Does Most Mortality in Patients on ART Occur in Care or After Lost to Follow-Up? Evidence From the Themba Lethu Clinic, South Africa

In resource-limited settings, early mortality on antiretroviral therapy (ART) is approximately 10%; yet, it is unclear how much of that mortality occurs in care or after lost to follow-up. We assessed mortality rates and predictors of death among 12,222 nonpregnant ART-naive adults initiating first-line ART between April 2004 and May 2012 in South Africa, stratified by person-years in care and lost. We found 14.6% of patients died and being lost accounted for a minority of deaths across multiple definitions of loss (population attributable-risk percent ranged from 10.4% to 42.5%). Although mortality rates in patients lost were much higher than in care, most ART-related mortality occurred on treatment…

Our findings confirm that although MRs in patients lost are much higher than in care, most ART-related mortality occurs while patients are still in care. The high early mortality observed suggests that death is more likely to lead to loss from care than the reverse, yet what happens in the short window around loss remains unknown. It is possible that critically ill patients, sensing that death is near, simply leave care to return home or are unable to make it to the clinic. Interviews with family or other reliable informants close to the patient could help shed light on this issue.

As may be expected, using longer definitions of loss results in a greater proportion of deaths being classified as deaths in care, resulting in a decreasing hazard of death among patients lost. With loss defined as ≥3 months late for a scheduled visit, we found nearly 19% of patients lost died, less than half of the combined mortality reported in a systematic review,31 suggesting patients classified as lost in our cohort may be more likely to transfer into care at other clinics or are healthier when leaving care. However, without a universal definition for classifying patients as LTF, it is difficult to compare programs performance, including rates of loss and subsequent mortality, between facilities or cohorts. Efforts to standardize definitions of lost have found that defining loss as ≥180 days because the last clinic encounter minimizes the misclassification of loss,23 although this definition may not be ideal for patient management or the guiding of tracing activities. Our analysis shows relatively stable estimates of loss and subsequent MRs when the definition of loss is varied between 2 and 6 months late for a scheduled visit. To improve patient management and recall efforts, it may therefore be preferable to use a shorter definition of loss such as ≥2 months late for a scheduled visit, although other authors have stressed the importance of choosing a definition based on outcomes of interest, available visit data, and visit schedules...25

Full article at:   http://goo.gl/ex07De

By:  Eric P. Budgell, MSc,* Mhairi Maskew, PhD, MBBCh,* Lawrence Long, MCom,* Ian Sanne, MBBCh, FCP (SA), FRCP (Lon), DTM&H,*† and Matthew P. Fox, DSc, MPH*‡§

^*Health Economics and Epidemiology Research Office (HE²RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;

^†Right to Care, Johannesburg, South Africa;

^‡Center for Global Health & Development, Boston University, Boston, MA; and

^§Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, MA.

Corresponding author.

Correspondence to: Eric P. Budgell, MSc, Health Economics and Epidemiology Research Office (HE²RO), University of the Witwatersrand, Unit 2, 39 Empire Road, Parktown, Johannesburg 2193, South Africa (e-mail: gro.azoreh@llegdube).

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