title: The Majority of the Pre-Antiretroviral Population Who Were Lost to Follow-Up Stopped Their Care in Freetown, Sierra Leone: A 12-Month Prospective Cohort Study Starting with HIV Diagnosis.
abstract: BACKGROUND
  The heterogeneity of the pre-antiretroviral (pre-ART) population calls for more granular depictions of the cascade of HIV care.
  
  
  METHODS
  We studied a prospective cohort of persons newly diagnosed with HIV infection from a single center in Freetown, Sierra Leone, over a 12-month period and then traced those persons who were lost to follow-up (LTFU) during pre-ART care (before ART initiation). ART eligibility was based on a CD4 cell count result of ≤ 350 mm/cells and/or WHO clinical stage 3 or 4. Persons who attended an appointment in the final three months were considered to be retained in care. Adherence to ART was measured using pharmacy refill dates. "Effective HIV care" was defined as completion of the cascade of care at 12-months regardless of whether patients are on ART. Tracing outcomes were obtained for those who were LTFU during pre-ART care.
  
  
  RESULTS
  408 persons newly diagnosed with HIV infection were screened, 338 were enrolled, and 255 persons were staged for ART. ART-ineligible persons had higher retention rates than ART-eligible persons (59.6% vs 41.8%, p = 0.03). 77 (22.8%) of 338 persons received effective HIV care. Most attrition (61.9%) occurred with persons during pre-ART care. 123 of 138 persons (89.1%) who were LTFU prior to ART initiation were found, and 91 of those 123 (74.0%) were alive. Of the 74 persons who were alive and described their engagement in care, 40 (54.1%) stopped care. Nearly half (42.5%) of those 40 stopped after assessment of ART-eligibility but before ART initiation. The main limitation of this study was the lack of tracing outcomes for those lost during ART care.
  
  
  CONCLUSIONS
  The majority of the pre-ART LTFU population stopped their care, particularly after ART-eligibility but before ART initiation. Interventions to hasten ART initiation and retain this at-risk group may have significant downstream impact on effective HIV care.
authors.affiliation: Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America.|Wellbody Alliance, Koidu Town, Sierra Leone.|National HIV/AIDS Secretariat, Freetown, Sierra Leone.
authors.forename: J Daniel
authors.initials: JD
authors.lastname: Kelly
authors.affiliation: Wellbody Alliance, Koidu Town, Sierra Leone.
authors.forename: Gabriel Warren
authors.initials: GW
authors.lastname: Schlough
authors.affiliation: National HIV/AIDS Secretariat, Freetown, Sierra Leone.|College of Medicine and Allied Health Sciences of University of Sierra Leone, Freetown, Sierra Leone.
authors.forename: Sulaiman
authors.initials: S
authors.lastname: Conteh
authors.affiliation: Wellbody Alliance, Koidu Town, Sierra Leone.
authors.forename: M Bailor
authors.initials: MB
authors.lastname: Barrie
authors.affiliation: National HIV/AIDS Secretariat, Freetown, Sierra Leone.
authors.forename: Brima
authors.initials: B
authors.lastname: Kargbo
authors.affiliation: Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America.
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Giordano
mesh_terms: D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003695:Delivery of Health Care; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000453:epidemiology* / Q000821:virology; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D017063:Outcome Assessment, Health Care; D012307:Risk Factors; D012807:Sierra Leone / Q000453:epidemiology; D019562:Viral Load