Re-engagement in care for HIV infected Patients Who Leave their Original Clinic site

Authors: Matthew D Hickey, Charles R Salmen, Dan Omollo, Brian Mattah, Cinthia Blat, Gor Benard Ouma, Kathryn J Fiorella, Betty Njoroge, Monica Gandhi, Elizabeth A Bukusi, Craig R Cohen, Elvin H Geng

Background: HIV treatment is life-long, but many patients in East Africa are engaged in livelihoods that require travel or migration. Understanding the timeliness and completeness of connection to care across facilities – through either official or unofficial “silent” transfers – is critical for understanding engagement. To date, however, analyses of retention are mostly from the perspective of clinics, and therefore the success of movement between sites is not well understood.

Methods: We evaluated outcomes among patients on antiretroviral therapy who ceased accessing care from a clinic on Mfangano Island, Kenya. We defined stopping care from the perspective of the clinic – either leaving with an official transfer to a nearby facility or missing a scheduled appointment by ≥90 days (i.e. leaving without an official transfer). We traced all patients to determine reason for non-return and conducted chart review at target facilities for those who transferred. We report cumulative incidence of return to care at any facility. Results: Over two- years of follow-up, 15 patients made an official transfer and 89 left the clinic without making an official transfer. Among official transfers, 93% linked to their destination facility by 90 days (95%CI 74-100%). Among those without official transfers, 12% returned or linked to another facility by 90 days (95%CI 6-20%) and 57% by 180 days (95%CI 47-68%). By the end of follow-up, 77 (74%) had returned to care, 45% to another facility and 55% to the original clinic.

Conclusions: Patients who left with official transfers quickly and successfully linked to care at the new facility. Most patients who left without an official transfer eventually returned to care, either at the original clinic or another clinic. However, this process was slow, suggesting that treatment interruptions may have occurred. Increased efforts to coordinate transfers may reduce adverse patient outcomes during fragile transfer periods and improve overall clinical outcomes.