Characteristics and Outcomes of Adult Patients Lost to Follow-Up at an Antiretroviral Treatment Clinic in Johannesburg, South Africa

Background: A significant proportion of those initiating antiretroviral treatment (ART) for HIV infection are lost to follow-up. Causes for discontinuing ART follow-up in resource-limited settings are not well understood. Methods: A retrospective analysis was conducted of all adult patients receiving ART at an urban public clinic in Johannesburg, South Africa between April 2004 and June 2005. Patients discontinuing follow-up for at least 6 weeks were identified and further studied, and causes for treatment default were tabulated. Results: Of 1631 adult patients studied, 267 (16.4%) discontinued follow-up during the study period. Gender, ethnicity, and age were not predictive of loss to follow-up. Of those discontinuing follow-up, 173 (64.8%) were successfully traced. Death accounted for 48% (n = 83) of those traced. Characteristics associated with death were older age at ART initiation ('P' = 0.022), lower baseline CD4 cell count ('P' = 0.0073), higher initial HIV RNA load ('P' = 0.024), and loss of weight on ART ('P' = 0.033). Date of death was known for 71% (n = 59) of patients traced deceased, of whom 83% (n = 49) had died within 30 days of active ART. Common nonmortality losses included relocation or clinic transfer (25.4%) and hospitalization or illness not resulting in death (10.4%). Few cited financial difficulty or medication toxicity as reasons for discontinuing follow-up. Conclusions: Nearly 1 in 6 patients receiving ART in a resource constrained setting had discontinued follow-up over a 15-month period. Early mortality was high, especially in those with profound immunosuppression. Improving access to care and streamlining patient tracking may improve ART outcomes.