Patients returning to HIV care after an interruption have a high risk of short-term illness and death

HIV-positive patients who return to care after being lost to follow-up are five times more likely to die in the short term than patients who remain in HIV care continuously, French investigators report in the online edition of AIDS.

“Increased efforts are needed to reduce loss to follow-up and encourage those patients who no longer attend clinic to return to care,” recommend the authors.

Thanks to effective antiretroviral treatment, the prognosis of many HIV-positive individuals is now near normal. However, despite the benefits of treatment and care, some patients stop attending their HIV clinic.

Investigators in northern France looked at the characteristics and outcome of patients who were lost to follow-up for at least twelve months and who subsequently returned to HIV care.

A total of 1007 patients received HIV care at five treatment centres in the Nord Pas-de-Calais region between 1997 and 2006. Of these patients, 135 (13%) were lost to follow-up. A total of 74 (55%) of these individuals subsequently returned to their HIV clinic.

There were some significant differences between patients lost to follow-up and those remaining in HIV care. Those lost to follow-up were younger (median, 31 years vs 35 years, p 3 vs 334 cells/mm³).

The 74 patients returning to care did so after a median interval of 19 months. Their median CD4 cell count was significantly lower at the time they returned to care (305 cells/mm³) than at the point they were lost to follow-up (401 cells/mm³, p

Upon return, 33 patients (45%) had a CD4 cell count below 200 cells/mm³ and 20 (27%) had an AIDS-defining illness. A total of 14% of individuals lost to follow-up were hospitalised within six months of their return to care, the median stay in hospital being 23 days. The mortality rate amongst patients returning to care was 8% compared to 5% amongst individuals who attended clinic regularly.

When the investigators conducted statistical analysis that controlled for CD4 cell count and AIDS-defining events on first enrolment, they found that individuals returning after being lost to follow-up were over five times more likely to die than patients who remained in HIV care (5.14, 95% CI, 2.11 to 12.54).

“Similar to patients who present to care very late, these patients [lost to follow-up] are more likely to have one or more AIDS-defining illness, to be hospitalised as a result of an AIDS-defining event, and to die,” comment the investigators.

Moreover, the investigators suggest “lost to follow-up may also increase the risk of HIV transmission, as patients who interrupt combination antiretroviral therapy cannot benefit from the favourable effect of antiretroviral drugs on infectiousness.”