title: The social and clinical characteristics of patients on antiretroviral therapy who are 'lost to follow-up' in KwaZulu-Natal, South Africa: a prospective study.
abstract: A significant proportion of those initiating antiretroviral treatment (ART) for HIV infection are lost to follow-up. Causes (including HIV symptoms, quality of life, depression, herbal treatment and alcohol use) for discontinuing ART follow-up in predominantly rural resource-limited settings are not well understood. This is a prospective study of the treatment-naïve patients recruited from three (one urban, one-semi-urban and one rural) public hospitals in Uthukela health district in KwaZulu-Natal from October 2007 to February 2008. The aim of this study was to investigate predictors of loss to follow-up or all caused attrition from an ART programme within a cohort followed up for over 12 months. A total of 735 patients (217 men and 518 women) prior to initiating ART completed a baseline questionnaire and 6- and 12-months' follow-up. At 12-months follow-up 557 (75.9%) individuals continued active ART, 177 (24.1%) were all cause attrition, there were 82 deaths (13.8%), 58 (7.9%) transfers, 7 (1.0%) refused participation, 8 (1.1%) were not yet on ART and 22 (3.0%) could not be traced. Death by 12-months of follow-up was associated with lower CD4 cell counts (risk ratio, RR=2.05, confidence intervals, CI=1.20-3.49) and higher depression levels (RR=1.05, CI=1.01-1.09) at baseline assessment. The high early mortality rates indicate that patients are enrolling into ART programmes with far too advanced immunodeficiency; median CD4 cell counts 119 (IQR=59-163). Causes of late access to the ART programme, such as delays in health care access (delayed health care seeking), health system delays, or inappropriate treatment criteria, need to be addressed. Differences in health status (lower CD4 cell counts and higher depression scores) should be taken into account when initiating patients on ART. Treating depression at ART initiation is recommended to improve treatment outcome.
authors.affiliation: Research Programme HIV/AIDS, STI and TB-HAST, Human Sciences Research Council, South Africa. kpeltzer@hsrc.ac.za
authors.forename: Karl
authors.initials: K
authors.lastname: Peltzer
authors.forename: Shandir
authors.initials: S
authors.lastname: Ramlagan
authors.forename: Mohamed Salim
authors.initials: MS
authors.lastname: Khan
authors.forename: Bernhard
authors.initials: B
authors.lastname: Gaede
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000428:Alcohol Drinking; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D057210:Delayed Diagnosis; D003863:Depression / Q000150:complications; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000401:mortality*; D006297:Health Services Accessibility; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D008517:Phytotherapy; D028321:Plant Preparations / Q000627:therapeutic use; D011446:Prospective Studies; D011788:Quality of Life; D012424:Rural Population; D012959:Socioeconomic Factors; D013019:South Africa / Q000453:epidemiology; D011795:Surveys and Questionnaires; D014505:Urban Population; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents; D028321:Plant Preparations