Physical tracing of patients in antiretroviral (ARV) programmes results in a decrease in loss to follow-up, but an increase in reported mortality, according to a systematic review of low- and middle-income country ARV programmes presented at the 19th International AIDS Conference (AIDS 2012) in Washington DC today.
Retention in care is a serious problem for treatment programmes in sub-Saharan Africa, both among patients not yet eligible for treatment and among those already on treatment. Although there is some evidence to suggest that patient tracing helps to retain patients in care after they miss clinic appointments, there has been no systematic analysis of the experience of treatment programmes in low- and middle-income countries to determine which features of the treatment programme are associated with better retention in care.
The review, by Dr James McMahon of the Alfred Hospital in Melbourne and colleagues, included 32 published papers and 7 conference abstracts to compare summary estimates of loss to follow-up, mortality and retention in low- and middle-income countries 12 months after ARV initiation in cohorts of patients, with and without physical tracing of patients. Physical tracing involves tracking patients to their home address or following up with household members to check where the patient may be found.
According to the review, which involved the analysis of 62,791 people who had started ARVs, from 25 cohorts that carried out patient tracing and 124,875 patients from 29 cohorts that did not practice patient tracing, 7.6% of patients were lost to follow-up in the programmes which included patient tracing, compared to 15.1% in those programmes which did not use physical tracing (p<0.001).
Patient retention on ARVs was higher in physical tracing programmes at 80%, compared to 75.8% in those that did not use physical tracing (p=0.006). In addition, the review found higher retention rates at the original site where the patient began treatment than at those sites where patient tracing was conducted (80% compared to 72.9%).
According to the researchers, this suggests that patient tracing may increase re-engagement in care. However, mortality was higher in the cohorts including physical tracing, at 80%, compared to 75.8 % in those that did not use physical tracing (p=0.04), because it was able to definitively establish that patients had died.
Risk factors for attrition
A study among adults in antiretroviral treatment programs in Tanzania, Uganda and Zambia found that the most significant individual risk factors for patients not being retained in ARV programmes (attrition) were if the patients were male, less than 30 years old, had experienced a weight loss of more than 10%, were at WHO stages 3 or 4, or had a lower CD4 count at baseline. The most significant programmatic factor that determined patient attrition was if ARVs were dispensed at community level.
The retrospective cohort study presented at AIDS 2012 today by Dr Olivier Koole of the Antwerp Institute of Tropical Medicine and colleagues included 17 rural and urban ARV sites. A total of 4147 ARV patients’ medical charts were randomly selected and reviewed between April and August 2010. In addition, Health Care Manager questionnaires were conducted at the 17 sites to determine programme characteristics of each site.
According to the multivariable analysis, patients who were over 30 years old were 33% more likely to be retained in the ARV programme, compared to those between the ages of 18 and 29 (aHR 0.77 95% CI 0.67 – 0.88), while women were 72% more likely to remain in care compared to men (aHR 1.28 95% CI 1.14-1.43). Patients with a baseline CD4 count of 5 cells/ mm3 were 30% more likely to reach attrition (most likely due to death), while those with a baseline CD4 count of 20 or 50 cells/ mm3 were 15 and 6% respectively more likely to reach attrition when compared to those with a baseline of CD4 count of 100 cells/mm3. Patients who had lost more than 10% of their body weight were 17% more likely to reach attrition, compared to those who had not (aHR 1.17 95% CI 1.00 – 1.37).
The study found that patients were 39% more likely to be retained in if ARVs were dispensed in the community, outside of the clinic (aHR 0.61 95%CI 0.42-0.88). However, the study found lower retention rates amongst men in programmes without community dispensing but similar retention rates for men and women in programmes with ARV dispensing at community level. Men were 64% less likely to be retained, compared to women, at sites where there was no community dispensing of ARVs, while the adjusted hazard ratios were similar at 0.68 and 0.66 for women and men respectively at sites where ARVs were distributed at community level. The researchers suggested that this may indicate that it is difficult for men to pick their ARVs up from the clinic.
Dr Koole stressed the importance of community ARV dispensing, particularly for men, younger people and those who were very ill. He suggested that this could be done through mobile clinics, community pharmacies or community ARV support groups.
McMahon J et al. Effects of patient tracing on estimates of lost to follow-up, mortality and retention in antiretroviral therapy programs in low-middle income countries: a systematic review. 19th International Conference on AIDS, abstract MOAC0302, Washington, DC, July 2012.
Koole O et al. Retention and risk factors for attrition among adults in antiretroviral treatment programs in Tanzania, Uganda and Zambia. 19th International Conference on AIDS, abstract MOAC0305, Washington, DC, July 2012.