Estimating retention in HIV care accounting for clinic transfers using electronic medical records: evidence from a large antiretroviral treatment programme in the Western Cape, South Africa

• Published in: Tropical medicine & international health 2020-08, Vol.25 (8), p.936-943
• Main Authors: Bengtson, Angela M., Colvin, Christopher, Kirwa, Kipruto, Cornell, Morna, Lurie, Mark N.
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Anti-Retroviral Agents - therapeutic use; Antiretroviral agents; Antiretroviral drugs; Antiretroviral therapy; attrition; Cohort Studies; Confidence intervals; Databases, Factual; Electronic health records; Electronic Health Records - statistics & numerical data; Electronic medical records; engagement in HIV care; Estimates; Female; Health care; Health services; HIV; HIV Infections - drug therapy; Human immunodeficiency virus; Humans; loss to follow‐up; Lost to Follow-Up; Male; Medical records; Middle Aged; patient transfer; Patient Transfer - statistics & numerical data; Patients; Retention; retention in care; Retention in Care - statistics & numerical data; Sexually transmitted diseases; South Africa; STD; validation; Young Adult
• ISSN: 1360-2276; 1365-3156
• DOI: 10.1111/tmi.13412

Background Estimates of retention in antiretroviral treatment (ART) programmes may be biased if patients who transfer to healthcare clinics are misclassified as lost to follow‐up (LTFU) at their original clinic. In a large cohort, we estimated retention in care accounting for patient transfers using medical records. Methods Using linked electronic medical records, we followed adults living with HIV (PLWH) in Cape Town, South Africa from ART initiation (2012‐2016) through database closure at 36 months or 30 June 2016, whichever came first. Retention was defined as alive and with a healthcare visit in the 180 days between database closure and administrative censoring on 31 December 2016. Participants who died or did not have a healthcare visit in > 180 days were censored at their last healthcare visit. We estimated the cumulative incidence of retention using Kaplan–Meier methods considering (i) only records from a participant’s ART initiation clinic (not accounting for transfers) and (ii) all records (accounting for transfers), over time and by gender. We estimated risk differences and bootstrapped 95% confidence intervals to quantify misclassification in retention estimates due to patient transfers. Results We included 3406 PLWH initiating ART. Retention through 36 months on ART rose from 45.4% (95% CI 43.6%, 47.2%) to 54.3% (95% CI 52.4%, 56.1%) after accounting for patient transfers. Overall, 8.9% (95% CI 8.1%, 9.7%) of participants were misclassified as LTFU due to patient transfers. Conclusions Patient transfers can appreciably bias estimates of retention in HIV care. Electronic medical records can help quantify patient transfers and improve retention estimates. Contexte Les estimations de la rétention dans les programmes de traitement antirétroviral (ART) peuvent être biaisées si les patients qui sont transférés dans des cliniques de soins de santé sont classés à tort comme perdus au suivi (PS) dans leur clinique d'origine. Dans une large cohorte, nous avons estimé la rétention dans les soins en tenant compte des transferts de patients à l'aide des dossiers médicaux. Méthodes A l'aide de dossiers médicaux électroniques reliés entre eux, nous avons suivi des adultes vivant avec le VIH (PVVIH) à Cape Town, en Afrique du Sud, depuis le début de l’ART (2012–2016) jusqu'à la clotûre de la base de données à 36 mois ou au 30 juin 2016, selon la première éventualité. La rétention a été définie comme étant en vie et avec une visite médicale dans les 180 jours e