Outcomes of tuberculosis patients who start antiretroviral therapy under routine programme conditions in Malawi

SETTING: Public sector facilities in Malawi providing antiretroviral therapy (ART) to human immunodeficiency virus (HIV) positive patients, including those with tuberculosis (TB). OBJECTIVES: To compare 6-month and 12-month cohort treatment outcomes of HIV-positive TB patients and HIV-positive non-TB patients treated with ART. DESIGN: Retrospective data collection using ART patient master cards and ART patient registers. RESULTS: Between July and September 2005, 7905 patients started ART, 6967 with a non-TB diagnosis and 938 with a diagnosis of active TB. 6-month cohort outcomes of non-TB and TB patients censored on 31 March 2006 showed significantly more TB patients alive and on ART (77%) compared with non-TB patients (71%) (P < 0.001). Between January and March 2005, 4580 patients started ART, 4179 with a non-TB diagnosis and 401 with a diagnosis of active TB. 12-month cohort outcomes of non-TB and TB patients censored on 31 March 2006 showed significantly more TB patients alive and on ART (74%) compared with non-TB patients (66%) (P < 0.001). Other outcomes of default and transfer out were also significantly less frequent in TB compared with non-TB patients. CONCLUSION: HIV-positive TB patients on ART in Malawi have generally good treatment outcomes, and more patients need to access this HIV treatment

Outcomes and associated risk factors of patients traced after being lost to follow-up from antiretroviral treatment in Lilongwe, Malawi

Abstract Background Loss to follow-up is a major challenge of antiretroviral treatment (ART) programs in sub-Saharan Africa. Our objective was to a) determine true outcomes of patients lost to follow-up (LTFU) and b) identify risk factors associated with successful tracing and deaths of patients LTFU from ART in a large public sector clinic in Lilongwe, Malawi. Methods Patients who were more than 2 weeks late according to their last ART supply and who provided a phone number or address in Lilongwe were eligible for tracing. Their outcomes were updated and risk factors for successful tracing and death were examined. Results Of 1800 patients LTFU with consent for tracing, 724 (40%) were eligible and tracing was successful in 534 (74%): 285 (53%) were found to be alive and on ART; 32 (6%) had stopped ART; and 217 (41%) had died. Having a phone contact doubled tracing success (adjusted odds ratio, aOR = 2.1, 95% CI 1.4-3.0) and odds of identifying deaths [aOR = 1.8 (1.2-2.7)] in patients successfully traced. Mortality was higher when ART was fee-based at initiation (aOR = 2.3, 95% CI 1.1-4.7) and declined with follow-up time on ART. Limiting the analysis to patients living in Lilongwe did not change the main findings. Conclusion Ascertainment of contact information is a prerequisite for tracing, which can reveal outcomes of a large proportion of patients LTFU. Having a phone contact number is critical for successful tracing, but further research should focus on understanding whether phone tracing is associated with any differential reporting of mortality or LTFU

Mortality of Patients Lost to Follow-Up in Antiretroviral Treatment Programmes in Resource-Limited Settings: Systematic Review and Meta-Analysis

BACKGROUND: The retention of patients in antiretroviral therapy (ART) programmes is an important issue in resource-limited settings. Loss to follow up can be substantial, but it is unclear what the outcomes are in patients who are lost to programmes. METHODS AND FINDINGS: We searched the PubMed, EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS), Indian Medlars Centre (IndMed) and African Index Medicus (AIM) databases and the abstracts of three conferences for studies that traced patients lost to follow up to ascertain their vital status. Main outcomes were the proportion of patients traced, the proportion found to be alive and the proportion that had died. Where available, we also examined the reasons why some patients could not be traced, why patients found to be alive did not return to the clinic, and the causes of death. We combined mortality data from several studies using random-effects meta-analysis. Seventeen studies were eligible. All were from sub-Saharan Africa, except one study from India, and none were conducted in children. A total of 6420 patients (range 44 to 1343 patients) were included. Patients were traced using telephone calls, home visits and through social networks. Overall the vital status of 4021 patients could be ascertained (63%, range across studies: 45% to 86%); 1602 patients had died. The combined mortality was 40% (95% confidence interval 33%-48%), with substantial heterogeneity between studies (P<0.0001). Mortality in African programmes ranged from 12% to 87% of patients lost to follow-up. Mortality was inversely associated with the rate of loss to follow up in the programme: it declined from around 60% to 20% as the percentage of patients lost to the programme increased from 5% to 50%. Among patients not found, telephone numbers and addresses were frequently incorrect or missing. Common reasons for not returning to the clinic were transfer to another programme, financial problems and improving or deteriorating health. Causes of death were available for 47 deaths: 29 (62%) died of an AIDS defining illness. CONCLUSIONS: In ART programmes in resource-limited settings a substantial minority of adults lost to follow up cannot be traced, and among those traced 20% to 60% had died. Our findings have implications both for patient care and the monitoring and evaluation of programmes

An audit of how patients get on to antiretroviral therapy in Malawi, and the weight gain they experience in the first six months

An operational study was conducted in 6 public sector health facilities in the Southern Region of Malawi to determine a) drop-out rates during the referral process of patients to antiretroviral therapy (ART) and b) weight gained during the first 6 months in patients who were alive and on ART at that time. There were 738 adult HIV-infected eligible patients booked for group counseling, of whom 550 (74.5%) attended individual counseling and started ART. 16% of patients dropped out between booking and group counseling and 9.5% between group counseling and start of ART. In patients who were alive and on ART 6 months after starting, there was a gradual increase in weight with a mean gain of 6.0 kg in men and 5.0 kg in women. There was a slight increase in weight gain in patients in WHO Clinical Stage 3 and 4 compared with those in Stage 1&2, although this was only significant at 6-months between women in Stage 4 compared with women in Stage 1&2 (p <0.05). More information is needed on why patients drop out of the counseling process before starting ART, and whether weight gain is a marker for survival in the early months of ART

Who is accessing antiretroviral therapy in Malawi? A study in the Southern Region on the occupation category “other”

As part of quarterly national reports on the scale up of antiretroviral therapy (ART), demographic and clinical characteristics are recorded including data on occupation. The largest occupational category is that of “other”. As there is no information on the composition of the different occupations of patients placed in this category, a formal study was therefore conducted in 6 representative public sector facilities in the Southeastern Region of Malawi. Between January to June 2006, there were 126 adult patients recorded as “other” in the occupation column. A great variety of different occupations was recorded including no employment 30%, administration jobs 24%, general labourers 11%, builders 10%, tailors 9% and drivers 7%. A wide range of people with different jobs are accessing ART, and this should help in improving the economy of the patients as well as the country at large

An audit of how patients get on to antiretroviral therapy in Malawi, and the weight gain they experience in the first six months

An operational study was conducted in 6 public sector health facilities in the Southern Region of Malawi to determine a) drop-out rates during the referral process of patients to antiretroviral therapy (ART) and b) weight gained during the first 6 months in patients who were alive and on ART at that time. There were 738 adult HIV-infected eligible patients booked for group counseling, of whom 550 (74.5%) attended individual counseling and started ART. 16% of patients dropped out between booking and group counseling and 9.5% between group counseling and start of ART. In patients who were alive and on ART 6 months after starting, there was a gradual increase in weight with a mean gain of 6.0 kg in men and 5.0 kg in women. There was a slight increase in weight gain in patients in WHO Clinical Stage 3 and 4 compared with those in Stage 1&2, although this was only significant at 6-months between women in Stage 4 compared with women in Stage 1&2 (

Who is accessing antiretroviral therapy in Malawi? study in the Southern Region on the occupation category “other”

As part of quarterly national reports on the scale up of antiretroviral therapy (ART), demographic and clinical characteristics are recorded including data on occupation. The largest occupational category is that of “other”. As there is no information on the composition of the different occupations of patients placed in this category, a formal study was therefore conducted in 6 representative public sector facilities in the Southeastern Region of Malawi. Between January to June 2006, there were 126 adult patients recorded as “other” in the occupation column. A great variety of different occupations was recorded including no employment 30%, administration jobs 24%, general labourers 11%, builders 10%, tailors 9% and drivers 7%. A wide range of people with different jobs are accessing ART, and this should help in improving the economy of the patients as well as the country at large. Malawi Medical Journal Vol. 19 (4) 2007 pp. 138-13