Original articles

Loss to follow-up in a community clinic in South Africa - roles of gender, pregnancy, and CD4 count

Bingxia Wang, Elena Losina, Ruth Stark, Alison Munro, Rochelle P Walensky, Marisa Wilke, Des Martin, Zhigang Lu, Kenneth A Freedberg, Robin Wood

Abstract


Background. Faith-based organisations have expanded antiretroviral therapy (ART) in community clinics across South Africa. Loss to follow-up (LTFU), however, limits the potential individual and population treatment benefits and optimal care.
Objective. To identify patient characteristics associated with LTFU 6 months after starting ART in a large community clinic.
Methods. Patients initiating ART between April 2004 and October 2006 in one South African Catholic Bishops’ Conference HIV treatment clinic who had at least one follow-up visit were included and routinely monitored every 6 months after ART initiation. Standardised instruments were used to collect data. Rates of LTFU over time were estimated by the Kaplan-Meier method. The Cox proportional hazard regression examined the impact of age, baseline CD4 count, baseline HIV RNA, gender and pregnancy status on LTFU.
Results. Data from 925 patients (age >14 years, median age 36 years, 70% female, of whom 16% were pregnant) were included: 51 (6%) were lost to follow-up 6 months after ART initiation. Younger age (≤30 years) (hazard ratio (HR) 2.14, 95% confidence interval (CI) 1.05 - 4.38) and pregnancy for women (HR 3.75, 95% CI 1.53 - 9.16) were significantly associated with higher LTFU rates. When stratified by baseline CD4 count, gender and pregnancy status, pregnant women with lower baseline CD4 counts (≤200 cells/µl) had 6.06 times the hazard (95% CI 2.20 - 16.71) of LTFU at 6 months compared with men.
Conclusions. HIV-infected pregnant women initiating ART were significantly more likely to be lost to follow-up in a community clinic in South Africa. Urgent interventions to successfully retain pregnant women in care are needed.

Authors' affiliations

Bingxia Wang, Massachusetts General Hospital; Harvard Medical School

Elena Losina, Harvard Medical School; Brigham and Women's Hospital; Boston University School of Public Health

Ruth Stark, Southern African Catholic Bishops' Conference

Alison Munro, University of Pretoria

Rochelle P Walensky, Massachusetts General Hospital; Harvard Medical School; Brigham and Women's Hospital

Marisa Wilke, Catholic Relief Services South Africa

Des Martin, University of Pretoria

Zhigang Lu, Massachusetts General Hospital

Kenneth A Freedberg, Massachusetts General Hospital; Harvard Medical School

Robin Wood, University of Cape Town

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Keywords

Loss to follow-up; HIV; CD4; pregnancy; South Africa

Cite this article

South African Medical Journal 2011;101(4):253-257.

Article History

Date submitted: 2010-02-15
Date published: 2011-04-04

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