• J. Acquir. Immune Defic. Syndr. · Apr 2014

    Tracing of patients lost to follow-up and HIV transmission: mathematical modeling study based on 2 large ART programs in Malawi.

    • Janne Estill, Hannock Tweya, Matthias Egger, Gilles Wandeler, Caryl Feldacker, Leigh F Johnson, Nello Blaser, Luisa Salazar Vizcaya, Sam Phiri, and Olivia Keiser.
    • *Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland; †The International Union Against Tuberculosis and Lung Disease, Paris, France; ‡Lighthouse Trust, Lilongwe, Malawi; §Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa; ‖Department of Infectious Diseases, University Hospital Bern, Bern, Switzerland; ¶Department of Infectious Diseases, University of Dakar, Dakar, Senegal; #International Training and Education Center for Health, University of Washington, Seattle, WA.
    • J. Acquir. Immune Defic. Syndr. 2014 Apr 15; 65 (5): e179-86.

    ObjectiveTreatment as prevention depends on retaining HIV-infected patients in care. We investigated the effect on HIV transmission of bringing patients lost to follow-up (LTFU) back into care.DesignMathematical model.MethodsStochastic mathematical model of cohorts of 1000 HIV-infected patients on antiretroviral therapy, based on the data from 2 clinics in Lilongwe, Malawi. We calculated cohort viral load (sum of individual mean viral loads each year) and used a mathematical relationship between viral load and transmission probability to estimate the number of new HIV infections. We simulated 4 scenarios: "no LTFU" (all patients stay in care), "no tracing" (patients LTFU are not traced), "immediate tracing" (after missed clinic appointment), and "delayed tracing" (after 6 months).ResultsAbout 440 of 1000 patients were LTFU over 5 years. Cohort viral loads (million copies/mL per 1000 patients) were 3.7 [95% prediction interval (PrI), 2.9-4.9] for no LTFU, 8.6 (95% PrI, 7.3-10.0) for no tracing, 7.7 (95% PrI, 6.2-9.1) for immediate, and 8.0 (95% PrI, 6.7-9.5) for delayed tracing. Comparing no LTFU with no tracing, the number of new infections increased from 33 (95% PrI, 29-38) to 54 (95% PrI, 47-60) per 1000 patients. Immediate tracing prevented 3.6 (95% PrI, -3.3 to 12.8) and delayed tracing 2.5 (95% PrI, -5.8 to 11.1) new infections per 1000. Immediate tracing was more efficient than delayed tracing: to 116 and 142 tracing efforts, respectively, were needed prevent 1 new infection.ConclusionsTracing of patients LTFU enhances the preventive effect of antiretroviral therapy, but the number of transmissions prevented is small.

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