Cost-effective ways to reduce loss to follow-up in ART programmes identified

Measures to reduce loss to follow-up in antiretroviral treatment programmes such as abolishing user fees, paying transportation costs, providing meals and improving staff training would be cost-effective even if they prevented less than half of patients from failing to return to the clinic, according to projections based on data from Côte d’Ivoire.

The study, published in the October edition of PLoS Medicine, was designed to examine the cost-effectiveness of various measures to improve patient retention in care.

Loss to follow-up is a serious problem in treatment programmes in low and middle-income countries. Patients who are lost to follow-up are often sicker, and without regular medical attention and antiretroviral treatment may either die or return to hospital with serious illnesses or drug resistance due to interrupted treatment.

These outcomes result in increased costs for the health system and an increased burden for affected families.

Using data from the Aconda programme, an Abidjan-based organisation providing antiretroviral therapy to around 6,700 patients, researchers from nine institutions in the US, France and Côte d’Ivoire modelled the effects of several different interventions designed to reduce loss to follow-up on life expectancy and cost-effectiveness.

The interventions analysed were chosen with a view to addressing some of the key factors repeatedly associated with loss to follow-up in studies in sub-Saharan Africa: user fees for HIV care; the cost of transport to the clinic; need to obtain food instead of attending the clinic, and lack of staff follow-up of defaulters.

Detailed description of the methodology and results is available in an open-access paper.

Assuming that 18% of patients were lost to follow-up within one year of initiating treatment, and did not return until they developed an opportunistic infection, they found that the life expectancy of patients lost to follow-up during the first year of treatment would be halved. If they never returned to care they would be dead within two and half years.

Based on the GDP per capita of Côte d’Ivoire, strategies to reduce loss to follow-up would be cost-effective if they cost less than $2832 per year of life saved.

Stopping co-payments for antiretroviral therapy would be cost-effective at a cost of $22 per person per year if it reduced the rate of loss to follow-up by 12% (i.e. from 18% to 16%).

Using a combination of methods for preventing loss to follow-up would be cost-effective at a cost of $77 if they reduced loss to follow-up by 40% (i.e. from 18% to 10.8%). In the Aconda programme loss to follow-up was reduced by 40% through a single intervention, phoning or visiting patients who missed clinic appointments. This intervention cost between $22 and $53 per patient per year.

The study has a number of limitations, the authors note. It may not be possible to generalise the findings beyond Côte d’Ivoire, or beyond clinics with specialist skills in patient management. The study also lacks firm evidence on the extent to which various interventions reduce loss to follow-up; the researchers were forced to extrapolate from various studies.

Further operational research on easily replicable methods of reducing loss to follow-up is needed, but the findings of the study will strengthen the case for abolishing user fees. Although the World Health Organization recommended the removal of user fees for HIV care in 2005, fees for services such as tests and consultations remain in place in many countries.

However, removing financial barriers is only one aspect of reducing loss to follow-up. Professor Anthony Harries, who has advised the Malawi government on its HIV and TB programmes, told the 2009 HIV Implementers' conference that reducing loss to follow-up requires a wide range of interventions, including improved record-keeping, reliable drug supplies, decentralisation of care and creative approaches to maintaining adherence.

In a

">related Perspective article in PLoS Medicine

, Gregory Bisson of the University of Pennsylvania School of Medicine and Jeffrey Stringer (of the University of Alabama School of Medicine), both uninvolved with the research, agree that improving retention in HIV/AIDS care makes programmatic and economic sense. They stress that "the major AIDS donors, such as the US President's Emergency Plan For AIDS Relief (PEPFAR) and the Global Fund, should be keenly interested in this issue, and willing to invest in strategies to improve retention.''

Further information

See HIV & AIDS Treatment in Practice 90, August 2007 for an extended review of strategies to address loss to follow-up, A follow up on follow up: switching to a community-based response to improve retention in care.