Retention in Care and Patient-Reported Reasons for Undocumented Transfer or Stopping Care Among HIV-Infected Patients on Antiretroviral Therapy in Eastern Africa: Application of a Sampling-Based Approach
Retention in Care and Patient-Reported Reasons for Undocumented Transfer or Stopping Care Among HIV-Infected Patients on Antiretroviral Therapy in Eastern Africa: Application of a Sampling-Based Approach
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DOI：
10.1093/cid/civ1004
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发表时间：
2016-04-01
影响因子：
11.8
通讯作者：
Martin, Jeffrey
中科院分区：
文献类型：
--
作者：
Geng, Elvin H.;Odeny, Thomas A.;Martin, Jeffrey
背景改善全球应对人类免疫缺陷病毒的实施需要了解开始抗逆转录病毒治疗（ART）后的保留，但后续损失破坏了对停止治疗的程度和原因的评估。我们在乌干达、坦桑尼亚和肯尼亚的14家诊所评估了开始ART超过2.5年的成年人。我们追踪了失访患者的随机样本，并将更新的信息纳入保留的加权竞争风险估计中。未返回的原因进行了调查。在18081例患者中，3150例（18%）失访，579例（18%）追踪。在497例（86%）确定生命状态的患者中，340例（69%）存活，278例（82%）获得了最新护理状态。在所有开始抗逆转录病毒治疗的患者中，结合追踪结果的加权估计发现，抗逆转录病毒治疗后2年，69%在其原始诊所接受治疗，14%转移（4%官方和10%非官方），6%活着但不接受治疗，6%在治疗中死亡（末次访视后< 60天），6%在治疗中死亡（末次访视后>= 60天）。在其他地方的护理中发现的流失患者中，结构性障碍（例如，交通）最普遍（65%），其次是基于诊所的（例如，等待时间）（33%）和心理社会（例如，耻辱）（27%）。在未在其他地方接受治疗的患者中，心理社会障碍最普遍（76%），其次是结构性障碍（51%）和临床障碍（15%）。在失访者中对结局进行核算，可获得更翔实的保留评估。结构性障碍是造成无声转移的主要原因，而心理和社会障碍往往导致长期护理中断。
Background. Improving the implementation of the global response to human immunodeficiency virus requires understanding retention after starting antiretroviral therapy (ART), but loss to follow-up undermines assessment of the magnitude of and reasons for stopping care.Methods. We evaluated adults starting ART over 2.5 years in 14 clinics in Uganda, Tanzania, and Kenya. We traced a random sample of patients lost to follow-up and incorporated updated information in weighted competing risks estimates of retention. Reasons for nonreturn were surveyed.Results. Among 18 081 patients, 3150 (18%) were lost to follow-up and 579 (18%) were traced. Of 497 (86%) with ascertained vital status, 340 (69%) were alive and, in 278 (82%) cases, updated care status was obtained. Among all patients initiating ART, weighted estimates incorporating tracing outcomes found that 2 years after ART, 69% were in care at their original clinic, 14% transferred (4% official and 10% unofficial), 6% were alive but out of care, 6% died in care (< 60 days after last visit), and 6% died out of care (>= 60 days after last visit). Among lost patients found in care elsewhere, structural barriers (eg, transportation) were most prevalent (65%), followed by clinic-based (eg, waiting times) (33%) and psychosocial (eg, stigma) (27%). Among patients not in care elsewhere, psychosocial barriers were most prevalent (76%), followed by structural (51%) and clinic based (15%).Conclusions. Accounting for outcomes among those lost to follow-up yields a more informative assessment of retention. Structural barriers contribute most to silent transfers, whereas psychological and social barriers tend to result in longer-term care discontinuation.