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True outcomes for patients on antiretroviral therapy who are "lost to follow-up" in Malawi Translated title: Véritables issues du traitement antirétroviral pour les patients considérés comme « perdus de vue » au Malawi Translated title: Evolución real de los pacientes sometidos a terapia antirretroviral y perdidos en el seguimiento en Malawi

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      Abstract

      PROBLEM: In many resource-poor countries that are scaling up antiretroviral therapy (ART), 5-25% of patients are reported as "lost to follow-up". This figure is 9% in Malawi. There is no published information about the true outcome status of these patients. APPROACH: In four facilities in northern Malawi, ART registers and master cards were used to identify patients who had not attended the facility for 3 months or more and were thus registered as "lost to follow-up". Clinic staff attempted to trace these patients and ascertain their true outcome status. LOCAL SETTING: Of 253 patients identified as "lost to follow-up", 127 (50%) were dead, 58% of these having died within 3 months of their last clinic visit. Of the 58 patients (23%) found to be alive, 21 were still receiving ART and 37 had stopped treatment (high transport costs being the main reason for 13 patients). Sixty-eight patients (27%) could not be traced, most commonly because of an incorrect address in the register. Fewer patients were alive and more patients could not be traced from the central hospital compared with the peripheral hospitals. RELEVANT CHANGES:Better documentation of patients’ addresses and prompt follow-up of patients who are late for their appointments are required. LESSONS LEARNED: ART clinics in resource-poor countries should ensure that patients’ addresses are correct and comprehensive. Clinics should also undertake contact tracing as soon as possible in the event of non-attendance, consider facilitating access to ART clinics and take loss to follow-up into consideration when assessing death rates.

      Translated abstract

      PROBLEMATIQUE: Dans nombre de pays à revenu modeste qui ont entrepris d’étendre le traitement antirétroviral (ART), 5 à 25 % des patients sont signalés comme « perdus de vue ». Ce chiffre est de 9 % pour le Malawi. On ne dispose pas de données publiées sur la véritable issue pour ces patients. DEMARCHE: Dans quatre établissements de la partie nord du Malawi, on a utilisé les livres-registres de délivrance des ART et les cartes maîtresses pour identifier les patients ne s’étant pas rendu dans l’établissement depuis 3 mois ou plus et enregistrés ainsi comme « perdus de vue ». Le personnel clinique s’est attaché à retrouver la trace de ces patients et à déterminer l’issue véritable du traitement dans leur cas. CONTEXTE LOCAL: Sur 253 patients classés comme « perdus de vue », 127 (50 %) étaient morts et parmi ces patients décédés, 58 % avaient perdu la vie dans les 3 mois suivant leur dernière visite au dispensaire. Parmi les 58 patients retrouvés en vie (23 %), 21 prenaient encore des antirétroviraux et 37 avaient interrompu leur traitement (les coûts excessif du transport étant la principale raison de cet arrêt pour 13 d’entre eux). Soixante-huit patients (27 %) n’on pu être retrouvés, le plus souvent à cause de l’inexactitude de l’adresse enregistrée dans leur dossier. Peu des patients perdus de vue étaient encore en vie et le nombre des patients impossibles à retrouver était plus important pour l’hôpital central que pour les établissements périphériques. MODIFICATIONS PERTINENTES: Il convient de relever avec plus de rigueur l’adresse des patients et d’entreprendre rapidement un suivi de ceux qui tardent à se présenter aux rendez-vous. ENSEIGNEMENTS TIRÉS: Les établissements délivrant les traitements ART dans les pays à faible revenu doivent s’assurer de l’exactitude et de la complétude de l’adresse qu’ils enregistrent pour leurs patients. Ils doivent aussi entreprendre dès que possible une recherche des contacts si un patient ne se présente plus aux rendez-vous, envisager de faciliter l’accès au lieu de délivrance du traitement ART et prendre en compte les « perdus de vue » dans l’évaluation des taux de mortalité.

      Translated abstract

      PROBLEMA: En muchos países con recursos escasos que están extendiendo masivamente la terapia antirretroviral (TAR) se informa de que un 5%-25% de los pacientes tratados se pierde en el seguimiento. En Malawi el porcentaje es del 9%. No hay datos publicados sobre la verdadera evolución de esos pacientes. MÉTODOS: En cuatro establecimientos del norte de Malawi, se utilizaron los registros de TAR y las tarjetas maestras para identificar a los pacientes que no habían acudido al establecimiento durante 3 o más meses y estaban registrados por tanto como «perdidos en el seguimiento». Trabajadores de esos centros intentaron localizar a los pacientes y evaluar su estado de salud real. CONTEXTO LOCAL: De 253 pacientes identificados como «perdidos en el seguimiento», 127 (50%) habían muerto, el 58% de ellos en los 3 meses siguientes a su última visita al consultorio. De los 58 pacientes (23%) hallados con vida, 21 seguían recibiendo TAR y 37 habían interrumpido el tratamiento (13 de ellos adujeron como causa principal el alto precio de los transportes). Sesenta y ocho pacientes (27%) no pudieron ser localizados, fundamentalmente porque en los registros figuraba una dirección incorrecta. En comparación con los hospitales periféricos, en el caso del hospital central había menos pacientes vivos y más a los que no se pudo localizar. CAMBIOS DESTACABLES: Es necesario registrar mejor las direcciones de los pacientes y reanudar rápidamente el seguimiento de los que falten a las citas concertadas. ENSEÑANZAS RESULTANTES: Los consultorios de TAR de los países de recursos escasos deben procurar que las direcciones de sus pacientes se registren correctamente y sin omisiones. Los consultorios deben adoptar además lo antes posible medidas de localización de contactos en caso de no asistencia, estudiar la manera de facilitar el acceso a los consultorios de TAR, y tener en cuenta las pérdidas en el seguimiento a la hora de evaluar las tasas de mortalidad.

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      Most cited references 16

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      Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries.

      Highly active antiretroviral therapy (HAART) is being scaled up in developing countries. We compared baseline characteristics and outcomes during the first year of HAART between HIV-1-infected patients in low-income and high-income settings. 18 HAART programmes in Africa, Asia, and South America (low-income settings) and 12 HIV cohort studies from Europe and North America (high-income settings) provided data for 4810 and 22,217, respectively, treatment-naïve adult patients starting HAART. All patients from high-income settings and 2725 (57%) patients from low-income settings were actively followed-up and included in survival analyses. Compared with high-income countries, patients starting HAART in low-income settings had lower CD4 cell counts (median 108 cells per muL vs 234 cells per muL), were more likely to be female (51%vs 25%), and more likely to start treatment with a non-nucleoside reverse transcriptase inhibitor (NNRTI) (70%vs 23%). At 6 months, the median number of CD4 cells gained (106 cells per muL vs 103 cells per muL) and the percentage of patients reaching HIV-1 RNA levels lower than 500 copies/mL (76%vs 77%) were similar. Mortality was higher in low-income settings (124 deaths during 2236 person-years of follow-up) than in high-income settings (414 deaths during 20,532 person-years). The adjusted hazard ratio (HR) of mortality comparing low-income with high-income settings fell from 4.3 (95% CI 1.6-11.8) during the first month to 1.5 (0.7-3.0) during months 7-12. The provision of treatment free of charge in low-income settings was associated with lower mortality (adjusted HR 0.23; 95% CI 0.08-0.61). Patients starting HAART in resource-poor settings have increased mortality rates in the first months on therapy, compared with those in developed countries. Timely diagnosis and assessment of treatment eligibility, coupled with free provision of HAART, might reduce this excess mortality.
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        Scaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment.

        The recording of outcomes from large-scale, simplified HAART (highly active antiretroviral therapy) programmes in sub-Saharan Africa is critical. We aimed to assess the effectiveness of such a programme held by Médecins Sans Frontières (MSF) in the Chiradzulu district, Malawi. We scaled up and simplified HAART in this programme since August, 2002. We analysed survival indicators, CD4 count evolution, virological response, and adherence to treatment. We included adults who all started HAART 6 months or more before the analysis. HIV-1 RNA plasma viral load and self-reported adherence were assessed on a subsample of patients, and antiretroviral resistance mutations were analysed in plasma with viral loads greater than 1000 copies per mL. Analysis was by intention to treat. Of the 1308 patients who were eligible, 827 (64%) were female, the median age was 34.9 years (IQR 29.9-41.0), and 1023 (78%) received d4T/3TC/NVP (stavudine, lamivudine, and nevirapine) as a fixed-dose combination. At baseline, 1266 individuals (97%) were HAART-naive, 357 (27%) were at WHO stage IV, 311 (33%) had a body-mass index of less than 18.5 kg/m2, and 208 (21%) had a CD4 count lower than 50 cells per muL. At follow-up (median 8.3 months, IQR 5.5-13.1), 967 (74%) were still on HAART, 243 (19%) had died, 91 (7%) were lost to follow-up, and seven (0.5%) discontinued treatment. Low body-mass index, WHO stage IV, male sex, and baseline CD4 count lower than 50 cells per muL were independent determinants of death in the first 6 months. At 12 months, the probability of individuals still in care was 0.76 (95% CI 0.73-0.78) and the median CD4 gain was 165 (IQR 67-259) cells per muL. In the cross-sectional survey (n=398), 334 (84%) had a viral load of less than 400 copies per mL. Of several indicators measuring adherence, self-reported poor adherence (<80%) in the past 4 days was the best predictor of detectable viral load (odds ratio 5.4, 95% CI 1.9-15.6). These data show that large numbers of people can rapidly benefit from antiretroviral therapy in rural resource-poor settings and strongly supports the implementation of such large-scale simplified programmes in Africa.
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          Viability and effectiveness of large-scale HIV treatment initiatives in sub-Saharan Africa: experience from western Kenya.

          To determine the clinical and immunological outcomes of a cohort of HIV-infected patients receiving antiretroviral therapy. Retrospective study of prospectively collected data from consecutively enrolled adult HIV-infected patients in eight HIV clinics in western Kenya. CD4 cell counts, weight, mortality, loss to follow-up and adherence to antiretroviral therapy were collected for the 2059 HIV-positive non-pregnant adult patients treated with antiretroviral drugs between November 2001 and February 2005. Median duration of follow-up after initiation of antiretroviral therapy was 40 weeks (95% confidence interval, 38-43); 111 patients (5.4%) were documented as deceased and 505 (24.5%) were lost to follow-up. Among 1766 (86%) evaluated for adherence to their antiretroviral regimen, 78% reported perfect adherence at every visit. Although patients with and without perfect adherence gained weight, patients with less than perfect adherence gained 1.04 kg less weight than those reporting perfect adherence (P = 0.059). CD4 cell counts increased by a mean of 109 cells/microl during the first 6 weeks of therapy and increased more slowly thereafter, resulting in overall CD4 cell count increases of 160, 225 and 297 cells/microl at 12, 24, and 36 months respectively. At 1 year, a mean increase of 170 cells/microl was seen among patients reporting perfect adherence compared with 123 cells/microl among those reporting some missed doses (P < 0.001). Antiretroviral treatment of adult Kenyans in this cohort resulted in significant and persistent clinical and immunological benefit. These findings document the viability and effectiveness of large-scale HIV treatment initiatives in resource-limited settings.
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            Author and article information

            Affiliations
            [1 ] Mzuzu Central Hospital Malawi
            [2 ] Pingtung Christian Hospital Peoples R China
            [3 ] Ministry of Health Jamaica
            Contributors
            Role: ND
            Role: ND
            Role: ND
            Role: ND
            Role: ND
            Role: ND
            Role: ND
            Journal
            bwho
            Bulletin of the World Health Organization
            Bull World Health Organ
            World Health Organization (Genebra )
            0042-9686
            July 2007
            : 85
            : 7
            : 550-554
            S0042-96862007000700013

            http://creativecommons.org/licenses/by/4.0/

            Product
            Product Information: SciELO Public Health
            Categories
            Health Policy & Services

            Public health

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