The Causal Effect of Tracing by Peer Health Workers on Return to Clinic Among Patients Who Were Lost to Follow-up From Antiretroviral Therapy in Eastern Africa: A "Natural Experiment" Arising From Surveillance of Lost Patients.
The effect of tracing human immunodeficiency virus (HIV)-infected patients who are lost to follow-up (LTFU) on reengagement has not been rigorously assessed. We carried out an ex post analysis of a surveillance study in which LTFU patients were randomly selected for tracing to identify the effect of tracing on reengagement.
We evaluated HIV-infected adults on antiretroviral therapy who were LTFU (>90 days late for last visit) at 14 clinics in Uganda, Kenya, and Tanzania. A random sample of LTFU patients was selected for tracing by peer health workers. We assessed the effect of selection for tracing using Kaplan-Meier estimates of reengagement among all patients as well as the subset of LTFU patients who were alive, contacted in person by the tracer, and out of care.
Of 5781 eligible patients, 991 (17%) were randomly selected for tracing. One year after selection for tracing, 13.3% (95% confidence interval [CI], 11.1%-15.3%) of those selected for tracing returned compared with 10.0% (95% CI, 9.1%-10.8%) of those not randomly selected, an adjusted risk difference of 3.0% (95% CI, .7%-5.3%). Among patients found to be alive, personally contacted, and out of care, tracing increased the absolute probability of return at 1 year by 22% (95% CI, 7.1%-36.2%). The effect of tracing on rate of return to clinic decayed with a half-life of 7.0 days after tracing (95% CI, 2.6 %-12.9%).
Tracing interventions increase reengagement, but developing methods for targeting LTFU patients most likely to benefit can make this practice more efficient.
Institute for Disease Modeling, Bellevue, Washington.
Anna
A
Bershetyn
Kenya Medical Research Institute, Nairobi.
Thomas A
TA
Odeny
National AIDS Control Program, Dar es Salaam, Tanzania.
Rita
R
Lyamuya
Infectious Diseases Institute, Kampala, Uganda.
Alice
A
Nakiwogga-Muwanga
United States Agency for International Development-Academic Partnership Program, Eldoret, Kenya.
Lameck
L
Diero
Department of Epidemiology and Biostatistics, University of California, San Francisco.|Mbarara University of Science and Technology, Uganda.
Mwebesa
M
Bwana
United States Agency for International Development-Academic Partnership Program, Eldoret, Kenya.
Paula
P
Braitstein
National AIDS Control Program, Dar es Salaam, Tanzania.
Geoffrey
G
Somi
Infectious Diseases Institute, Kampala, Uganda.
Andrew
A
Kambugu
Kenya Medical Research Institute, Nairobi.
Elizabeth
E
Bukusi
Division of HIV/AIDS, Department of Medicine, San Francisco General Hospital, California.
Wendy
W
Hartogensis
Department of Epidemiology and Biostatistics, University of California, San Francisco.
David V
DV
Glidden
Division of Infectious Diseases, Department of Medicine, and.
Kara
K
Wools-Kaloustian
Department of Biostatistics, Fairbanks School of Public Health, Indiana University, Indianapolis.
Constantin
C
Yiannoutsos
Department of Epidemiology and Biostatistics, University of California, San Francisco.|Division of HIV/AIDS, Department of Medicine, San Francisco General Hospital, California.
Jeffrey
J
Martin
Division of HIV/AIDS, Department of Medicine, San Francisco General Hospital, California.
Elvin H
EH
Geng
D000328:Adult; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D062665:Epidemiological Monitoring; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology* / Q000821:virology; D006282:Health Personnel; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D059012:Lost to Follow-Up; D008297:Male; D013636:Tanzania / Q000453:epidemiology; D014454:Uganda / Q000453:epidemiology
D019380:Anti-HIV Agents
Africa; antiretroviral therapy; loss to follow-up.; retention