High retention in care among HIV-infected patients entering care with CD4 levels >350 cells/μL under routine program conditions in Uganda

Abstract

Background: In Africa, human immunodeficiency virus (HIV)-infected patients who present to care with CD4 levels >350 cells/µL (ie, current antiretroviral treatment thresholds) are often thought to be poorly retained in care, but most estimates do not account for outcomes among patients lost to follow-up.

Methods: We evaluated HIV-infected adults who had made a visit in the last 2.5 years in a program in Uganda. We identified a random sample of patients lost to follow-up (9 months without a visit). Ascertainers sought patients in the community in this sample and outcomes were incorporated into revised survival estimates of mortality and retention for the clinic population using a probability weight.

Results: Of 6473 patients, (29% male, median age 29 years, median CD4 count 550 cells/µL), 1294 (20%) became lost to follow-up over 2.5 years. Two hundred seven (16%) randomly selected lost patients were sought, and in 175 (85%) vital status was ascertained. In 19 of 175 (11%), the patient had died. Of the 156 (89%) alive, 74 (47%) were interviewed in person, and 38 of 74 (51%) reported HIV care elsewhere, whereas 36 of 74 (49%) were not in care. Application of weights derived from sampling found that at 2.5 years, retention among patients who enrolled with CD4 levels >350 cells/µL was 88.2% and mortality was 2.5%. Lower income, unemployment, and rural residence were associated with failure to be retained.

Conclusions: Retention in patients entering care with high CD4 counts under routine program conditions in Africa is high in a Ugandan care program and may be systematically underestimated in many other settings.

Keywords: Africa; CD4; HIV; retention.

Figures

Figure 1.

Flow chart depicting patients who presented to care with a CD4 level >350 cells/µL and who were not immediately eligible for antiretroviral therapy. Abbreviations: ART, antiretroviral therapy; HIV, human immunodeficiency virus.

Figure 2.

Proportion of patients retained in care (black line) and retained in clinic (gray line). Considering all lost patients to be out of care underestimates retention.

Figure 3.

Sample-weighted cumulative incidence (A) and hazard of mortality (B) among patients who present to care with a CD4 level >350 cells/µL.