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. 2022 Jan 29;74(2):171-179.
doi: 10.1093/cid/ciab428.

Tracing People Living With Human Immunodeficiency Virus Who Are Lost to Follow-up at Antiretroviral Therapy Programs in Southern Africa: A Sampling-Based Cohort Study in 6 Countries

Marie Ballif  1 , Benedikt Christ  1 , Nanina Anderegg  1 , Frédérique Chammartin  1 , Josephine Muhairwe  2 , Laura Jefferys  3 , Jonas Hector  3 , Janneke van Dijk  4 , Michael J Vinikoor  5 , Monique van Lettow  6 , Cleophas Chimbetete  7 , Sam J Phiri  8 , Dorina Onoya  9 , Matthew P Fox  9   10 , Matthias Egger  1   11   12
Affiliations

Tracing People Living With Human Immunodeficiency Virus Who Are Lost to Follow-up at Antiretroviral Therapy Programs in Southern Africa: A Sampling-Based Cohort Study in 6 Countries

Marie Ballif et al. Clin Infect Dis. .

Abstract

Background: Attrition threatens the success of antiretroviral therapy (ART). In this cohort study, we examined outcomes of people living with human immunodeficiency virus (PLHIV) who were lost to follow-up (LTFU) during 2014-2017 at ART programs in Southern Africa.

Methods: We confirmed LTFU (missed appointment for ≥60 or ≥90 days, according to local guidelines) by checking medical records and used a standardized protocol to trace a weighted random sample of PLHIV who were LTFU in 8 ART programs in Lesotho, Malawi, Mozambique, South Africa, Zambia, and Zimbabwe, 2017-2019. We ascertained vital status and identified predictors of mortality using logistic regression, adjusted for sex, age, time on ART, time since LTFU, travel time, and urban or rural setting.

Results: Among 3256 PLHIV, 385 (12%) were wrongly categorized as LTFU and 577 (17%) had missing contact details. We traced 2294 PLHIV (71%) by phone calls, home visits, or both: 768 (34% of 2294) were alive and in care, including 385 (17%) silent transfers to another clinic; 528 (23%) were alive without care or unknown care; 252 (11%) had died. Overall, the status of 1323 (41% of 3256) PLHIV remained unknown. Mortality was higher in men than women, higher in children than in young people or adults, and higher in PLHIV who had been on ART <1 year or LTFU ≥1 year and those living farther from the clinic or in rural areas. Results were heterogeneous across sites.

Conclusions: Our study highlights the urgent need for better medical record systems at HIV clinics and rapid tracing of PLHIV who are LTFU.

Keywords: HIV; Southern Africa; lost to follow-up; tracing; vital status.

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Figures

Figure 1.
Figure 1.
Study flowchart. Abbreviations: ART, antiretroviral therapy; LTFU, lost to follow-up; PLHIV, people living with HIV.
Figure 2.
Figure 2.
Vital status and care outcomes among participants who were traced, by antiretroviral therapy program and overall. Abbreviations: LTFU, lost to follow-up; MoH-CIDRZ, Ministry of Health–Centre for Infectious Disease Research in Zambia; SMART, SolidarMed-supported antiretroviral therapy program.
Figure 3.
Figure 3.
Differences across antiretroviral therapy programs in the proportions of participants confirmed lost to follow-up, medical records not found, alive or who have died, among those sampled (first bar), the subgroup of those traced (second bar), and the combined outcomes (third bar). Abbreviations: LTFU, lost to follow-up; MoH-CIDRZ, Ministry of Health–Centre for Infectious Disease Research in Zambia; SMART, SolidarMed-supported antiretroviral therapy program.
Figure 4.
Figure 4.
Univariable and multivariable logistic regressions of mortality, among 1548 participants who were traced with determined vital status. Abbreviations: ART, antiretroviral therapy; CI, confidence interval; OR, odds ratio.
Figure 5.
Figure 5.
Univariable and multivariable logistic regressions of being in care, among 1193 participants who were traced and found alive. Abbreviations: ART, antiretroviral therapy; CI, confidence interval; OR, odds ratio.
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