Movement between facilities for HIV care among a mobile population in Kenya: transfer, loss to follow-up, and reengagement

ABSTRACT

HIV treatment is life-long, yet many patients travel or migrate for their livelihoods, risking treatment interruption. We examine timely reengagement in care among patients who transferred-out or were lost-to-follow-up (LTFU) from a rural HIV facility. We conducted a cohort study among 369 adult patients on antiretroviral therapy between November 2011 and November 2013 on Mfangano Island, Kenya. Patients who transferred or were LTFU (i.e., missed a scheduled appointment by ≥90 days) were traced to determine if they reengaged or accessed care at another clinic. We report cumulative incidence and time to reengagement using Cox proportional hazards models adjusted for patient demographic and clinical characteristics. Among 369 patients at the clinic, 23(6%) requested an official transfer and 78(21%) were LTFU. Among official transfers, cumulative incidence of linkage to their destination facility was 91% at three months (95%CI (confidence intervals) 69–98%). Among LTFU, cumulative incidence of reengagement in care at the original or a new clinic was 14% at three months (95%CI 7–23%) and 60% at six months (95%CI 48–69%). In the adjusted Cox model, patients who left with an official transfer reengaged in care six times faster than those who did not (adjusted hazard ratio 6.2, 95%CI 3.4–11.0). Patients who left an island-based HIV clinic in Kenya with an official transfer letter reengaged in care faster than those who were LTFU, although many in both groups had treatment gaps long enough to risk viral rebound. Better coordination of transfers between clinics, such as assisting patients with navigating the process or improving inter-clinic communication surrounding transfers, may reduce delays in treatment during transfer and improve overall clinical outcomes.

KEYWORDS:

• HIV
• transfer
• lost to follow-up
• stigma
• resource-limited setting

Acknowledgements

We would like to thank the research team and staff at the Ekialo Kiona Center for their tireless work. We would also like to thank the Director of the Centre for Microbial Research at the Kenya Medical Research Institute (KEMRI) for support of this project. Most importantly, we would like to thank the study participants in the MIHNIS trial for their willingness to contribute time toward improving HIV care delivery in the region. This paper was published with the permission of the Director, KEMRI.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by Doris Duke Charitable Foundation; Rise Up Foundation; Horace W. Goldsmith Foundation; Mulago Foundation; Google Inc. via the Tides Foundation; Craigslist Foundation; Segal Family Foundation; and UCSF School of Medicine Dean's Research Fellowship.