BMJ open · 2026
Incidence and predictors of loss to follow-up after ART initiation at public health facilities in Sierra Leone (2020-2024): a retrospective cohort study.
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Fornah Lovel, Osborne Augustus, Shimbre Mulugeta Shegaze, Ma Wei
Аннотация
OBJECTIVE: This study aimed to estimate the incidence and predictors of loss to follow-up (LTFU) among adults after antiretroviral therapy (ART) initiation at five provincial referral hospitals in Sierra Leone.
DESIGN: A facility-based retrospective cohort study.
SETTING: This study was conducted at five provincial government referral hospitals in Sierra Leone from January 2020 to December 2024.
PARTICIPANT: HIV patients aged 15 and above who initiated ART between 1 January 2020, and 31 December 2020, and attended at least one follow-up visit at the five national referral hospitals.
PRIMARY OUTCOME MEASURE: The primary outcome in this study was LTFU. LTFU was defined as absence from care, operationalised as no documented clinical encounter and/or ART refill for ≥90 days after the last expected clinical contact among patients not recorded as dead or transferred out.
RESULTS: Of the 1544 patients (67.7% female), the median follow-up was 4.25 years (IQR not stated), totalling 5748.6 PY. Outcomes were 550 LTFU (35.6%), 853 in care (55.2%), 64 (4.1%) transferred and 77 (5.0%) died. The LTFU incidence was 9.57 per 100 PY (95% CI 8.78 to 10.37). Multivariable analyses revealed several factors significantly associated with higher LTFU: lack of tuberculosis (TB) screening (HR=4.47; 95% CI 3.66 to 5.46), WHO stage III/IV (HR=1.51; 95% CI 1.20 to 1.89), no regimen change (HR=5.12; 95% CI 2.39 to 11.00), non-disclosure of HIV status (HR=1.63; 95% CI 1.19 to 2.25), underweight body mass index (BMI) at follow-up (HR=1.37; 95% CI 1.05 to 1.78) and residence in the Southern (HR=1.97; 95% CI 1.57 to 2.48) or Eastern region (HR=2.13; 95% CI 1.49 to 3.03). Conversely, rural residence was associated with lower LTFU (HR=0.58; 95% CI 0.43 to 0.79).
CONCLUSION: The study found a substantial incidence of LTFU. Risk factors of LTFU were gaps in TB screening, advanced clinical stage, absence of timely regimen adjustments, non-disclosure, low BMI and regional disparities. Strengthening integrated TB/HIV services, nutritional support, disclosure-enabling counselling and region-specific retention strategies, especially in urban, Southern and Eastern areas, may improve retention.
DESIGN: A facility-based retrospective cohort study.
SETTING: This study was conducted at five provincial government referral hospitals in Sierra Leone from January 2020 to December 2024.
PARTICIPANT: HIV patients aged 15 and above who initiated ART between 1 January 2020, and 31 December 2020, and attended at least one follow-up visit at the five national referral hospitals.
PRIMARY OUTCOME MEASURE: The primary outcome in this study was LTFU. LTFU was defined as absence from care, operationalised as no documented clinical encounter and/or ART refill for ≥90 days after the last expected clinical contact among patients not recorded as dead or transferred out.
RESULTS: Of the 1544 patients (67.7% female), the median follow-up was 4.25 years (IQR not stated), totalling 5748.6 PY. Outcomes were 550 LTFU (35.6%), 853 in care (55.2%), 64 (4.1%) transferred and 77 (5.0%) died. The LTFU incidence was 9.57 per 100 PY (95% CI 8.78 to 10.37). Multivariable analyses revealed several factors significantly associated with higher LTFU: lack of tuberculosis (TB) screening (HR=4.47; 95% CI 3.66 to 5.46), WHO stage III/IV (HR=1.51; 95% CI 1.20 to 1.89), no regimen change (HR=5.12; 95% CI 2.39 to 11.00), non-disclosure of HIV status (HR=1.63; 95% CI 1.19 to 2.25), underweight body mass index (BMI) at follow-up (HR=1.37; 95% CI 1.05 to 1.78) and residence in the Southern (HR=1.97; 95% CI 1.57 to 2.48) or Eastern region (HR=2.13; 95% CI 1.49 to 3.03). Conversely, rural residence was associated with lower LTFU (HR=0.58; 95% CI 0.43 to 0.79).
CONCLUSION: The study found a substantial incidence of LTFU. Risk factors of LTFU were gaps in TB screening, advanced clinical stage, absence of timely regimen adjustments, non-disclosure, low BMI and regional disparities. Strengthening integrated TB/HIV services, nutritional support, disclosure-enabling counselling and region-specific retention strategies, especially in urban, Southern and Eastern areas, may improve retention.