Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa.

<h4>Background</h4>Evaluation of antiretroviral treatment (ART) programmes in sub-Saharan Africa is difficult because many patients are lost to follow-up. Outcomes in these patients are generally unknown but studies tracing patients have shown mortality to be high. We adjusted programme-...

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Autores principales:	Martin W G Brinkhof, Ben D Spycher, Constantin Yiannoutsos, Ralf Weigel, Robin Wood, Eugène Messou, Andrew Boulle, Matthias Egger, Jonathan A C Sterne, International epidemiological Database to Evaluate AIDS (IeDEA)
Formato:	article
Lenguaje:	EN
Publicado:	Public Library of Science (PLoS) 2010
Materias:	Medicine R Science Q
Acceso en línea:	https://doaj.org/article/e1150c3cd5064b668af546466fadff3d
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spelling	oai:doaj.org-article:e1150c3cd5064b668af546466fadff3d2021-11-18T07:02:21ZAdjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa.1932-620310.1371/journal.pone.0014149https://doaj.org/article/e1150c3cd5064b668af546466fadff3d2010-11-01T00:00:00Zhttps://www.ncbi.nlm.nih.gov/pmc/articles/pmid/21152392/?tool=EBIhttps://doaj.org/toc/1932-6203<h4>Background</h4>Evaluation of antiretroviral treatment (ART) programmes in sub-Saharan Africa is difficult because many patients are lost to follow-up. Outcomes in these patients are generally unknown but studies tracing patients have shown mortality to be high. We adjusted programme-level mortality in the first year of antiretroviral treatment (ART) for excess mortality in patients lost to follow-up.<h4>Methods and findings</h4>Treatment-naïve patients starting combination ART in five programmes in Côte d'Ivoire, Kenya, Malawi and South Africa were eligible. Patients whose last visit was at least nine months before the closure of the database were considered lost to follow-up. We filled missing survival times in these patients by multiple imputation, using estimates of mortality from studies that traced patients lost to follow-up. Data were analyzed using Weibull models, adjusting for age, sex, ART regimen, CD4 cell count, clinical stage and treatment programme. A total of 15,915 HIV-infected patients (median CD4 cell count 110 cells/µL, median age 35 years, 68% female) were included; 1,001 (6.3%) were known to have died and 1,285 (14.3%) were lost to follow-up in the first year of ART. Crude estimates of mortality at one year ranged from 5.7% (95% CI 4.9-6.5%) to 10.9% (9.6-12.4%) across the five programmes. Estimated mortality hazard ratios comparing patients lost to follow-up with those remaining in care ranged from 6 to 23. Adjusted estimates based on these hazard ratios ranged from 10.2% (8.9-11.6%) to 16.9% (15.0-19.1%), with relative increases in mortality ranging from 27% to 73% across programmes.<h4>Conclusions</h4>Naïve survival analysis ignoring excess mortality in patients lost to follow-up may greatly underestimate overall mortality, and bias ART programme evaluations. Adjusted mortality estimates can be obtained based on excess mortality rates in patients lost to follow-up.Martin W G BrinkhofBen D SpycherConstantin YiannoutsosRalf WeigelRobin WoodEugène MessouAndrew BoulleMatthias EggerJonathan A C SterneInternational epidemiological Database to Evaluate AIDS (IeDEA)Public Library of Science (PLoS)articleMedicineRScienceQENPLoS ONE, Vol 5, Iss 11, p e14149 (2010)
institution	DOAJ
collection	DOAJ
language	EN
topic	Medicine R Science Q
spellingShingle	Medicine R Science Q Martin W G Brinkhof Ben D Spycher Constantin Yiannoutsos Ralf Weigel Robin Wood Eugène Messou Andrew Boulle Matthias Egger Jonathan A C Sterne International epidemiological Database to Evaluate AIDS (IeDEA) Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa.
description	<h4>Background</h4>Evaluation of antiretroviral treatment (ART) programmes in sub-Saharan Africa is difficult because many patients are lost to follow-up. Outcomes in these patients are generally unknown but studies tracing patients have shown mortality to be high. We adjusted programme-level mortality in the first year of antiretroviral treatment (ART) for excess mortality in patients lost to follow-up.<h4>Methods and findings</h4>Treatment-naïve patients starting combination ART in five programmes in Côte d'Ivoire, Kenya, Malawi and South Africa were eligible. Patients whose last visit was at least nine months before the closure of the database were considered lost to follow-up. We filled missing survival times in these patients by multiple imputation, using estimates of mortality from studies that traced patients lost to follow-up. Data were analyzed using Weibull models, adjusting for age, sex, ART regimen, CD4 cell count, clinical stage and treatment programme. A total of 15,915 HIV-infected patients (median CD4 cell count 110 cells/µL, median age 35 years, 68% female) were included; 1,001 (6.3%) were known to have died and 1,285 (14.3%) were lost to follow-up in the first year of ART. Crude estimates of mortality at one year ranged from 5.7% (95% CI 4.9-6.5%) to 10.9% (9.6-12.4%) across the five programmes. Estimated mortality hazard ratios comparing patients lost to follow-up with those remaining in care ranged from 6 to 23. Adjusted estimates based on these hazard ratios ranged from 10.2% (8.9-11.6%) to 16.9% (15.0-19.1%), with relative increases in mortality ranging from 27% to 73% across programmes.<h4>Conclusions</h4>Naïve survival analysis ignoring excess mortality in patients lost to follow-up may greatly underestimate overall mortality, and bias ART programme evaluations. Adjusted mortality estimates can be obtained based on excess mortality rates in patients lost to follow-up.
format	article
author	Martin W G Brinkhof Ben D Spycher Constantin Yiannoutsos Ralf Weigel Robin Wood Eugène Messou Andrew Boulle Matthias Egger Jonathan A C Sterne International epidemiological Database to Evaluate AIDS (IeDEA)
author_facet	Martin W G Brinkhof Ben D Spycher Constantin Yiannoutsos Ralf Weigel Robin Wood Eugène Messou Andrew Boulle Matthias Egger Jonathan A C Sterne International epidemiological Database to Evaluate AIDS (IeDEA)
author_sort	Martin W G Brinkhof
title	Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa.
title_short	Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa.
title_full	Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa.
title_fullStr	Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa.
title_full_unstemmed	Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa.
title_sort	adjusting mortality for loss to follow-up: analysis of five art programmes in sub-saharan africa.
publisher	Public Library of Science (PLoS)
publishDate	2010
url	https://doaj.org/article/e1150c3cd5064b668af546466fadff3d
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Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa.

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