RISK FACTORS AND OUTCOMES ASSOCIATED WITH LOST-TO-FOLLOW-UP PATIENTS AMONG ART PATIENTS

Lost-to-follow-up (LTFU) on ART programmes
The effectiveness of ART programmes is evaluated using key indicators, which include percentage of deaths, percentage of LTFU, and patients retained on ART care, and among these retention patients is the most important, because poor retention shows poor survival with HIV infection (Giordano et al., 2007). A systematic review of patient retention in antiretroviral therapy in programs in sub-Saharan Africa indicated that the rate of LTFU was 40%.(Rosen et al 2007).Loss to follow-up was (the major cause of attrition, followed by death. Better patient tracing procedures, better understanding of loss to follow-up, and earlier initiation of ART to reduce mortality are needed if retention is to be improved. Retention varies widely across programs, and programs that have achieved higher retention rates can serve as models for future improvements) (Rosenet al., 2007).
Different studies across sub-Saharan Africa on patients LTFU estimated the percentage of patients LTF(U to be 19%, 24% and 31% at 6 months, 12 months and 24 months of treatment, respectively) (Brinkhof et al., 2010). These studies have documented an increase in patients LTFU due to increasing problems such as expanding programmes and declining staff-to-patient ratios (Brinkhof et al., 2010). In Kenya, studies have shown that proportions of patients LTFU differ between clinics ranging from 7 % in Médecins Sans Frontières (MSF) programmes,Busia district hospital (Rosen etal., 2007) to 40% in western Kenya migori district hospital(Karcher et al 2007).
A Nigeria study, that describes longitudinal analysis for risk factors on patient retention and adherence to antiretroviral drugs has shown that increased risk of patients LTFU was associated with being male, younger, having CD4 count level of ? 100 cells/µl or CD4 count of ?350 cells/µl at ART initiation. Stavudine (d4T) based regimen patients were also at higher risk of being LTFU compared to those on Zidovudine or azidothymidine (AZT) and Tenofovir Disoproxil Fumarate (TDF) regimens (Charurat et al., 2010). Stavudine (d4T)based regimen has been associated with Peripheral neuropathy (Scarsella et al., 2002).
Higher proportion of women on ART remained on care compared to other treatment cohorts in Africa and this shows gender difference in health-seeking behaviour affecting retention (Braitstein et al., 2008).
Risk of non-adherence was observed to be the highest in the first six months after ART initiation suggesting importance of adherence should be emphasized in the beginning of the treatment (Charurat et al., 2010) and counselling and social support could reduce stigma (Wouters et al., 2009).
Another observation on distance was patients who spent time travelling to treatment facilities were at higher risk of non-adherence, which interferes with treatment (Charurat et al., 2010), while others due to lack of transport they could not fulfil the medical appointments on time hence become defaulters (Deribe et al., 2008). At St. Helen’s hospital in Johannesburg, South Africa, financial difficulties among patients on care were likely to default of follow up appointments (Maskew et al., 2007) while a Haiti study shows that, despite of ARV treatment been free, poor patients have had a challenge due to other associated costs (Fitzgerald & Krain, 2005).
Other contributing issues like lack of food, mental illness, having a partner whose HIV status was unknown, excessive consumption of alcohol and using substances of abuse like cocaine and cannabis were also associated with defaulting on patient on ARV treatment at JimmaUniversity hospital, Ethiopia (Deribe et al., 2008).
In the issue of gender and poverty, poor women were likely to be less compliant to treatment plans than the male counterparts (Skhosana et al., 2006).
A retrospective analysis was conducted of all adult patients (above 18 years) at the   South African Hospital HIV clinic receiving ART medications at any time between April 2, 2004 and June 23, 2005. Some characteristics associated with patients’ LTFU included prior exposure to TB, prior exposure to ART medication and among those who died on the patients’ LTFU category had a median baseline CD4 count of 33 cells/µl, indicating significant immunodeficiency at enrolment (Dalal et al., 2008).
In France, a study on prevalence and predictors of loss to follow up in FrenchHospital was done. LTFU was frequently, among men who have sex with men (MSM) and among patients with AIDS more frequent among immigrants(Lebouche’ et al., 2006). In Mozambique, Tete town, a retrospective study to determine risk factors and outcomes for LTFU, on HIV/AIDS care programme was done. Some risk factors associated LTFU include, CD4 count <50 cells/µl time on ART <3months and tuberculosis infection. Among 2818 individuals on ART, 594(21%) were LTFU (Fernando et al., 2007).
The above studies show that every ART programme has a potential risk of category of patients becoming loss to follow up. The health professionals on each HIV clinic should be able evaluate the potential indicators of having the population that cannot be traced or do not return to the clinic. The above reasons for studies done are at resources limited that need intervention during care on ART and retention of patients to show the efficacy of ART programmes
Factors affecting medical appointments of People living with HIV/AIDSMissed appointments are known to interfere with appropriate care of acute and chronic health conditions and to misspend medical and administrative resources.They represent a major burden on health care systems
and costs [1,], by reducing the effectiveness of outpatient health care delivery.
Medical factors
Doctor to patient relationship has proven to affect the patients attitudes towards health care given. A study conducted at Geneva university Hospital showed lack of interpersonal continuity care, where by patients were less interactive with junior doctors on training as opposed to senior doctors, due to frequent changing of the junior doctors. With lack of interpersonal continuity, junior doctor patients were more likely to miss appointments than the senior doctors (Perrone et al., 2010). Consistent medical care by a provider over time may be important because it provides opportunities for patients to build trust with health professionals (Besch et al., 1995). Continuity of care may be an important factor related to adherence in AIDS clinical trials found. A study in Tanzania showed on how patients would like to be treated well. Treating patients in negative discriminative way affects patients hence causing distrust in service providers and ultimately cause the patients drop out from treatment plan (Hardon et al., 2006).
In regards to adverse drug reactions, most commonly with found in PLWHA include headaches, nausea, rash, peripheral neuropathy, lipodystrophy and lactic acidosis (Max & Sherer, 2000). Stavudine based regimen has been associated with Peripheral neuropathy (Scarsella et al., 2002) and lipodystrophy (Véroniqueaet al., 2002). A Botswana, study has shown that adverse drug reactions contributed to fifth most mentioned reason for missing doses and adherence (Weiser et al., 2003) while another study shows that side effects of ART on patients on developed nations were associated with poor adherence (Ammassari et al., 2000). Clinicians should be able to deal with adverse drug reactions occurring in patients. This includes early substitution of drugs in the event of an ADR and counselling a patient thereof in different approaches of regimens required to be changed.
Psychosocial factors
Psychosocial factors including social support have proven to contribute to default of ART treatment.This may be particularly true for PLHWA.a study done in Sagamu,Nigeria indicated that stigma, cultural influences(widowhood rites),lack of family support due to patient not disclosing their HIV support,were among the reasons that patients defaulted from treatment (Daniel et al O.J 2008).
Another study in the United Kingdom, concluded that social discrimination of people of Black African ethnicity,been recently diagonised of HIV infection and infection from outside United Kingdom were the reasons p medical appointments in the clinic Brian (D.
Therefore, intensifying counselling of patients before initiating and during treatment is of utmost importance so that PLWA can adjust both psychologically and emotionally to the disease).
Traditional medicine
((The use of herbal and traditional medicine is wise and spreading among PLWHA though not sufficiently documented (MacPhail et al., 2002). Traditional and herbal medicine may cause severe adverse reactions on PLWHA and may also contain adulterated products (Peters et al., 2004). Patients on ARV who were visiting traditional healers and using traditional medicine have also been found to be defaulters (Worley et al., 2007). In South Africa, Antiretroviral therapy is been introduced to an environment where this therapy is competing with alternative medicine, which are traditional African therapies (Chopra et al., 2006). Murchison hospital study in South Africa, shows that patients who preferred traditional medicine contributed to non attendance by 7.4% (Kahelo, zulu 2009).

Religious beliefs
The influence of religion has been observed to have negative impact contributing of defaulting of treatment and positive outcomes in providing education. Murchison hospital study identified that 1.1 % of patient who defaulted cited religious beliefs and all were female patients (Kahelo Zulu 2009). Treatment programmes have also obtained positive outcomes by involving religious high treatment by using religious organization to provide adherence education and HIV support programmes (Karpf 2007). However, religious beliefs may also play a negative role in treatment programmes due to stigma attached to HIV disease, particularly in geographical areas and in population subgroups where religious practices are strong (Karpf, 2007).
Social Economic factors
United Nations Development Program (2006) reported that in the crucial economic times, the interruption of work is not taking lightly, with most population living in less that a $2 a day, the immediate concerns for missing work, is the loss of wages. Consistently missing work a day, to attend to medical appointment has led to strain employer-employee relationship.
In South Africa, discrimination against HIV/AIDS is still a reality, which has led to most employees, not concealing HIV status and causing failure to treatment plan (Whiteside & Sunter, 2000). The economic status in terms of source of income for the patients has also been an influence to the treatment. A Soweto study in south Africa revealed that the main reason reported for missing medical appointments was been away travelling and with high rate of unemployment (41%), patients must have been away from home looking for jobs, thus clinical appointment default was too high (Nachega et al., 2004).
Studies have reported that patient treatment literacy, disclosure, lifestyle have shown increase in patients sticking to treatment plans, and provision of several months supply of drugs would ease the burden of travelling to the clinic frequently, thus minimizing transport cost and default incidences (Skhosana et al., 2006; Hardon et al., 2006).
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Other factors
Other factors contributing to non-adherence identified include side effects, high number of doses per day, number of different pills, food restrictions, lack of education, demanding job, poverty, mental incompetence, substance abuse other than intravenous drugs, homelessness and the clinical state of HIV (Cheevers, 2000; Harries et al., 2001).
References

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