Who will be lost? Identifying patients at risk of loss to follow-up in Malawi. The DREAM Program Experience.
Retention of subjects in HIV treatment programmes is crucial for the success of treatment. We evaluated retention/loss to follow-up (LTFU) in subjects receiving established care in Malawi.



Data for HIV-positive patients registered in Drug Resource Enhancement Against AIDS and Malnutrition centres in Malawi prior to 2014 were reviewed. Visits entailing HIV testing/counselling, laboratory evaluations, nutritional evaluation/supplementation, community support, peer education, and antiretroviral (ART) monitoring/pharmacy were noted. LTFU was defined as > 90 days without an encounter. Parameters potentially associated with LTFU were explored, with univariate/multivariate logistic regression analyses being performed.



Fifteen thousand and ninety-nine patients registered before 2014; 202 (1.3%) were lost to follow-up (LTFU) (1.3%). Nine (0.5%) of 1744 paediatric patients were LTFU vs. 1.4% (n = 193) of 13 355 adults (P < 0.001). Subjects who were LTFU had fewer days in care than retained subjects (1338 vs. 1544, respectively; P < 0.001) and a longer duration of ART (1530 vs. 1300 days, respectively; P < 0.001). Subjects who were LTFU had higher baseline HIV viral loads (P = 0.016) and higher body mass indexes (P < 0.001), were more likely to live in urban settings (88% of patients who were LTFU lived in urban settings) with better housing [relative risk (RR) 2.3; 95% confidence interval (CI) 1.67-3.09; P < 0.001], and were more likely to be educated (RR 1.88; 95% CI 1.42-2.50; P < 0.001). Distance to the centre and cost of transportation were associated with LTFU (RR 3.4; 95% CI 2.84-5.37; P < 0.001), as was absence of a maternal figure (RR 1.57; 95% CI 1.17-2.09; P < 0.001). Viral load, distance index, education and a maternal figure were predictive of LTFU.



Educated, urbanized HIV-infected adults living far from programme centres are at high risk of LTFU, particularly if there is no maternal figure in the household. These variables must be taken into consideration when developing retention strategies.
Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
S
S
Mancinelli
Department of Pediatrics-Infectious Disease, University of California Los Angeles, Los Angeles, CA, USA.
K
K
Nielsen-Saines
DREAM Programme, Rome, Italy.
P
P
Germano
DREAM Programme, Rome, Italy.
G
G
Guidotti
Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
E
E
Buonomo
Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
P
P
Scarcella
DREAM Programme, Blantyre, Malawi.
R
R
Lunghi
DREAM Programme, Blantyre, Malawi.
H
H
Sangare
DREAM Programme, Rome, Italy.
S
S
Orlando
Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
G
G
Liotta
LUMSA University, Rome, Italy.
M C
MC
Marazzi
Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
L
L
Palombi
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D059012:Lost to Follow-Up; D008295:Malawi; D008297:Male; D008875:Middle Aged; D011247:Pregnancy; D018570:Risk Assessment; D055815:Young Adult
D044966:Anti-Retroviral Agents

HIV
; Malawi; loss to follow-up; predictors; retention