Understanding Reasons for and Outcomes of Patients Lost to Follow-Up in Antiretroviral Therapy Programs in Africa Through a Sampling-Based Approach
Elvin GengDavid R. BangsbergNicolas MusinguziNneka EmenyonuMwebesa BwanaConstantin T. YiannoutsosDavid V. GliddenSteven G. DeeksJeffrey N. Martin
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Losses to follow-up after initiation of antiretroviral therapy (ART) are common in Africa and are a considerable obstacle to understanding the effectiveness of nascent treatment programs. We sought to characterize, through a sampling-based approach, reasons for and outcomes of patients who become lost to follow-up.Cohort study.We searched for and interviewed a representative sample of lost patients or close informants in the community to determine reasons for and outcomes among lost patients.Three thousand six hundred twenty-eight HIV-infected adults initiated ART between January 1, 2004 and September 30, 2007 in Mbarara, Uganda. Eight hundred twenty-nine became lost to follow-up (cumulative incidence at 1, 2, and 3 years of 16%, 30%, and 39%). We sought a representative sample of 128 lost patients in the community and ascertained vital status in 111 (87%). Top reasons for loss included lack of transportation or money and work/child care responsibilities. Among the 111 lost patients who had their vital status ascertained through tracking, 32 deaths occurred (cumulative 1-year incidence 36%); mortality was highest shortly after the last clinic visit. Lower pre-ART CD4 T-cell count, older age, low blood pressure, and a central nervous system syndrome at the last clinic visit predicted deaths. Of patients directly interviewed, 83% were in care at another clinic and 71% were still using ART.Sociostructural factors are the primary reasons for loss to follow-up. Outcomes among the lost are heterogeneous: both deaths and transfers to other clinics were common. Tracking a sample of lost patients is an efficient means for programs to understand site-specific reasons for and outcomes among patients lost to follow-up.Keywords:
Cumulative incidence
Lost to follow-up
The standard method of analysing structural valve degeneration (SVD) of biological prostheses is the Kaplan-Meier method. In order to assess SVD with regard to competing risks (e.g. death particularly in elderly patients) cumulative incidence (actual analysis) was compared to Kaplan-Meier (actuarial analysis).We retrospectively analysed 257 patients older than 60 years, who underwent mitral valve replacement with different biological prostheses between 1974 and 2000. Reoperation-free survival was determined, both according to Kaplan-Meier and cumulative incidence analysis.For the total group of patients older than 60 years, the 10- and 15-year freedom from reoperation was 79+/-5 and 55+/-8%, respectively, according to Kaplan-Meier and 90+/-2 and 83+/-3% according to cumulative incidence analysis. For patients older than 65 years of age (n=170), Kaplan-Meier analysis revealed 85+/-7% freedom from reoperation at 10 years vs. 94+/-3% according to cumulative incidence analysis. For those between 60 and 65 years of age (n=87), Kaplan-Meier freedom from reoperation was 76+/-7% at 10 years and 48+/-9% at 15 years vs. 86+/-4 and 75+/-5% according to cumulative incidence analysis.Kaplan-Meier analysis overestimates the 10- and 15-year risk of SVD compared to cumulative incidence analysis, thus underestimating the benefit of biological valve replacement. Cumulative incidence analysis may lead to a more complete evaluation of risk and benefit and thus better patient management.
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Cumulative risk
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ANTIRETROVIRAL AGENTS
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ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Ayeno HD, Imer AA. First-line antiretroviral treatment failure and associated factors in HIV patients following highly active antiretroviral therapy at the Shashemene Referral Hospital, Oromia region, Ethiopia. HIV & AIDS Review. International Journal of HIV-Related Problems. 2020;19(2):125-131. doi:10.5114/hivar.2020.96388. APA Ayeno, H. D., & Imer, A. A. (2020). First-line antiretroviral treatment failure and associated factors in HIV patients following highly active antiretroviral therapy at the Shashemene Referral Hospital, Oromia region, Ethiopia. HIV & AIDS Review. International Journal of HIV-Related Problems, 19(2), 125-131. https://doi.org/10.5114/hivar.2020.96388 Chicago Ayeno, Hunduma D, and Ahmedyasin A Imer. 2020. "First-line antiretroviral treatment failure and associated factors in HIV patients following highly active antiretroviral therapy at the Shashemene Referral Hospital, Oromia region, Ethiopia". HIV & AIDS Review. International Journal of HIV-Related Problems 19 (2): 125-131. doi:10.5114/hivar.2020.96388. Harvard Ayeno, H., and Imer, A. (2020). First-line antiretroviral treatment failure and associated factors in HIV patients following highly active antiretroviral therapy at the Shashemene Referral Hospital, Oromia region, Ethiopia. HIV & AIDS Review. International Journal of HIV-Related Problems, 19(2), pp.125-131. https://doi.org/10.5114/hivar.2020.96388 MLA Ayeno, Hunduma et al. "First-line antiretroviral treatment failure and associated factors in HIV patients following highly active antiretroviral therapy at the Shashemene Referral Hospital, Oromia region, Ethiopia." HIV & AIDS Review. International Journal of HIV-Related Problems, vol. 19, no. 2, 2020, pp. 125-131. doi:10.5114/hivar.2020.96388. Vancouver Ayeno H, Imer A. First-line antiretroviral treatment failure and associated factors in HIV patients following highly active antiretroviral therapy at the Shashemene Referral Hospital, Oromia region, Ethiopia. HIV & AIDS Review. International Journal of HIV-Related Problems. 2020;19(2):125-131. doi:10.5114/hivar.2020.96388.
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Objectives We assessed cumulative incidence rates of and factors associated with re-engagement in HIV care for PLHIV lost to follow-up in Mali. Methods HIV-1-infected individuals lost to follow-up before 31/12/2013, ≥ 18 years old, who started ART from 2006 to 2012 at one of 16 care centres were considered. Loss to follow-up (LTFU) was defined as an interruption of ≥ 6 months during follow-up. The re-engagement in care in PLHIV lost to follow-up before 31/12/2013 was defined as having at least one clinical visit after LTFU. The cumulative incidence rates of re-engagement in care was estimated by Kaplan-Meier and its predictive factors were assessed using Cox models. Socio-demographic characteristics, clinical and immune status, period, region, centre expertise level, and distance from home at the start of ART plus a combined variable of duration of ART until LTFU and 12-month change in CD4 count were assessed. Multiple imputation was used to deal with missing data. Results We included 3,650 PLHIV lost to follow-up before December 2013, starting ART in nine outpatient clinics and seven hospitals (5+2 in Bamako and 4+5 in other regions): 35% male, median (IQR) age 35 (29–43), and duration of ART until LTFU 11 months (5–22). Among these PLHIV, 1,975 (54%) were definitively LTFU and 1,675 (46%) subsequently returned to care. The cumulative incidence rates of re-engagement in care rose from 39.0% at one year to 47.0% at three years after LTFU. Predictors of re-engagement in care were starting ART with WHO stage 1–2 and CD4 counts ≥ 200 cells/μL, being treated for ≥ 12 months with CD4 count gain ≥ 50 cells/μL, or being followed in Bamako. People followed at regional hospitals or outpatient clinics ≥ 5 km away, or being treated for ≥ 12 months with CD4 count gain < 50 cells/μL were less likely to return to care. Conclusions Starting ART with a higher CD4 count, better gain in CD4 count, and being followed either in Bamako or close to home in the regions were associated with re-engagement in care.
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Objective. Spondyloarthritis (SpA) is an extraintestinal manifestation of inflammatory bowel disease with significant clinical effects, although the frequency is uncertain. We assessed the cumulative incidence and clinical spectrum of SpA in patients with Crohn’s disease (CD) in a population-based cohort. Methods. The medical records of a population-based cohort of Olmsted County, Minnesota, residents diagnosed with CD between 1970 and 2004 were reviewed. Patients were followed longitudinally until migration, death, or December 31, 2010. We used the European Spondylarthropathy Study Group, Assessment of Spondyloarthritis international Society (ASAS) criteria and modified New York criteria to identify patients with SpA. The Kaplan-Meier method was used to estimate the cumulative incidence of SpA following diagnosis of CD. Results. The cohort included 311 patients with CD (49.8% females; median age 29.9 yrs, range 8–89). Thirty-two patients developed SpA based on ASAS criteria. The cumulative incidence of SpA after CD diagnosis was 6.7% (95% CI 2.5%–6.7%) at 10 years, 13.9% (95% CI 8.7%–18.8%) at 20 years, and 18.6% (95% CI 11.0%–25.5%) at 30 years. The 10-year cumulative incidence of ankylosing spondylitis was 0, while both the 20-year and 30-year cumulative incidences were 0.5% (95% CI 0–1.6%). Conclusion. We have for the first time defined the actual cumulative incidence of SpA in CD using complete medical record information in a population-based cohort. The cumulative incidence of all forms of SpA increased to approximately 19% by 30 years from diagnosis of CD. Our results emphasize the importance of maintaining a high level of suspicion for SpA when following patients with CD.
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HLA-haploidentical transplantation (haplo-HCT) using post-transplantation-cyclophosphamide (PT-Cy) is a feasible procedure in children with malignancies. However, large studies on Haplo-HCT with PT-Cy for childhood acute lymphoblastic leukemia (ALL) are lacking. We analyzed haplo-HCT outcomes in 180 children with ALL. Median age was 9 years, and median follow-up was 2.7 years. Disease status was CR1 for 24%, CR2 for 45%, CR+3 for 12%, and active disease for 19%. All patients received PT-Cy day +3 and +4. Bone marrow (BM) was the stem cell source in 115 patients (64%). Cumulative incidence of 42-day engraftment was 88.9%. Cumulative incidence of day-100 acute graft-versus-host disease (GVHD) grade II-IV was 28%, and 2-year chronic GVHD was 21.9%. At 2 years, cumulative incidence of nonrelapse mortality (NRM) was 19.6%. Cumulative incidence was 41.9% for relapse and 25% for patients in CR1. Estimated 2-year leukemia free survival was 65%, 44%, and 18.8% for patients transplanted in CR1, CR2, CR3+ and 3% at 1 year for active disease. In multivariable analysis for patients in CR1 and CR2, disease status (CR2 [hazard ratio {HR} = 2.19; P = .04]), age at HCT older than 13 (HR = 2.07; P = .03) and use of peripheral blood stem cell (PBSC) (HR = 1.98; P = .04) were independent factors associated with decreased overall survival. Use of PBSC was also associated with higher NRM (HR = 3.13; P = .04). Haplo-HCT with PT-Cy is an option for children with ALL, namely those transplanted in CR1 and CR2. Age and disease status remain the most important factors for outcomes. BM cells as a graft source is associated with improved survival.
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