Male, Mobile, and Moneyed: Loss to Follow-up in an Urban African Antiretroviral Treatment Clinic
Marson, Kara G.
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<b>Abstract</b> <b>Introduction:</b> Loss to follow-up (LTFU) from an antiretroviral therapy (ART) clinic is understood to be an indicator of potential ART interruption and increased clinical risk for HIV-infected individuals. Little is known about the timing, characteristics, and reasons for loss among patients in Africa who have transferred HIV care elsewhere and those who are LTFU without care. <b>Methods:</b> This analysis utilized data from a prospective randomized clinical trial of adherence interventions involving participants followed in a large ART clinic in Nairobi, Kenya. Participants were followed for 18 months after ART initiation, and were defined as LTFU if they failed to return within 60 days of their monthly pharmacy visit. Reasons for loss were captured through phone or home visit. LTFU clients were sub-classified as `transferred' if they transferred care to another facility or `no care' if they did not seek further care. Characteristics were compared between `transferred' LTFU, `no care' LTFU, and those who were retained using Chi square, Mann Whitney U and logistic regression. <b>Results:</b> Of 393 participants followed, total attrition was 83 (21%), of whom 75 (90%) were successfully traced. There were 38 (51%) deaths and 37 (49%) LTFU alive at tracing, of whom 18 (49%) were lost prior to ART initiation and 22 (59%) reported transferring their care. Those who transferred care paid higher monthly rent (US$57 vs. 24; p=0.004) and were less likely to use a pit latrine (32% vs. 54%; p=0.04) than those who remained in clinic. The odds of LTFU without care were significantly greater for men compared to women [Odds Ratio (OR), 3.4; 95% CI: >1.0, 11.7; p<0.05). Among all LTFU, the most common reason for loss was moving residence, predominantly due to job loss or change in employment. <b>Conclusion:</b> Half of LTFU in this ART cohort occurred before ART initiation, identifying this period as an important time for intervention. A broad definition of LTFU that includes those who have transferred their care may overestimate negative effects of LTFU on ART treatment continuation. Interventions targeting treatment adherence for men and considering job mobility at enrollment may be useful to improve retention in urban ART clinics.
- Epidemiology