True Outcomes for Patients on Antiretroviral Therapy Who Are "Lost to Follow-Up" in Malawi/Veritables Issues Du Traitement Antiretroviral Pour Les Patients Consideres Comme « Perdus De Vue » Au Malawi/Evolucion Real De Los Pacientes Sometidos a Terapia Antirretroviral Y Perdidos En El Seguimiento En Malawi

Introduction Many resource-poor countries with HIV epidemics are scaling up antiretroviral therapy (ART). By December 2005, an estimated 1.3 million people from low-and middle-income countries had been placed on treatment; 810 000 of these were in sub-Saharan Africa. (1) Treatment outcomes reported from various clinics in sub-Saharan Africa, Haiti, Asia and South America have been good, comparable with those observed in countries with higher incomes. (2-7) Patient outcomes are usually categorized as patients alive and on treatment, stopped treatment, transferred to another facility, dead or "lost to follow-up". Depending on the facility, patients are classified as lost to follow-up if they have missed two or more consecutive clinic appointments (2) or have not been seen for at least 2 or 3 months. (4-6) The proportion of patients lost to follow-up differs between clinics, ranging from 5% in programmes supported by Medecins Sans Frontieres (5) to 25% in western Kenya. (4) In 18 ART-delivery programmes in Africa, Asia and South America, 15% of 4810 patients were lost to follow-up in the first year of ART, with the average being 12% in programmes with active follow-up and 19% in those with no active follow-up. (7) To our knowledge, there ate no published data from resource-poor countries on the true outcome status of these patients. Malawi--a small resource-poor country in southern Africa--has been engaged in ART scale-up for nearly 3 years. By 31 March 2006, 46 702 patients had ever started receiving ART in 66 facilities in the public sector; of these, 33 891 (73%) were registered as alive, 5131 (11%) were dead, 4226 (9%) were lost to follow-up, 3140 (7%) had transferred to another facility and 314 (1%) had stopped therapy. (8) We hypothesized that many patients lost to follow-up may have died, and therefore conducted a study in northern Malawi to investigate this problem. Methods Details on the delivery and monitoring of ART in Malawi have been described previously. (9) When patients start ART, their details are entered on master cards and an ART register. Patients attend the ART clinic each month, at which time their outcome status is entered on the master card and they are given another month's supply of ART drugs. if a patient is not seen in the clinic for three consecutive months, the patient is registered as a "defaulter" (an abbreviated term for "lost to follow-up") on the master card and also on the register. Four public-sector ART facilities in the northern region of Malawi were selected for the study. These included one central hospital and three peripheral hospitals (two district hospitals and one mission hospital). Provision of free ART was initiated at the central and mission hospitals in July 2004, and at the two district hospitals in January and June 2005 respectively. For the period between the date when each facility started to provide free ART and 31 March 2006, we identified all patients indicated on the master cards and registers as a defaulter. Using contact details, ART facility staff visited the patients' homes to try to ascertain their true outcome status. If patients were traced to the home, they were asked whether they were still taking ART and if not, why they had stopped. If the patient had died, the relatives were asked when the patient had died. If the patient had moved away, relatives or friends were asked when they had moved. Ethical approval for the study was granted by the Malawi National Health Sciences Research Committee. Informed consent was obtained from patients being interviewed, and staff took care not to disclose that the patient was receiving ART when interviewing relatives or friends in the event of the patient's death or transfer. Data were collected, on Structured forms, and analysis was carried out using Epi Info version 6.0. Patients from the central and the peripheral hospitals were compared: the [chi square] test with relative risks (RR) and 95% confidence intervals (CI) were used for characteristics and outcomes, and the student's t-test was used for time periods between start of ART, default and patient tracing, with differences at the level Of 0. …