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Matthew Lamb [email protected]&E
Barriers to Retention and
Factors Associated with LTF in HIV Programs
The literature and ICAP
Barriers to retention
Structural• Financial
• Transportation• Competing priorities
Biomedical• Illness• Health
• Clinical issues
Psychosocial• Forgetfulness• Drug abuse• Stigma/disclosure• Available support
systems• Knowledge/beliefs
Questions asked by Geng et al.
1. What happened to patients who were LTF?• vital status• current care and ART status
2. What reasons do patients LTF give for no longer attending clinic?
Study design and sampling frame
3,628 ART patients
77% (2,799) remained in care
23% (829) LTF
15% (128) tracked
13% (17) not found 25% (32) died 62% (79) alive
61% (48) patient interviewed
39% (31) informant interviewed
Questionnaire: reasons for LTF; current care and
ART status
Automatically generated from electronic medical records when patient has not been
seen for 6 monthsOutreach Worker:
Visits location of patient, asks around~ 1 afternoon/patient
Cumulative LTF Incidence:12 mo: 16%24 mo: 30%36 mo: 39%
Reasons for LTF among 48 patients directly interviewed
Patient characteristics associated with Death among those LTF
32 died (25%) 79 alive
111 tracked and vital status ascertained
Clinical measure at last visit
Hazard Ratio 95% CI
Increasing Age Per 10 yr increase 2.0 (1.1-3.8)
Low blood pressure
< 75 mm HG vs. > 75 mm HG
3.0 (1.2-7.7)
CNS syndrome Yes vs. no 2.9 (1.1-7.4)
Pre-ART CD4 count Per 50 cells/mm3 increase
0.6 (0.4-0.9)
* death rate highest 1-3 mo > last clinic visit
Predictors of Survival in LTF Patients
Study design and sampling frame
3,628 ART patients
77% (2,799) remained in care
23% (829) LTF
15% (128) tracked
13% (17) not found 25% (32) died 62% (79) alive
61% (48) patient interviewed
39% (31) informant interviewed
83% (40) in care elsewhere in last 3 months71% (34) taking ART in the last month
*self report
Extrapolating to all LTF patients
Patient attends clinic
Recorded survival and
retention
Unknown (LTF)
Recorded transfer
Recorded death
Unrecorded withdrawal
Unrecorded death
Self-reported transfer
~ 50% ~ 25% ~ 25%
Conclusions and points for future discussion
• Structural barriers to retention dominate the given reasons in this study– Are there program characteristics that address enablers
to retention?• Among those LTF later ascertained to be dead, highest
death rate shortly after last clinic visit
• Clinical/demographic factors associated with death among LTF patients suggests areas of potential intervention– How can this inform clinic monitoring of patients at high
risk of death?
• LTF is a mix of undocumented deaths (bad!), unknown (bad!) and transfers (problematic!)
Program characteristics associated with non-retention,
LTF, and death at ICAP sitesPreliminary workMatthew Lamb
Aims
• Are program-level characteristics (e.g., adherence support, outreach) associated with retention, LTF, or death at ICAP-supported sites?
• Are the observed associations similar when using aggregate (URS) and patient-level data?
Program characteristics
• Measured from PFaCTS• Only gets at program availability, not quality
or coverage• Reliability study ongoing, results soon!
• Current ICAP ‘retention’ programs focus primarily on psychosocial interventions to improve adherence to ART in addition to retention
Data sources
URS: 349 sites, 10 countries,
233,000 patients
URS: 242 sites, 5 countries,
156,000 patients
PLD: 84 sites, 5 countries, 80,000
patients
Program characteristics: PFaCTS
Study Design
• Aggregate estimates of LTF, Death, and Non-retention (LTF + Death) rates obtained from Track 1.0 indicators reported to URS• Cumulative number on ART – cumulative number LTF or dead• Excluding known transfers
• Patient-level estimates based on person-years since ART initiation until (a) documented death or (b) 6 months with no visit
• Excluding known transfers
• Information combined with PFaCTS to assess association between characteristics targeting adherence and retention and the two measures of LTF rates
Program characteristics associated with LTF: aggregate data
N = 384 sites with PFaCTS and URS care and treatment data through July, 2009 (10 countries)N = 242 sites with PFaCTS in countries providing electronic PLD, to ICAP-NY (5 countries)
N = 84 sites with PFaCTS, electronic PLD, and URS care and treatment data through July, 2009 (5 countries)
Educational materials
>1 directedcounseling
Frequentcounseling
Supportgroups
Peereducators
Remindertools
Food support
Outreach
Through June 2009. Adjusting for urban/rural, facility type, year facility began providing ART care, cumulative number of patients seen in care
LTF
Rat
e R
atio
(95
% C
I)
Preliminary results: focusing on two programmatic services (active patient outreach and food support): 84 sites with patient-level data
Aggregate analysis
1st bar = crude, 2nd bar = adjusted
Patient-level analysis
1st bar = crude, 2nd bar = adjusted for
site-level factors3rd bar = adjusted for
site- and patient-level factors
LTF since ART initiation, by urban/rural:100 ICAP sites with patient-level data
LTF since ART initiation, by facility type:100 ICAP sites with patient-level data
LTF since ART initiation, by year of ART initiation:100 ICAP sites with patient-level data
ICAP analysis: Strengths and limitations
• Routinely-collected data• Aggregate analyses can
use all ICAP care and treatment sites
• Patient-level analyses show that results from aggregate are largely reliable
• Routinely-collected data• PFaCTS doesn’t get at
program quality or coverage
• Potential misclassification in PFaCTS harder to detect true associations
Strengths Limitations
Conclusions
• Routinely-collected data provide evidence that program services may influence patient retention
• Structural barriers may be important (Geng), and one intervention aimed at these barriers (food support) is associated with reduced LTF
• Use of routinely collected data for program evaluation can provide insights for further research
Acknowledgements• ICAP country programs• ICAP M&E Advisors• Ministries of Health, provincial and district-level
programs• Non-governmental organizations and partners• PEPFAR• Doris Duke Charitable Foundation ORACTA program• ICAP M&E NY team• Molly McNairy• Denis Nash