Universal definition of loss to follow-up in HIV treatment programs: a statistical analysis of 111 facilities in Africa, Asia, and Latin America.
BACKGROUND
Although patient attrition is recognized as a threat to the long-term success of antiretroviral therapy programs worldwide, there is no universal definition for classifying patients as lost to follow-up (LTFU). We analyzed data from health facilities across Africa, Asia, and Latin America to empirically determine a standard LTFU definition.


RESULTS
At a set "status classification" date, patients were categorized as either "active" or "LTFU" according to different intervals from time of last clinic encounter. For each threshold, we looked forward 365 d to assess the performance and accuracy of this initial classification. The best-performing definition for LTFU had the lowest proportion of patients misclassified as active or LTFU. Observational data from 111 health facilities-representing 180,718 patients from 19 countries-were included in this study. In the primary analysis, for which data from all facilities were pooled, an interval of 180 d (95% confidence interval [CI]: 173-181 d) since last patient encounter resulted in the fewest misclassifications (7.7%, 95% CI: 7.6%-7.8%). A secondary analysis that gave equal weight to cohorts and to regions generated a similar result (175 d); however, an alternate approach that used inverse weighting for cohorts based on variance and equal weighting for regions produced a slightly lower summary measure (150 d). When examined at the facility level, the best-performing definition varied from 58 to 383 d (mean=150 d), but when a standard definition of 180 d was applied to each facility, only slight increases in misclassification (mean=1.2%, 95% CI: 1.0%-1.5%) were observed. Using this definition, the proportion of patients classified as LTFU by facility ranged from 3.1% to 45.1% (mean=19.9%, 95% CI: 19.1%-21.7%).


CONCLUSIONS
Based on this evaluation, we recommend the adoption of ≥180 d since the last clinic visit as a standard LTFU definition. Such standardization is an important step to understanding the reasons that underlie patient attrition and establishing more reliable and comparable program evaluation worldwide. Please see later in the article for the Editors' Summary.
University of Alabama at Birmingham, Birmingham, Alabama, United States of America. bchi@cidrz.org
Benjamin H
BH
Chi
Constantin T
CT
Yiannoutsos
Andrew O
AO
Westfall
Jamie E
JE
Newman
Jialun
J
Zhou
Carina
C
Cesar
Martin W G
MW
Brinkhof
Albert
A
Mwango
Eric
E
Balestre
Gabriela
G
Carriquiry
Thira
T
Sirisanthana
Henri
H
Mukumbi
Jeffrey N
JN
Martin
Anna
A
Grimsrud
Melanie
M
Bacon
Rodolphe
R
Thiebaut
D000293:Adolescent; D000328:Adult; D000349:Africa; D023241:Antiretroviral Therapy, Highly Active / Q000706:statistics & numerical data*; D001208:Asia; D015331:Cohort Studies; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D005500:Follow-Up Studies; D006678:HIV; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007843:Latin America; D059012:Lost to Follow-Up; D010349:Patient Compliance; D009626:Terminology as Topic