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Loss to Follow-Up Worsens Outcomes for HIV Patients, Even If They Return to Care

Summary and Comment |
August 3, 2009

Loss to Follow-Up Worsens Outcomes for HIV Patients, Even If They Return to Care

  1. Rochelle P. Walensky, MD, MPH

Mortality risk was five times higher among HIV patients in northern France who returned to care after being lost to follow-up than among those who were never lost.

  1. Rochelle P. Walensky, MD, MPH

Despite the challenges of studying outcomes among patients who are lost to follow-up, researchers at five HIV clinical centers in northern France have managed to do just that.

Of 1007 HIV-infected patients followed from 1997 through 2006, 135 (13%) were lost to follow-up, defined as not showing up for care for at least 1 year. Seventy-four of the 135 (55%) returned to care after having been lost for a median of 19 months after their last appointment, and 61 (45%) never returned. Compared with patients who were never lost, those who returned to care were significantly younger, were significantly more likely to be intravenous drug users, and had a significantly higher median CD4 count at enrollment (369 cells/mm3 vs. 334 cells/mm3).

Among the 74 patients who returned to care, the median CD4 count dropped significantly from the last measurement before their loss to follow-up to the first measurement after their return (from 401 cells/mm3 to 305 cells/mm3), and the percentage with AIDS-defining events increased significantly during that period (from 11% to 27%). After adjustment for CD4-cell count and AIDS-defining events at enrollment, mortality risk during follow-up was 5.14 times higher among the patients who returned to care than among those who were never lost.

Comment

Because HIV-infected patients are so challenging to find and reengage after they are lost, few studies report their clinical outcomes. These data show a much higher risk for death among patients who are lost and return to care than among those who remain in care. It is reasonable to assume that the patients who never returned to care fared even worse. Studies like this one are critical for assessing the magnitude of the problem of loss to follow-up and for starting to identify the best ways to prevent it.

Dr. Walensky is Associate Director of the Program in Epidemiology and Outcomes Research at the Center for AIDS Research at Harvard Medical School. She is also an infectious disease specialist at Massachusetts General Hospital and Brigham and Women's Hospital.

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Reader Comments (1)

Kafilat Oyefunke Oloyede

Indeed patients who never returned to care fared worse.I have worked on different HIV Care and Treatment projects and one of the major challenges we've always had is the hydra-headed problem of "lost to followup". Some of these clients after starting treatment will stop mid- way because 1.) they had received miracle healing after a religious leader prayed for them 2.) there is a religious program lasting several weeks that will prevent meeting hospital appointments 3.) some cultural beliefs that forbade the use of the drugs but favoured appeasement of some spiritual forces behind thier sickness.

The next thing we often heard of these clients was the news of their death. Some would be brought to the hospitals when their case had become really worsened and very little could be done to save them.

Counsellors and treatment support teams are trying to devise different methods to help clients remain in care.

Competing interests: None declared

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