The magnitude and factors associated with loss to follow up among children attending the Hiv clinic at Kangundo level four hospital

Abstract

Background: Over the past decade, significant gains have been made in enrolment and care of HIV-infected children in Kenya. Their long-term survival depends on lifetime adherence to antiretroviral therapy. African studies have reported high rates of Loss to Follow up (LTFU) among children in HIV care and treatment centres. Factors associated with LTFU may vary across populations and countries. Few studies have been conducted among HIV infected children in care in rural areas of Kenya. Objective: To evaluate the incidence and factors associated with loss to follow up in a cohort of children aged less than 15 years attending the HIV clinic at Kangundo Level Four Hospital. Study design: We employed a multi-design approach in which we conducted i) A retrospective cohort study to determine incidence and risk factors for LTFU through abstraction of medical records and ii) A cross sectional survey in which we traced and interviewed caregivers of children LTFU and conducted Focus Discussion Groups of the healthcare workers to gain further insight into factors contributing to loss to follow up. Methodology: We included all HIV-infected children aged below 15 years who were on follow-up at the HIV clinic at Kangundo Level 4 Hospital between January 2010 and December 2015. We obtained sociodemographic and clinical information from patient files and electronic databases. Caregivers of children who had dropped out of care were traced physically and interviewed using a questionnaire on the status of the child (whether dead, alive), and the reasons for dropping out of care. We conducted focus group discussions among the healthcare givers working in the HIV clinic to evaluate health system factors associated with LTFU. Ethical approval was granted by Kenyatta National Hospital/University of Nairobi Ethics and Review Committee. We calculated period prevalence and incidence of LTFU over the 6 year period before and after physical tracing of those LTFU. We performed logistic regression models to identify factors strongly associated with LTFU. Qualitative data from focus group discussion was transcribed and summarized into main themes manually.Results: Between January 2010 and December 2015, 261 HIV-infected children were followed up at Kangundo Level 4 Hospital, with 51.3% being males. The mean age was 10.0 years (IQR 7-13), and median CD4 count of 582cells/ul (IQR 314-984). At the time of enrolment into the study, 70 children (26.8%) were in HIV WHO stage I, 115 (44.1%) were stage II, 61 (26.4%) were stage III and 2 children (0.8%) were WHO stage IV. The overall follow up time of the whole cohort was 1003.9 person years with a median of 4 years (IQR1-5). By December 2015, 171 children (65.5%) remained in active care, 32 (12.3%) transferred out, 13 (5%) died, while 45 (17.2%) were classified as LTFU giving a period prevalence of LTFU as 17.2% and incidence rate 44.9 (95% CI 43 to 47) per 1000 child years. Out of the 45 children presumed as LTFU, we successfully traced 44 out of the 45 children (98%),and found that their actual current status was as follows: 33 of the 44 children (75.0%) had dropped out of care, hence fulfilled the criteria for true LTFU, 6 children (13.6%) were dead and 5 (11.4%) had transferred themselves to other facilities. The median time for those LTFU was 8 months (IQR 4-34) with a follow up time of 79.7 child years. Following tracing the true period prevalence and incidence of LTFU was 12.6% and 32.9 (95% CI 30.9 to 34.9) per 1000 child years respectively. Factors strongly predictive of LTFU included male gender ( HR 1.22, 1.08-2.63, p= 0.025) low caregiver level of education (HR 2.3, 1.9-3.9, P =0.001), WHO stage I and II at enrolment (HR 1.6, 1.4-2.1, P =0.05) and children not on ART at last contact with hospital (HR 4.7, 4.4-6.0, p=0.03). The factors perceived by healthcare workers to contribute to loss to follow up included stigma, inadequate staffing, poor clinic physical infrastructure and poor attitude of health care workers. Conclusions: Over the 6 year period, LTFU of HIV infected children was common with an incidence rate of 32.9 per 1000 child years and occurred early in treatment and risk factors included low caregiver education, male child, early HIV disease stage and not being on ART.