. 2018 Jun;5(6):e301-e308.

doi: 10.1016/S2352-3018(18)30048-1.

A continuum of HIV care describing mortality and loss to follow-up: a longitudinal cohort study

Sophie Jose¹, Valerie Delpech², Alison Howarth³, Fiona Burns⁴, Teresa Hill⁵, Kholoud Porter¹, Caroline A Sabin⁶; UK CHIC Study Steering Committee

Collaborators, Affiliations

Collaborators

UK CHIC Study Steering Committee:
Jonathan Ainsworth, Sris Allan, Jane Anderson, Abdel Babiker, David R Chadwick, Duncan Churchill, David Dunn, Richard Gilson, Mark Gompels, Phillip Hay, Margaret Johnson, Stephen Kegg, Clifford Leen, Fabiola Martin, Dushyant Mital, Mark Nelson, Chloe Orkin, Adrian Palfreeman, Andrew Phillips, Deenan Pillay, Frank Post, Jillian Pritchard, Achim Scwenk, Anjum Tariq, Roy Trevelion, Andy Ustianowski, John Walsh

Affiliations

¹ Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK; National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, London, UK.
² Public Health England, London, UK; National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, London, UK.
³ Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK.
⁴ Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK; Royal Free London NHS Foundation Trust, London, UK.
⁵ Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK.
⁶ Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK; National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, London, UK. Electronic address: c.sabin@ucl.ac.uk.

PMID: 29893243
PMCID: PMC5990495
DOI: 10.1016/S2352-3018(18)30048-1

A continuum of HIV care describing mortality and loss to follow-up: a longitudinal cohort study

Sophie Jose et al. Lancet HIV. 2018 Jun.

. 2018 Jun;5(6):e301-e308.

doi: 10.1016/S2352-3018(18)30048-1.

Authors

Sophie Jose¹, Valerie Delpech², Alison Howarth³, Fiona Burns⁴, Teresa Hill⁵, Kholoud Porter¹, Caroline A Sabin⁶; UK CHIC Study Steering Committee

Collaborators

UK CHIC Study Steering Committee:
Jonathan Ainsworth, Sris Allan, Jane Anderson, Abdel Babiker, David R Chadwick, Duncan Churchill, David Dunn, Richard Gilson, Mark Gompels, Phillip Hay, Margaret Johnson, Stephen Kegg, Clifford Leen, Fabiola Martin, Dushyant Mital, Mark Nelson, Chloe Orkin, Adrian Palfreeman, Andrew Phillips, Deenan Pillay, Frank Post, Jillian Pritchard, Achim Scwenk, Anjum Tariq, Roy Trevelion, Andy Ustianowski, John Walsh

Affiliations

¹ Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK; National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, London, UK.
² Public Health England, London, UK; National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, London, UK.
³ Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK.
⁴ Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK; Royal Free London NHS Foundation Trust, London, UK.
⁵ Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK.
⁶ Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK; National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, London, UK. Electronic address: c.sabin@ucl.ac.uk.

PMID: 29893243
PMCID: PMC5990495
DOI: 10.1016/S2352-3018(18)30048-1

Abstract

Background: The cross-sectional HIV care continuum is widely used to assess the success of HIV care programmes among populations of people with HIV and the potential for ongoing transmission. We aimed to investigate whether a longitudinal continuum, which incorporates loss to follow-up and mortality, might provide further insights about the performance of care programmes.

Methods: In this longitudinal cohort study, we included individuals who entered the UK Collaborative HIV Cohort (CHIC) study between Jan 1, 2000, and Dec 31, 2004, and were linked to the national HIV cohort database (HIV and AIDS Reporting System). For each month during a 10 year follow up period, we classified individuals into one of ten distinct categories according to engagement in care, antiretroviral therapy (ART) use, viral suppression, loss to cohort follow-up and loss to care, and mortality, and assessed the proportion of person-months of follow-up spent in each stage of the continuum. 5 year longitudinal continuums were also constructed for three separate cohorts (baseline years of entry 2000-03, 2004-07, and 2008-09) to compare changes over time.

Findings: We included 12 811 people contributing 1 537 320 person-months in our analysis. During 10 years of follow-up, individuals spent 811 057 (52·8%) of 1 537 320 person-months on ART. Of the 811 057 person-months spent on ART, individuals had a viral load of 200 copies per mL or less for 607 185 (74·9%) person-months. 10 years after cohort entry, 3612 (28·1%) of 12 811 individuals were lost to follow-up, 954 (26·4%) of whom had transferred to a non-CHIC UK clinic for care. By 10 years, 759 (5·9%) of 12 811 participants who entered the cohort had died. Loss to follow-up decreased and the proportion of person-months that individuals spent virally suppressed increased over calendar time.

Interpretation: Loss to follow-up in HIV care programmes was high and rates of viral suppression were lower than previously reported. Complementary information provided by a longitudinal continuum might highlight areas for intervention along the HIV care pathway, however, transfers outside the cohort must be accounted for.

Funding: Medical Research Council, UK.

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Figures

**Figure 1**
10 year longitudinal continuum of care Person-months for each stage of the continuum: ART–/EIC/CD4 >350, 130 114 person-months; ART–/EIC/CD4 ≤350, 82 102 person-months; ART–/NIC, 74 917 person-months; ART+/EIC/VL >200, 116 599 person-months; ART+/EIC/VL ≤200, 579 410 person-months; ART+/NIC/VL ≤200, 27 775 person-months; ART+/NIC/VL >200, 87 273 person-months; true LTC, 293 048 person-months; transfer, 86 771 person-months; and dead, 59 311 person-months. See appendix (p 1) for a full description of each stage of the continuum. LTC=loss to care. ART+=antiretroviral therapy experienced. ART–=antiretroviral therapy naive. NIC=not in care. EIC=engaged in care. VL=viral load. ART–=antiretroviral therapy naive.

**Figure 2**
5 year longitudinal care continuum by calendar year of cohort entry Person-months for each stage of the continuum: ART–/EIC/CD4 >350, 70 576 (2000–03), 93 695 (2004–07), and 42 573 (2008–09) person-months; ART–/EIC/CD4 ≤350, 51 350 (2000–03), 44 498 (2004–07), 13 210 (2008–09) person-months; ART–/NIC, 49 105 (2000–03), 45 749 (2004–07), 18 293 (2008–09) person-months; ART+/EIC/VL >200, 54 154 (2000–03), 51 058 (2004–07), 22 545 (2008–09) person-months; ART+/EIC/VL ≤200, 179 775 (2000–03), 259 598 (2004–07), 140 887 (2008–09) person-months; ART+/NIC/VL ≤200, 8775 (2000–03), 12 408 (2004–07), 7453 (2008–09) person-months; ART+/NIC/VL >200, 34 444 (2000–03), 38 018 (2004–07), 19 395 (2008–09) person-months; true LTC, 107 733 (2000–03), 87 975 (2004–07), 37 805 (2008–09) person-months; transfer, 24 724 (2000–03), 27 032 (2004–07), 10 713 (2008–09) person-months; dead, 16 604 (2000–03), 15 509 (2004–07), 6206 (2008–09) person-months. See appendix (p 1) for a full description of each stage of the continuum. LTC=loss to care. ART+=antiretroviral therapy experienced. ART–=antiretroviral therapy naive. NIC=not in care. EIC=engaged in care. VL=viral load.

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Comment in

Understanding the HIV care continuum.
Hogg RS. Hogg RS. Lancet HIV. 2018 Jun;5(6):e269-e270. doi: 10.1016/S2352-3018(18)30102-4. Lancet HIV. 2018. PMID: 29893238 No abstract available.

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A continuum of HIV care describing mortality and loss to follow-up: a longitudinal cohort study

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A continuum of HIV care describing mortality and loss to follow-up: a longitudinal cohort study

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