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Clin Infect Dis. 2018 Nov 13;67(11):1643-1652. doi: 10.1093/cid/ciy347.

Outcomes of Patients Lost to Follow-up in African Antiretroviral Therapy Programs: Individual Patient Data Meta-analysis.

Author information

1
Institute of Social and Preventive Medicine, University of Bern.
2
Institute of Global Health, University of Geneva, Switzerland.
3
Faculty of Health, Witten/Herdecke University, Witten, Germany.
4
Lighthouse Trust, Lilongwe, Malawi.
5
Department of Surgery, University of Cape Town, South Africa.
6
Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
7
Liverpool School of Tropical Medicine, United Kingdom.
8
Institut de Recherche pour le Développement, Inserm, Univ Montpellier, Recherches Translationnelles sur le VIH et les Maladies Infectieuses, Montpellier, France.
9
Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa.
10
Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, United Kingdom.
11
Division of Infectious Diseases, HIV and Global Medicine, Department of Medicine, University of California, San Francisco.
12
Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
13
Departments of Epidemiology and Global Health, Boston University School of Public Health, Massachusetts.

Abstract

Background:

Low retention on combination antiretroviral therapy (cART) has emerged as a threat to the Joint United Nations Programme on human immunodeficiency virus (HIV)/AIDS (UNAIDS) 90-90-90 targets. We examined outcomes of patients who started cART but were subsequently lost to follow-up (LTFU) in African treatment programs.

Methods:

This was a systematic review and individual patient data meta-analysis of studies that traced patients who were LTFU. Outcomes were analyzed using cumulative incidence functions and proportional hazards models for the competing risks of (i) death, (ii) alive but stopped cART, (iii) silent transfer to other clinics, and (iv) retention on cART.

Results:

Nine studies contributed data on 7377 patients who started cART and were subsequently LTFU in sub-Saharan Africa. The median CD4 count at the start of cART was 129 cells/μL. At 4 years after the last clinic visit, 21.8% (95% confidence interval [CI], 20.8%-22.7%) were known to have died, 22.6% (95% CI, 21.6%-23.6%) were alive but had stopped cART, 14.8% (95% CI, 14.0%-15.6%) had transferred to another clinic, 9.2% (95% CI, 8.5%-9.8%) were retained on cART, and 31.6% (95% CI, 30.6%-32.7%) could not been found. Mortality was associated with male sex, more advanced disease, and shorter cART duration; stopping cART with less advanced disease andlonger cART duration; and silent transfer with female sex and less advanced disease.

Conclusions:

Mortality in patients LTFU must be considered for unbiased assessments of program outcomes and UNAIDS targets in sub-Saharan Africa. Immediate start of cART and early tracing of patients LTFU should be priorities.

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