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C. Ardura Gracia , H. Tweya , C Feldacker , S. Phiri , R. Weigel

Risk factors and true outcomes of children lost to follow-up from antiretroviral therapy in Lilongwe, Malawi. C. Ardura Gracia , H. Tweya , C Feldacker , S. Phiri , R. Weigel. Lost to follow-up in ART programmes.

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C. Ardura Gracia , H. Tweya , C Feldacker , S. Phiri , R. Weigel

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  1. Risk factors and true outcomes of children lost to follow-up from antiretroviral therapy in Lilongwe, Malawi C. ArduraGracia, H. Tweya, C Feldacker, S. Phiri, R. Weigel

  2. Lost to follow-up in ART programmes • Lost to follow-up (LTFU) is common in ART programmes in sub-Saharan Africa • 21% in the first 6 months • 26-30% in the first 2 years • LTFU can lead to treatment interruptions • Development of viral resistance to ART • Hamper HIV prevention efforts • Limited information regarding LTFU in children

  3. Objectives • To explore factors associated with LTFU in children accessing ART • To describe children’s true ART outcomes as determined through Back-To-Care project

  4. Methods: Study Setting • Lighthouse and Martin Preuss centre (MPC) clinics: large, public HIV/AIDS clinics in Lilongwe, Malawi • Lighthouse and MPC use electronic data systems (EDS) • All HIV-infected patients are registered in the EDS • Visits are initially scheduled monthly then extended to 2 months for ART patients • At each visit, number of remaining ARV pills and new supply are recorded and next appointment is electronically calculated

  5. Methods: Back-To-Care • Active tracing of LTFU patients was established in July 2006 – called Back-To-Care (B2C) project • The B2C program intends to decrease treatment interruption and prevent loss to follow-up • Every month, B2C staff generate a list of patients that miss an appointment by at least 3 weeks • B2C team confirms the list by checking in patients files • Patients who consent are traced up to 3 times by phone or home visit

  6. Methods: B2C Data Collection • B2C tracing staff complete paper forms on tracing efforts • Information on tracing outcomes and future patient intention of ART are entered in B2C MS Access database • B2C data linked to the EDS using unique identifiers • To identify patients who return after tracing

  7. Methods: Analysis • ART outcomes for national programme include transfer out, LTFU, ART stop, death and alive on ART • B2C outcomes include death, uninterrupted therapy, on ARV with gaps, official transfer out, self transfer out, ART stop, never started ART and not traced • Patients were censored on • Last clinic visit date • Outcome date ( death) • Cox proportional hazard model was used to identify independent risk factors for LTFU among baseline patient characteristics

  8. Results: Patients details • Between Apr 2006 and Dec 2010, 1182 children accessed ART at Lighthouse and MPC clinics • 197 were then excluded from analysis due to incomplete or inaccurate data • Of the 985 included in the analysis, • 1,999 children-years of follow-up • 48% were male • Median age at ART initiation 81 months (IQR: 39-128)

  9. Results: LTFU • 251 (25%) had at least one missed appointment • Median follow-up time was 9 months (IQR: 2 -24 months) • LTFU rate was 12.6/100 children-years • 11.8% at 6 months; 16.8% at 12 months • Risk factors for LTFU in multivariable analysis • Wasting (AHR 1.6 95% CI 1.17-2.18) • < 2 years at ART start (AHR 1.55 95% CI 1.02 – 2.37) • No statistically significant association with • Gender, distance to clinic, advanced WHO stage

  10. 201 in B2C 158 (78,6%) 43 (21,4%) Successfully Traced Not traced / Not found 17 (10,8%) 41 (25,9%) 100 (63,3%) Died TO Alive not TO 2 Never started ART 38 (93%) Official 39 3 (7%) Stop ART ‘Silent’ 28 On ART with Gaps 31 On ART Uninterrupted Results: B2C tracing *No significant differences between those included in B2C list or not, or between those traced or not

  11. Results: ART outcomes Alive on ART LTFU Died Stopped ART Transfer Out 80% of children expected after tracing returned ART outcomes before/after correcting for true outcomes of LTFU children actively traced by the B2C team

  12. Conclusions • Majority of LTFU children were alive but had missed appointments • May be due to less capable or motivated guardians • Wasting and young age (<2 years) were associated with higher rate of LTFU • Lower mortality rate (11%) among children traced compared to other studies • Higher proportion of official transfer-outs compared to other studies but similar to adults – poor documentation • After tracing, LTFU rate reduced by 62% and mortality estimates increased from 2.6% to 4.8%

  13. Recommendations • Active LTFU of children on ART should be encouraged • Reduces LFTU rates • Increases retention • Improves mortality estimates • Transfer out patients should be better documented to prevent unnecessary tracing

  14. Acknowledgments

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