Men are at much higher risk of becoming lost from HIV care programmes according to an analysis of clients attending USAID-AMPATH partnership’s HIV clinics in Western Kenya. This study, which also identified reasons why both men and women may be at risk of loss to follow-up (LTFU), was presented on Tuesday at the XVII International AIDS Conference in Mexico City.
“Outreach and retention strategies specifically designed for men may improve their ability to remain in care,” said Dr Vincent Ochieng Ooko. “However, as much as we say that men are at a higher risk of LTFU, women also bear the burden of becoming lost to follow-up. Strategies for enabling women to remain in care should also be explored and strengthened.”
Understanding losses to follow-up
Losses to follow-up are a major challenge to the successful delivery of HIV care and antiretroviral therapy, with up to 44% of patients dropping out of care at some sites.
“High rates of LFTU have been widely cited as a cause for concern that ART programmes are failing, and this was picked up by an article in the Financial Times (July 31) last week,” said Dr Nathan Ford of Médecins Sans Frontières (MSF), in a talk introducing the symposium at the conference. He noted that as the MSF programme has matured in Khayelitsha, loss to follow-up has been increasing. A number of reasons have been identified such as fear of disclosure, treatment costs, alternative medicines, social problems, and treatment fatigue, healthcare worker discrimination, poor side-effect management, poor understanding of treatment.
“These are things that the programme could do something about if they know what they are,” said Ford. “And there are issues of access, with large centralised hospital-based programmes having much higher rates of attrition than small peripheral clinics, so while the word defaulter tends to locate the problem at the level of the patient, the actual model of delivery could be the most significant factor in retention to care.”
A number of other programmes have also reported that men with HIV often present late for care and start antiretroviral therapy with lower CD4 cell counts and more advanced HIV disease leading to poorer outcomes.
Loss to follow-up has also been an issue at the USAID-AMPATH partnership. The Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH) was launched in 2001 as a partnership between Moi University in Kenya and Indiana University and began receiving USAID (PEPFAR) support in 2004. AMPATH has enrolled over 70,000 patients at 18 urban and rural clinic sites throughout western Kenya, but currently has around 55,000 active clients. Anecdotally, the partnership had noticed that men were more likely to drop out.
“We need to improve the understanding of LTFU issues in order to design interventions to improve clinic retention and subsequent clinical outcomes,” said Dr Ochieng Ooko who works with the USAID-AMPATH partnership in Eldoret, Kenya.
So to calculate the number of people lost to follow-up from their HIV clinics — and to determine whether men were indeed more likely to become lost to follow-up after adjusting for other factors, Dr Ochieng Ooko and colleagues reviewed data from all individuals aged 14 or over, enrolled between November 2001 and November 2007, who had at least one follow-up visit.
Loss to follow-up was defined as being absent from clinic appointments for more than three months for people on antiretroviral treatment and for more than six months if not yet on treatment. However, it is important to note that AMPATH has an aggressive peer-based outreach programme to follow-up on its patients. Whenever a scheduled appointment is missed, the peer outreach workers try to contact the patient by phone and since May 2005, by making home visits. In July 2006, they also initiated a programme to prioritise patients to provide more intensive follow-up. Loss to follow-up is defined only after all these outreach attempts fail.
The incidence of loss to follow-up was calculated using Kaplan-Meier methods, and Cox regression was used to model socio-demographic and clinical characteristics associated with loss to follow-up.
Results
There were 50,275 clients included in the six-year analysis; 69% were female and the median age was 36. 15,752 (31%) of people became lost to follow-up. From enrolment, there were 13,243 events (deaths or loss to follow-up) in 51,609 person years, for an incidence rate of 25.7 per 100 person years. The rate was higher in men 30.5 (23.1-24.2) than in women, 23.7 (23.1-24.2). From the point of starting of antiretroviral treatment, there were 5701 events in 31,383 person years with an incidence rate of 18.2 per 100 py. Again, men had a higher loss to follow-up rate (21.2 in men, 16.8 in women).
At enrolment, men were older, more likely to be attending an urban clinic, to have disclosed their HIV status, to have lower CD4 counts and advanced HIV disease (WHO Stage III/IV). There was no significant difference between how far they were from the clinic, previous antiretroviral treatment or the year of enrolment.
Reasons for missed visits
| Men n=1037 | Women N=2117 | |
| Deceased | 10% | 5% |
| Family commitments | 12% | 21% |
| Work commitments | 24% | 11% |
| Transport costs | 12% | 17% |
| Forgot appointment | 5% | 6% |
| Transferred clinic | 1% | 1% |
| Health issues | 6% | 8% |
| Didn’t miss appointment | 6% | 6% |
| Patient refusal | 1% | 2% |
| Other non-coded | 22% | 22% |
In the multivariate analysis, distance from clinic, disclosure, CD4 count and clinical stage at enrolment, and clinic location, men were still more likely versus women to be lost to follow-up from point of enrolment (adjusted hazard ratio of 1.25 (95% CI 1.19-1.31)) or from initiation of antiretroviral treatment (adjusted hazard ratio of 1.33 (CI 1.24-1.42).
“So men are at a higher risk for becoming LFTU even after adjusting for social factors and this finding is consistent from enrolment and from ART initiation,” said Dr Ochieng Ooko.
Strategies for retention
However, he listed several strategies that might lead to better retention for men and women.
For men who work during clinic hours, weekend, evening or early morning clinics might help. In addition, he recommended more intensive adherence counselling and support, as well as efforts to get men in for HIV testing and care earlier.
For women, setting up joint clinics for mothers and their children, having more flexible clinic schedules and transport defrayments.
And at least one the AMPATH sites (a hospital in the northern part of Kenya which is very rural and the community is semi-nomadic) has been dealing with people lost to follow-up by sending mobile clinics to visit the smaller peripheral rural clinics surrounding it.