title: Self-transfer and mortality amongst adults lost to follow-up in ART programmes in low- and middle-income countries: systematic review and meta-analysis.
abstract: OBJECTIVE
  To ascertain estimates of adult patients, recorded as lost to follow-up (LTFU) within antiretroviral treatment (ART) programmes, who have self-transferred care, died or truly stopped ART in low- and middle-income countries.
  
  
  METHODS
  PubMed, EMBASE, Web of Science, Science Direct, LILACS, IndMed and AIM databases (2003-2013) and IAS/AIDS conference abstracts (2011-2013) were searched for tracing studies reporting the proportion of traced patients found to have self-transferred, died or stopped ART. These estimates were then combined using random-effects meta-analysis. Risk of bias was assessed through subgroup and sensitivity analyses.
  
  
  RESULTS
  Twenty eight studies were eligible for inclusion, reporting true outcomes for 10,806 traced patients attending approximately 258 ART facilities. None were from outside sub-Saharan Africa. Twenty three studies reported 4.5-54.4% traced LTFU patients self-transferring care, providing a pooled estimate of 18.6% (95% CI 15.8-22.0%). A significant positive association was found between rates of self-transfer and LTFU in the ART cohort. The pooled estimates for unreported deaths were 38.8% (95% CI 30.8-46.8%; 27 studies) and 28.6% (95% CI 21.9-36.0%; 20 studies) for patients stopping ART. A significant decrease in unreported deaths from 50.0% (95% CI 41.5-58.4%) to 30.0% (95% CI 21.1-38.9%) was found comparing study periods before and after 31 December 2007.
  
  
  CONCLUSIONS
  Substantial unaccounted for transfers and deaths amongst patients LTFU confirms that retention and mortality is underestimated where the true outcomes of LTFU patients are not ascertained.
authors.affiliation: UCL Institute for Global Health, London, UK; Medecins Sans Frontieres, Khayelitsha, South Africa.
authors.forename: Lynne S
authors.initials: LS
authors.lastname: Wilkinson
authors.forename: Jolene
authors.initials: J
authors.lastname: Skordis-Worrall
authors.forename: Olawale
authors.initials: O
authors.lastname: Ajose
authors.forename: Nathan
authors.initials: N
authors.lastname: Ford
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003906:Developing Countries / Q000706:statistics & numerical data*; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality; D006801:Humans; D059012:Lost to Follow-Up; D017063:Outcome Assessment, Health Care; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010360:Patient Transfer / Q000706:statistics & numerical data
chemical_list: D019380:Anti-HIV Agents
keywords: Human immunodeficiency virus; VIH; analyse systématique; antiretroviral therapy; continuidad de cuidados; continuity of care; continuité des soins; lost to follow-up; mortalidad; mortality; mortalité; perdu au suivi; pérdida durante el seguimiento; revisión sistemática; systematic review; terapia antirretroviral; thérapie antirétrovirale