Determinants of loss to follow-up in patients on antiretroviral treatment, South Africa, 2004-2012: a cohort study

Abstract

Background: The number of Human Immunodeficiency Virus (HIV) infected people eligible for initiation on antiretroviral Therapy (ART) is increasing. ART programmatic success requires that patients who are taking ART remain on treatment and are followed up regularly. This study investigated factors associated with being lost to follow-up, in a cohort of patients enrolled in a pharmacovigilance study in South Africa.

Methods: This was a retrospective observational cohort study performed at one of the Medunsa National Pharmacovigilance Centre's (MNPC) ART sentinel surveillance sites. Loss to Follow-up (LTFU) was defined as "a patient who had been followed up at the sentinel site, who had not had contact with the health facility for 180 days or more since their last recorded expected date of return or if there were 180 days or more between the expected date of return and the next clinic visit".

Results: Out of 595 patients, 65.5% (n = 390) were female and 23.4% (n = 139) were LTFU. The median time on ART before LTFU was 21.5 months (interquartile range: 12.9 - 34.7 months). The incidence rate of LTFU was 103 per 1000 person-years in the first year on ART and increased to 405 per 1000 person-years in the eighth year of taking ART. Factors associated with becoming LTFU included not having a committed partner (Adjusted Hazard Ratio (aHR): 2.9, 95% Confidence Interval (CI):1.19-6.97, p = 0.019), being self-employed (aHR: 13.9, 95% CI:2.81 - 69.06, p = 0.001), baseline CD4 count > 200 cells/ml (aHR: 3.8, 95% CI: 1.85-7.85, p < 0.001), detectable last known Viral Load (VL) (aHR: 3.6, 95% CI:1.98-6.52, p < 0.001) and a last known World Health Organisation clinical stage three or four (aHR: 2.0, 95% CI:1.22-3.27, p = 0.006). Patients that previously had an ART adverse event had a lower risk (aHR: 0.6, 95% CI: 0.38 - 0.99, p = 0.044) of becoming LTFU than those that had not.

Conclusion: The incidence rate of LTFU increases with additional years on ART. Intensified measures to improve patient retention on ART must be prioritised with increasing patient time on ART and in patients that are at increased risk of becoming lost to follow-up.

Fig. 1

A flow diagram describing the patients enrolled into the Tshepang Pharmacovigilance cohort and their various outcomes, 2004–2012

Fig. 2

Kaplan Meier graph showing the probability of remaining in care with time, Tshepang Pharmacovigilance cohort, 2004–2012

Fig. 3

Number of patients and the period incidence of LTFU with each year of taking ART, Tshepang Pharmacovigilance cohort, 2004–2012

Fig. 4

Comparing CD4 counts, viral load levels and clinical staging in patients that were LTFU and that are in care, Tshepang Pharmacovigilance cohort, 2004–2012