As ART scales up, retention and loss to follow up raise as challenges to health care services. Factors related to drop-off, either voluntary or not, should be identified in each service, to ensure adherence to treatment and better outcomes to patients starting HAART in developing countries.

TUAB0202 - Gender and loss-to follow-up (LTFU) from a large HIV treatment program in Western Kenya - V. Ochieng, D. Ochieng, J. Sidle, M. Holdsworth, A. Siika, C. Yiannoutsos, W. Nyandiko, M. Owiti, S. Kimaiyo, P. Braitstein

This Kenyan study looked at loss to follow-up in over 46 000 patients.  “The incidence of men becoming LTFU was 30.3/100 person-years vs. 23.6/100 PY among women, representing a 29% increased risk for men (p<0.001).”  This held, even after adjustment for CD4, clinical state, disclosure, and distance from the clinic.  Male-focused interventions – such as evening and weekend clinics – were suggested as a way forward. Decentralised care was also suggested as a mechanism to facilitate retention.

TUAB0203 - Evaluating the flow of adults in public HIV care systems in Mozambique: identifying obstacles to care - M.A. Micek, A.J. Baptista, F. Josefo, M. Armando, K. Gimbel-Sherr, S. Gimbel-Sherr, M. Eduardo, J. Wendy, P. Montoya, J. Pfeiffer, S. Gloyd

Measured drop-offs were measured from the system at each level of care, using two major Mozambique clinics, both state run.  5 care steps identified – HIV testing, arrival at ART clinic, CD4 staging, starting ART, and finally chronic ART adherence.  There were significant differences in each step between the sites, except in adherence, which was excellent in both sites.  Overall, there were large fall-offs at each step, especially from HIV diagnosis to CD4 staging, with 44% lost to followup; this was far higher among those identified from the PMTCT programme.  The most influential step in improving number on treatment was isolated as ART initiation.  Multifactorial reasons were identified.  Decentralised and focused strategies addressing each step were proposed as improving these outcomes.  The lack of access to care for pregnant women was highlighted both from the speaker and from the audience.

TUAB0204 - Early survival and clinic retention among high risk HIV-infected patients initiating combination antiretroviral treatment (cART) in a pilot express care system compared to routine care in Western Kenya - P. Braitstein, A. Siika, R. Kosgei, E. Sang, J. Sidle, K. Wools-Kaloustian, C. Yiannoutsos, W. Tierney, J. Mamlin, S. Kimaiyo

Retrospective observational study.  This study evaluated accelerated access to care for high risk patients (CD4<100) while capacitating the clinic.  Patient sees clinical officer, but constant nursing contact (including telephonic).  14.6% of the total (2594)group was enrolled for express care.  The probability of staying alive was higher than in routine care.  Selection bias was controlled for, and the results remained the same. Death risk reduced by 50% if in express care ((0.37-0.77, p=0.001) after controlling for CD4, clinic location and gender.  Express care clearly helps, but unclear if due to better care, or better training of staff. However, clearly a nurse driven active care intervention has a large impact on death rates. 

TUAB0205 - HIV-positive patient retention in the UK: high rate of loss to clinical follow-up among patients from a London clinic - S. Gerver, T. Chadborn, F. Ibrahim, S. Ribeiro, B. Vatsa, V. Delpeche, P. Easterbrook

Loss to follow up from 1995 till 2005, defined as adults LTFU>1 year (after a single visit or more), with an intensive followup of several national and regional databases.  2070 patients were identified as LTFYU; 404 were traced; 432 were not found anywhere in the UK (18 had died).  Black African and black Caribbean heterosexuals men had the highest risk of LTFU.  Characteristics for those NOT on ART – black African and black Caribbean heterosexual men were predictive.  In those ON ART – black African heterosexual females, CD4<200 and a detectable VL – ie: those failing or not adherent to therapy, predicted LTFU.  Over a quarter of those LTFU had clinical notes suggesting they may soon leave the UK.  It was noted by the presenter that LTFU rates were similar to Rosen et al’s PLOS review of developing countries.

TUAB0206 - Determinants of delayed first consultation after diagnosis of HIV infection in Cameroon: results from the ANRS EVAL 12-116 study - P. Ongolo-Zogo, S. Loubiere, S. Boyer, F. Marcellin, S.-C. Abega, M.P. Carrieri, B. Spire, J.-P. Moatti

Earlier initiation saves lives, but is often delayed in poorer countries. There are over ½ million people with HIV in Cameroon. This cross sectional study identified factors associated with delayed initiation in a random sample of patients.  Patients were recruited from 27 hospitals and interviewed.  52% consulted within 1 month, 30% waited for >3 months, and a further 15% for >6 months before consulting, after diagnosis. Both patients and systemic issues seemed to account for the delays.