Risk factors and true outcomes of children
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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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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. ArduraGracia, H. Tweya, C Feldacker, S. Phiri, R. Weigel


Lost to follow up in art programmes

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


Objectives

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


Methods study setting

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


Methods back to care

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


Methods b2c data collection

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


Methods analysis

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


Results patients details

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)


Results ltfu

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


Results b2c tracing

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


Results art outcomes

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


Conclusions

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%


Recommendations

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


C ardura gracia h tweya c feldacker s phiri r weigel

Acknowledgments


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