Loss to follow-up among women in Option B+ PMTCT programme in Lilongwe, Malawi: Understanding...
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Transcript of Loss to follow-up among women in Option B+ PMTCT programme in Lilongwe, Malawi: Understanding...
Loss to follow-up among women in Option B+ PMTCT
programme in Lilongwe, Malawi:
Understanding outcomes and reasons
Hannock Tweya, Salem Gugsa, Mina Hosseinipour, Colin Speight,
Wingston Ng’ambi, Mphatso Bokosi, Janet Chikonda, Annie Chauma,
Veena Sampathkumar, Tiwonge Mtande, Sam Phiri
Option B+ PMTCT strategy in Malawi• Use of antiretroviral therapy in HIV-infected women
significantly reduces vertical transmission; from 25% to
2%
• In 2011, Malawi embarked on a novel PMTCT
programme known as “Option B+”– Lifelong ART for pregnant and breastfeeding women
regardless of WHO clinical stage or CD4 count
– NVP syrup for 6 weeks for infants
• Option B+ resulted in a 7-fold increase in the number of
women starting ART for PMTCT between the 2nd quarter
of 2011 and 3rd quarter 2012
Loss to follow-up in Option B+ PMTCT• Loss to follow-up (LTFU) from care is a considerable
barrier to the effectiveness of PMTCT
– 27% are LTFU at 12 month nationally (Malawi HIV Report Dec
2013)
– 24% are LTFU in the first 6 months in facilities with high
patient volume (Tenthani et al AIDS 2013)
• Information on LTFU in women starting lifelong ART for
PMTCT remains limited
Objectives
• To determine factors associated with LTFU among
women starting lifelong ART for PMTCT
• To determine true outcomes of women who are lost to
follow-up from PMTCT care
• To describe reasons for LTFU from Option B+ PMTCT
programme
Methods: Study design & Setting
• We conducted a retrospective cohort study using data from
– A real-time, touch screen-based, electronic Medical Records
(EMR)
– A patient tracing programme
• Bwaila Hospital, Lilongwe
– Has the busiest ANC and Maternity wings with over 14,000
ANC registrations annually
– Provision of PMTCT services is a collaborative effort, led by
the Lilongwe District Health Office and other partners
– Starts ~110 women on ART monthly based on Option B+
criteria
Methods: PMTCT services• All pregnant women with unknown HIV status undergo
– A group HIV counselling session
– ‘Opt-out’ provider-initiated HIV testing
• “Expert mothers” provide psychosocial and adherence support to HIV-infected women on initial and follow-up visits
• All HIV-infected women are registered in the EMR System and started on a lifelong ART on the day of HIV diagnosis
• At each visit, number of remaining ARV pills and new supply are recorded and next appointment is electronically calculated
Methods: Tracing programme• The patient tracing programme intends to decrease
treatment interruption and prevent LTFU
• Tracing staff generate a list of women that miss an
appointment by at least three weeks
• The staff confirms the list by checking in patients files
• Women who consent are traced up to three times by
phone call or home visit
• The staff complete standard paper forms on tracing
efforts, outcomes and reasons for missing
appointment
Methods: Analysis• Tracing outcomes include:
– Dead, uninterrupted therapy, treatment interruptions,
self transfer out, stopped ART, never started ART and
not traced
• For the purpose of the tracing programme, LTFU was
defined as missing a scheduled clinic appointment for
at least 3 weeks.
• Multivariable Poisson regression was used investigate
factors associated with LTFU
Results: Patients details & LTFU• Between September 2011 and September 2013, 2930 HIV-
infected women started ART for PMTCT Option B+:
– 2,458 (84%) were pregnant
• Median age at ART initiation was 26 years (IQR 22-30)
• Median follow-up of 8.2 months (IQR 3.1-16.7)
• Of 2,930 women, 577 (20%) missed a scheduled clinic
appointment for at least 3 weeks
– 272 only collected ARV’s at the time of initiation and did not
return
• Overall incidence of LTFU was 23.5 % per year
• In terms of retention: 85% at 3 months, 82% at 6 months
79% at 12 months
Results: Factors associated with LTFU
Characteristics Adjusted Rate
Ratios (95% CI) P-Value
Age at ART initiation (years) <0.001
13 - 24 1.29 (1.09 – .52)
25+ 1.00
Reason for ART initiation <0.001
Breastfeeding 0.63 (0.49-0.89)
Pregnant 1.00
Employment Status 0.177
Yes 0.87 (0.71-1.07)
No 1.00
Year of B+ Implementation <0.001
2011 1.25 (1.06-1.49)
2012 1.00
2013 0.41 (0.29-0.58
Results: Tracing Outcomes 577 LTFU women
228 (40%) Successfully Traced
349 (60%) Not traced / Not found
*No significant differences between those traced or not
Results: Tracing Outcomes 577 LTFU women
228 (40%) Successfully Traced
349 (60%) Not traced / Not found
67 (30%) Self Transfer
152 (66%) Alive not TO
9 (4%)Died
Results: Tracing Outcomes 577 LTFU women
228 (40%) Successfully Traced
349 (60%) Not traced / Not found
9 (4%) Died
67 (30%) Self Transfer
152 (66%) Alive not TO
9 (6%) ART interruption
7 (5%) Not started ART
5 (3%) Refused interview
Stopped ART118 (77%)
On ART Uninterrupted13 (9%)
Results: Reasons for ART discontinuations (N=111)
Reasons for ART discontinuation n
%
Travelled away 42 38%
Transport costs 17 16%
Limited information about ARVs 11 10%
Suspected side effects of ARVs 11 10%
Very weak/sick 11 10%
Non-disclosure of HIV status to the spouse 9 8%
Religious belief 5 5%
Forgotten to take ARVs 5 5%
Other reasons 49 44%
Discussion • Overall LTFU was 23.5% per year
– Higher than that reported in the general HIV-infected individuals
accessing ART for personal health ( 9.3% per year)
• 47% of women who were lost to follow-up received ARVs
once and never returned for their appointment– May suggest that a proportion of these women never started
ART
• Being older ( 25+ years) associated with reduced risk of
LTFU– May have settled lifestyles which allow them to better manage ARVs
• Likelihood of LTFU decreased with increasing year of
programme implementation between 2011 and 2013 Likely due to the stabilization of the programme
Discussion • A sizeable proportion of women could not be traced due
to incorrect addresses documented in the patient clinic
files.
– False physical addresses because of fear of stigma and
discrimination
• Among LTFU women that were traced:
– Half had stopped ART, leaving their infants at high risk of
HIV
– A third self-transferred to another clinic, suggesting
underestimation of national retention in PMTCT programme
Recommendations• ANC/ART clinics should further enhance post-test
counseling by engaging HIV testing counselors and
expert mothers for ongoing counseling and
psychosocial support.
• Establishing targeted programmes for young women
• ART clinics need to establish data linkages through
which information of patients that transfer can be
shared.
• Further decentralization of PMTCT services with good
ANC/Maternity services
AcknowledgmentsMother2Mother
Baobab Health Trust