Re-engagement in care of people living with HIV lost to follow-up after initiation of antiretroviral therapy in Mali: Who returns to care?

Objectives: We assessed cumulative incidence rates of and factors associated with re-engagement in HIV care for PLHIV lost to follow-up in Mali.

Methods: HIV-1-infected individuals lost to follow-up before 31/12/2013, ≥ 18 years old, who started ART from 2006 to 2012 at one of 16 care centres were considered. Loss to follow-up (LTFU) was defined as an interruption of ≥ 6 months during follow-up. The re-engagement in care in PLHIV lost to follow-up before 31/12/2013 was defined as having at least one clinical visit after LTFU. The cumulative incidence rates of re-engagement in care was estimated by Kaplan-Meier and its predictive factors were assessed using Cox models. Socio-demographic characteristics, clinical and immune status, period, region, centre expertise level, and distance from home at the start of ART plus a combined variable of duration of ART until LTFU and 12-month change in CD4 count were assessed. Multiple imputation was used to deal with missing data.

Results: We included 3,650 PLHIV lost to follow-up before December 2013, starting ART in nine outpatient clinics and seven hospitals (5+2 in Bamako and 4+5 in other regions): 35% male, median (IQR) age 35 (29-43), and duration of ART until LTFU 11 months (5-22). Among these PLHIV, 1,975 (54%) were definitively LTFU and 1,675 (46%) subsequently returned to care. The cumulative incidence rates of re-engagement in care rose from 39.0% at one year to 47.0% at three years after LTFU. Predictors of re-engagement in care were starting ART with WHO stage 1-2 and CD4 counts ≥ 200 cells/μL, being treated for ≥ 12 months with CD4 count gain ≥ 50 cells/μL, or being followed in Bamako. People followed at regional hospitals or outpatient clinics ≥ 5 km away, or being treated for ≥ 12 months with CD4 count gain < 50 cells/μL were less likely to return to care.

Conclusions: Starting ART with a higher CD4 count, better gain in CD4 count, and being followed either in Bamako or close to home in the regions were associated with re-engagement in care.