Lack of female head of household and distance to clinic linked to loss to follow-up in Malawi

10 February 2017

Identifying individuals at high risk of disengaging with HIV care remains an important strategy for realising the benefits of antiretroviral treatment for public health.

woman on a motorbike in Africa

A lack of a maternal figure in households in Malawi is being associated with poor antiretroviral (ART) adherence, as defined by loss to follow-up (LTFU) to HIV care, according to research conducted on the Drug Resource Enhancement Against AIDS and Malnutrition (DREAM) programme in Malawi.

Loss to follow-up was also linked to living far away from programme centres, having a higher viral load and living in cement housing.

The findings form part of a review of DREAM, in which the authors state there was a clear urban vs. rural difference in HIV care retention – with urban populations, who have better housing and high levels of education, more prone to loss to care.

Keeping people in HIV care is significantly correlated with antiretroviral therapy adherence and viral suppression and is a major proponent of successful HIV programmes. Loss to follow-up is defined as taking place when people go more than 90 days since their last unattended appointment or event – including medical visits, food collection or antiretroviral drug collections and lab visits.

15,099 people living with HIV who had been prescribed antiretroviral treatment as part of the DREAM programme were assessed for loss to follow-up in 2014.

The programme, which has since expanded to nine other sub-Saharan African countries, shows a remarkable success rate, with just 1.3% of all patients lost.

DREAM, developed by the Community of Sant'Egidio in Mozambique in 2002, provides free antiretroviral treatment, adherence counselling and monitoring by patient advocates and members of the patient community, as well as free nutritional supplements. This high level of incentive and support is likely to have been key in the positive HIV care retention rates.

Of the adults who were lost to care, not having a female matriarch in the household was estimated to increase the risk of loss to follow-up by 58%. As many African households are run by women who provide structure within the household, the authors point to the absence of a maternal figure, suggesting that her sphere of influence does have an impact on HIV care retention.

Loss to follow-up in urban populations may be the result of social mobility, according to the authors. Patients were more likely to be employed, or need to travel and move for work. Many of these loss to follow-up may have changed care, or moved to the private sector.

Keeping people in HIV care is particularly important to maximise the benefits of treatment as prevention and reduce HIV-related morbidity and mortality.

Programmes need to understand the complex challenges of keeping people in HIV care and develop strategies appropriate to the populations being targeted.

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Written by Caitlin Mahon

Content Specialist - HIV & Sexual Health