March 21, 2017
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Tracing interventions increase re-engagement rates among HIV patients lost to follow-up

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Recent study findings showed that tracking and connecting with HIV–infected patients who were lost to follow-up increased re-engagement rates. However, new methods are needed to target patients who will most likely benefit from tracing interventions to increase the overall efficacy of the practice, researchers reported.

“We present high-quality evidence based on random assignment of tracing, through a quasi-natural experiment, that the practice of tracing patients who are lost to follow-up from HIV treatment programs in Africa strongly but transiently increases rates of return to care for those patients who are alive, can be contacted and are not already in care elsewhere — a relatively small proportion of all lost patients,” Anna Bershetyn, PhD, from the Institute for Disease Modeling in Bellevue, Washington, and colleagues wrote in Clinical Infectious Diseases. “Tracing should be a part of the retention toolbox, but can be more efficient and effective if targeted — perhaps through prediction rules — to the subset of lost patients who are most able to benefit.”

According to the researchers, tracing interventions are widely practiced in low- and middle-income countries (LMICs); however, the causal effect of tracing has not been conclusively established. To better understand the efficacy of the intervention, they randomly assigned “tracers” to seek patients who received care at one of 14 clinic sites in eastern Africa 2.5 years before the study and were lost to follow-up. When possible, tracers inquired about the patients’ care status, counseled patients and encouraged them to return to care. The interaction lasted for approximately 10 to 15 minutes.

Bershetyn and colleagues identified 5,781 patients who were lost to follow-up and randomly selected 991 (17.1%) for tracing. Of the traced patients with available information, 23.5% had died, 21.4% said they were receiving treatment elsewhere and 14.9% reported being out of care.

One year after randomization, 13.3% (95% CI, 11.1-15.3) of traced patients returned to care vs. 10.0% (95% CI, 9.1-10.8) of patients in the control group, yielding an adjusted risk difference of 3.0% (95% CI, 0.7%-5.3%). When considering only patients who were alive and not receiving care elsewhere, the probability of returning to care further increased from 15.1% (95% CI, 0.4-29.7) to 37.1%, yielding an absolutely risk difference of 22.1% (95% CI, 7.1%-36.2%).

Additional analyses showed that re-engagement rates were higher within the first 2 weeks after tracing (HR = 5.9; 95% CI, 3.4-10.2). This was particularly evident when restricting the cohort to patients who were contacted and not receiving care (HR = 8.1; 95% CI, 3.9-16.6). In these patients, the half-life of the effect of tracing was 7 days (95% CI, 2.6-12.9 days).

Wendy Armstrong, MD
Wendy S. Armstrong
Carlos del-Rio
Carlos del Rio

In a related editorial, Wendy S. Armstrong, MD, professor of medicine at Emory University and chair of the HIV Medicine Association (HIVMA), and Carlos del Rio, MD, FIDSA, infectious disease physician at Emory University and immediate past chair of the HIV Medicine Association, said the study findings are “significant” and “underscore the need to appropriately identify patient populations that will respond to particular interventions.”

Although Bershetyn and colleagues concluded that tracing interventions may be useful in LMICs, Armstrong and del Rio noted that the results can be applied to areas of the United States where “retention in care is equally challenging.”

“This study once again demonstrates that global innovations in HIV care in LMICs have much to teach high-income countries; global lessons must be translated locally and vice versa,” they wrote. – by Stephanie Viguers

Disclosures: Armstrong and del Rio received institutional grants from the NIH/NIDA TEACH study. del Rio also received institutional grant support from NIH/National Institute of Allergy and Infectious Diseases Emory Clinical Trials Unit and consultancy fees from InnerVirVax. Bershetyn and colleagues report no relevant financial disclosures.