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Accounting for loss to follow-up changed life-years gained in HIV
The inclusion of loss to follow-up significantly changed the estimated life-years gained during the first 5 years of antiretroviral therapy, researchers from the University of Washington suggest.
“The survival of patients receiving ART is often reported in the literature in a way that accounts only for ‘known mortality,’” the researchers wrote. “This measure can be an overestimate of survival, as it does not account for mortality among patients who are lost to follow-up, which can be substantial.”
The researchers utilized data from 34 cohorts to evaluate retention, mortality and loss to follow-up. These cohorts included 102,306 adult patients from 18 sub-Saharan African countries. The study also included data from 13 studies that tracked death rates of patients lost to follow-up.
After adjusting for loss to follow-up, survival at 1 year was estimated to be 0.87 (95% CI, 0.72-0.94) and survival at 5 years was estimated to be 0.7 (95% CI, 0.36-0.86). Before adjustment, only accounting for known mortality, the rates were 0.93 at 1 year (95% CI, 0.71-0.98) and 0.79 at 5 years (95% CI, 0.12-0.95). If all patients lost to follow-up were assumed to have died, the rates would be 0.82 at 1 year (95% CI, 0.66-0.91) and 0.54 at 5 years (95% CI, 0.12-0.76).
When stratified by initial CD4 count, the survival for those with CD4 counts of more than 100 cells/mm3 had a 1-year survival estimate of 0.88 (95% CI, 0.76-0.94) and a 5-year survival estimate of 0.81 (95% CI, 0.59-0.90). Those with CD4 counts of less than 100 cells/mm3, the 1-year survival estimate was 0.82 (95% CI, 0.61-0.91) and the 5-year survival estimate was 0.64 (95% CI, 0.23-0.82).
In the adjusted model, the estimated life-years gained during the 5-year ART period was 2.1 (95% CI, 1.6-2.3). If 100% mortality was assumed among patients lost to follow-up, the life-years gained was 1.7 (95% CI, 1.1-2.0), and if 0% mortality was assumed, the life-years gained was 2.4 (95% CI, 1.7-2.7).
“Our work underlines the urgent need for more data on both retention and the outcomes of patients lost to follow-up after ART initiation, with a particular emphasis on the major determinants of retention in care,” the researchers wrote. “Research on interventions to improve patient follow-up and retention, strengthened by incorporating analytical methods such as the one presented here, is needed for the design of cost-effective strategies to prevent loss to follow-up.”
Disclosure: The researchers report no relevant financial disclosures.