A study released this week examining the outcomes of Ugandan patients considered “lost to follow-up” counters a widely held assumption that people entering care for HIV while still relatively healthy are not sufficiently motivated to follow medical directions and to remain in care.
The study was released this week by Clinical Infectious Diseases with the self-explanatory title: High Retention in Care among HIV-infected Patients Entering Care with CD4 Levels >350/µl under Routine Program Conditions in Uganda. Following patients in two Ugandan HIV care centers (one rural, one urban), it found not only were retention rates high for patients still considered too healthy to be eligible for medicine under guidelines of the last few years, but concluded those retention rates may be “systematically underestimated in many other settings.”
The findings carry weight against a long unchallenged perception that people who feel well drop out of treatment, the resulting conclusion that patients receiving medicine before they have begun to feel ill can’t be counted on to continue to take it, and the specter that is then raised — that early treatment could lead to widespread drug resistance. The study’s findings are all the more significant in the wake of the World Health Organization’s 2013 HIV treatment guidelines that say patients should be given medicine before their immune systems are severely damaged. The guidelines are intended both to protect patients’ health and to prevent transmission of the virus
With information on 85 percent of a sampling of patients who had gone 9 months without visiting the clinic where they had come for care in the previous two and a half years, the study pointed to the reality that the majority of patients considered “lost to follow-up” can be found. Of 175 patients who had been considered lost to follow-up but for whom updated information was gathered, more than half were receiving treatment at a new clinic. Most of the patients who actually had left care cited the barriers of work responsibilities and having moved to an area without accessible HIV treatment. Only a quarter of those patients who had left treatment said they did so because they felt well. The article detailing the findings notes these patients left “due to inadequate knowledge” of their need to stay in treatment. The study also found that 19 of those “lost to follow-up” — 11 percent — had died. The death rate increased over time elapsed after first showing up for care, suggesting, the article said, HIV was a cause.
With sound public health strategies, keeping people who are not yet debilitated by HIV in care is feasible, the authors concluded. Those strategies include giving patients access to medicine when their immune cell count is higher, with benefit of reducing disease progression and death, while preventing transmission. “Our findings suggest that real world patient populations, at least in some settings,” the authors wrote, “may be receptive and ready for these interventions.”