authors.lastname: Muyindike
authors.forename: Katerina A
authors.initials: KA
authors.lastname: Christopoulos
authors.forename: Torsten B
authors.initials: TB
authors.lastname: Neilands
authors.forename: Constantin T
authors.initials: CT
authors.lastname: Yiannoutsos
authors.forename: Steven G
authors.initials: SG
authors.lastname: Deeks
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Martin
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D016001:Confidence Intervals; D003695:Delivery of Health Care; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology*; D006801:Humans; D008297:Male; D012494:Sampling Studies; D014454:Uganda / Q000453:epidemiology