Tracking a sample of patients lost to follow-up has a major impact on understanding determinants of survival in HIV-infected patients on antiretroviral therapy in Africa

Elvin H. Geng, David V. Glidden, Nneka Emenyonu, Nicolas Musinguzi, Mwebwesa Bosco Bwana, Torsten B. Neilands, Winnie Muyindike, Constantin T. Yiannoutsos, Steven G. Deeks, David Bangsberg, Jeffrey N. Martin

Research output: Contribution to journalArticle

57 Citations (Scopus)

Abstract

Objective To date, data regarding the determinants of mortality in HIV-infected patients starting antiretroviral therapy (ART) in Africa have been primarily derived from routine clinical care settings practicing the public health approach. Losses to follow-up, however, are high in these settings and may lead to bias in understanding the determinants of mortality. Methods We evaluated HIV-infected adults initiating ART between January 1, 2004 and September 30th, 2007 in an ART clinic in southwestern Uganda. Clinical and demographic characteristics were obtained through routine clinical care. In evaluating determinants of mortality, a 'naïve' analysis used only deaths known through routine processes. A 'sample-corrected' approach incorporated, through probability weights, outcomes from a representative sample of patients lost to follow-up whose vital status was ascertained through tracking in the community. Results In 3,628 patients followed for up to 3.75 years after ART initiation, the 'naïve' approach identified male sex and lower pre-ART CD4 count as independent determinants of mortality. The 'sample-corrected' approach found lower pre-ART CD4 count, older age, lower weight and calendar year of ART initiation, but not male sex, to be independent determinants of mortality. Conclusions Analyses to identify determinants of mortality in HIV-infected patients on ART in Africa that do not account for losses to follow-up can identify spurious associations and miss actual relationships - both with the potential to mislead public health efforts. A sampling-based approach to account for losses to follow-up represents a feasible and potentially scalable method to strengthen the evidence available for implementation of ART delivery in Africa.

Original languageEnglish (US)
Pages (from-to)63-69
Number of pages7
JournalTropical Medicine and International Health
Volume15
Issue numberSUPPL. 1
DOIs
StatePublished - Jun 2010
Externally publishedYes

Fingerprint

Lost to Follow-Up
HIV
Survival
Mortality
Therapeutics
CD4 Lymphocyte Count
Public Health
Patient Advocacy
Weights and Measures
Uganda
Demography

Keywords

  • Africa
  • Antiretroviral scale-up strategies
  • Determinants of mortality on antiretroviral therapy
  • Losses to follow-up
  • Monitoring and evaluation
  • Sampling studies

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Infectious Diseases
  • Parasitology

Cite this

Tracking a sample of patients lost to follow-up has a major impact on understanding determinants of survival in HIV-infected patients on antiretroviral therapy in Africa. / Geng, Elvin H.; Glidden, David V.; Emenyonu, Nneka; Musinguzi, Nicolas; Bwana, Mwebwesa Bosco; Neilands, Torsten B.; Muyindike, Winnie; Yiannoutsos, Constantin T.; Deeks, Steven G.; Bangsberg, David; Martin, Jeffrey N.

In: Tropical Medicine and International Health, Vol. 15, No. SUPPL. 1, 06.2010, p. 63-69.

Research output: Contribution to journalArticle

Geng, Elvin H. ; Glidden, David V. ; Emenyonu, Nneka ; Musinguzi, Nicolas ; Bwana, Mwebwesa Bosco ; Neilands, Torsten B. ; Muyindike, Winnie ; Yiannoutsos, Constantin T. ; Deeks, Steven G. ; Bangsberg, David ; Martin, Jeffrey N. / Tracking a sample of patients lost to follow-up has a major impact on understanding determinants of survival in HIV-infected patients on antiretroviral therapy in Africa. In: Tropical Medicine and International Health. 2010 ; Vol. 15, No. SUPPL. 1. pp. 63-69.
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abstract = "Objective To date, data regarding the determinants of mortality in HIV-infected patients starting antiretroviral therapy (ART) in Africa have been primarily derived from routine clinical care settings practicing the public health approach. Losses to follow-up, however, are high in these settings and may lead to bias in understanding the determinants of mortality. Methods We evaluated HIV-infected adults initiating ART between January 1, 2004 and September 30th, 2007 in an ART clinic in southwestern Uganda. Clinical and demographic characteristics were obtained through routine clinical care. In evaluating determinants of mortality, a 'na{\"i}ve' analysis used only deaths known through routine processes. A 'sample-corrected' approach incorporated, through probability weights, outcomes from a representative sample of patients lost to follow-up whose vital status was ascertained through tracking in the community. Results In 3,628 patients followed for up to 3.75 years after ART initiation, the 'na{\"i}ve' approach identified male sex and lower pre-ART CD4 count as independent determinants of mortality. The 'sample-corrected' approach found lower pre-ART CD4 count, older age, lower weight and calendar year of ART initiation, but not male sex, to be independent determinants of mortality. Conclusions Analyses to identify determinants of mortality in HIV-infected patients on ART in Africa that do not account for losses to follow-up can identify spurious associations and miss actual relationships - both with the potential to mislead public health efforts. A sampling-based approach to account for losses to follow-up represents a feasible and potentially scalable method to strengthen the evidence available for implementation of ART delivery in Africa.",
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T1 - Tracking a sample of patients lost to follow-up has a major impact on understanding determinants of survival in HIV-infected patients on antiretroviral therapy in Africa

AU - Geng, Elvin H.

AU - Glidden, David V.

AU - Emenyonu, Nneka

AU - Musinguzi, Nicolas

AU - Bwana, Mwebwesa Bosco

AU - Neilands, Torsten B.

AU - Muyindike, Winnie

AU - Yiannoutsos, Constantin T.

AU - Deeks, Steven G.

AU - Bangsberg, David

AU - Martin, Jeffrey N.

PY - 2010/6

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N2 - Objective To date, data regarding the determinants of mortality in HIV-infected patients starting antiretroviral therapy (ART) in Africa have been primarily derived from routine clinical care settings practicing the public health approach. Losses to follow-up, however, are high in these settings and may lead to bias in understanding the determinants of mortality. Methods We evaluated HIV-infected adults initiating ART between January 1, 2004 and September 30th, 2007 in an ART clinic in southwestern Uganda. Clinical and demographic characteristics were obtained through routine clinical care. In evaluating determinants of mortality, a 'naïve' analysis used only deaths known through routine processes. A 'sample-corrected' approach incorporated, through probability weights, outcomes from a representative sample of patients lost to follow-up whose vital status was ascertained through tracking in the community. Results In 3,628 patients followed for up to 3.75 years after ART initiation, the 'naïve' approach identified male sex and lower pre-ART CD4 count as independent determinants of mortality. The 'sample-corrected' approach found lower pre-ART CD4 count, older age, lower weight and calendar year of ART initiation, but not male sex, to be independent determinants of mortality. Conclusions Analyses to identify determinants of mortality in HIV-infected patients on ART in Africa that do not account for losses to follow-up can identify spurious associations and miss actual relationships - both with the potential to mislead public health efforts. A sampling-based approach to account for losses to follow-up represents a feasible and potentially scalable method to strengthen the evidence available for implementation of ART delivery in Africa.

AB - Objective To date, data regarding the determinants of mortality in HIV-infected patients starting antiretroviral therapy (ART) in Africa have been primarily derived from routine clinical care settings practicing the public health approach. Losses to follow-up, however, are high in these settings and may lead to bias in understanding the determinants of mortality. Methods We evaluated HIV-infected adults initiating ART between January 1, 2004 and September 30th, 2007 in an ART clinic in southwestern Uganda. Clinical and demographic characteristics were obtained through routine clinical care. In evaluating determinants of mortality, a 'naïve' analysis used only deaths known through routine processes. A 'sample-corrected' approach incorporated, through probability weights, outcomes from a representative sample of patients lost to follow-up whose vital status was ascertained through tracking in the community. Results In 3,628 patients followed for up to 3.75 years after ART initiation, the 'naïve' approach identified male sex and lower pre-ART CD4 count as independent determinants of mortality. The 'sample-corrected' approach found lower pre-ART CD4 count, older age, lower weight and calendar year of ART initiation, but not male sex, to be independent determinants of mortality. Conclusions Analyses to identify determinants of mortality in HIV-infected patients on ART in Africa that do not account for losses to follow-up can identify spurious associations and miss actual relationships - both with the potential to mislead public health efforts. A sampling-based approach to account for losses to follow-up represents a feasible and potentially scalable method to strengthen the evidence available for implementation of ART delivery in Africa.

KW - Africa

KW - Antiretroviral scale-up strategies

KW - Determinants of mortality on antiretroviral therapy

KW - Losses to follow-up

KW - Monitoring and evaluation

KW - Sampling studies

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