title: Movement between facilities for HIV care among a mobile population in Kenya: transfer, loss to follow-up, and reengagement.
abstract: HIV treatment is life-long, yet many patients travel or migrate for their livelihoods, risking treatment interruption. We examine timely reengagement in care among patients who transferred-out or were lost-to-follow-up (LTFU) from a rural HIV facility. We conducted a cohort study among 369 adult patients on antiretroviral therapy between November 2011 and November 2013 on Mfangano Island, Kenya. Patients who transferred or were LTFU (i.e., missed a scheduled appointment by ≥90 days) were traced to determine if they reengaged or accessed care at another clinic. We report cumulative incidence and time to reengagement using Cox proportional hazards models adjusted for patient demographic and clinical characteristics. Among 369 patients at the clinic, 23(6%) requested an official transfer and 78(21%) were LTFU. Among official transfers, cumulative incidence of linkage to their destination facility was 91% at three months (95%CI (confidence intervals) 69-98%). Among LTFU, cumulative incidence of reengagement in care at the original or a new clinic was 14% at three months (95%CI 7-23%) and 60% at six months (95%CI 48-69%). In the adjusted Cox model, patients who left with an official transfer reengaged in care six times faster than those who did not (adjusted hazard ratio 6.2, 95%CI 3.4-11.0). Patients who left an island-based HIV clinic in Kenya with an official transfer letter reengaged in care faster than those who were LTFU, although many in both groups had treatment gaps long enough to risk viral rebound. Better coordination of transfers between clinics, such as assisting patients with navigating the process or improving inter-clinic communication surrounding transfers, may reduce delays in treatment during transfer and improve overall clinical outcomes.
authors.affiliation: a Division of General Internal Medicine , University of California, San Francisco (UCSF) , San Francisco , CA , USA.|b Mfangano Island Research Group, Organic Health Response , Homa Bay County , Kenya.|c Microclinic International (MCI) , San Francisco , CA , USA.
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Hickey
authors.affiliation: b Mfangano Island Research Group, Organic Health Response , Homa Bay County , Kenya.
authors.forename: Dan
authors.initials: D
authors.lastname: Omollo
authors.affiliation: b Mfangano Island Research Group, Organic Health Response , Homa Bay County , Kenya.|c Microclinic International (MCI) , San Francisco , CA , USA.|d Department of Family and Community Medicine , University of Minnesota , Minneapolis , MN , USA.
authors.forename: Charles R
authors.initials: CR
authors.lastname: Salmen
authors.affiliation: b Mfangano Island Research Group, Organic Health Response , Homa Bay County , Kenya.
authors.forename: Brian
authors.initials: B
authors.lastname: Mattah
authors.affiliation: e Global Health Sciences , University of California, San Francisco (UCSF) , San Francisco , CA , USA.
authors.forename: Cinthia
authors.initials: C
authors.lastname: Blat
authors.affiliation: b Mfangano Island Research Group, Organic Health Response , Homa Bay County , Kenya.
authors.forename: Gor Benard
authors.initials: GB
authors.lastname: Ouma
authors.affiliation: b Mfangano Island Research Group, Organic Health Response , Homa Bay County , Kenya.|f Atkinson Center for a Sustainable Future , Cornell University , Ithaca , NY , USA.
authors.forename: Kathryn J
authors.initials: KJ
authors.lastname: Fiorella
authors.affiliation: g Centre for Microbial Research, Kenya Medical Research Institute , Nairobi , Kenya.
authors.forename: Betty
authors.initials: B
authors.lastname: Njoroge
authors.affiliation: h HIV-ID-Global Medicine Division , University of California, San Francisco (UCSF) , San Francisco , CA , USA.
authors.forename: Monica
authors.initials: M
authors.lastname: Gandhi
authors.affiliation: g Centre for Microbial Research, Kenya Medical Research Institute , Nairobi , Kenya.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.affiliation: e Global Health Sciences , University of California, San Francisco (UCSF) , San Francisco , CA , USA.|i Department of Obstetrics, Gynecology and Reproductive Sciences , University of California, San Francisco (UCSF) , San Francisco , CA , USA.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
authors.affiliation: h HIV-ID-Global Medicine Division , University of California, San Francisco (UCSF) , San Francisco , CA , USA.
authors.forename: Elvin H
authors.initials: EH
authors.lastname: Geng
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D015994:Incidence; D007630:Kenya; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010360:Patient Transfer / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D014171:Transients and Migrants / Q000706:statistics & numerical data*
chemical_list: D019380:Anti-HIV Agents
keywords: HIV; lost to follow-up; resource-limited setting; stigma; transfer