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					                                                                       Tracking of Pediatric Patients Lost to Follow-Up
                                                                                Bahir Dar, Northern Ethiopia
                                                                      William J. Clinton Foundation HIV/AIDS Initiative (CHAI Ethiopia)
                                                                                            Anna Talman, Dept of Global Health MPH 2010
                                                                                              Site Supervisor: Dr. Happyson Musvosvi

                                                                                                                                                             Reported Reasons for Loss to Follow-up

Introduction                                                      Methods                                                                                                                                                              We have seen that registration and
    Clinton Foundation’s HIV/AIDS Initiative                          Unlike most initiatives examining loss to                                                                                                                     documentation problems account for a
(CHAI Ethiopia) provides mentorship and                           follow-up, this pilot project examined default                              Denies HIV/Unwilling to
                                                                                                                                                  Continue Care
                                                                                                                                                                                                                                    substantial proportion (21%) of patients thought
                                                                                                                                                                                                       Reporting Error
technical assistance to health facilities in                      among all pediatric HIV patients—both those                           Death or Illness of Parent                                                                  to be lost to follow-up. The problem of under- or
Ethiopia. Among its major foci are scaling up                     taking antiretroviral medications and those not                                                                                                                   miss-documentation is particularly severe among
                                                                                                                                                   Holy Water

pediatric HIV testing and treatment, including                    yet initiated on therapy. Felige Hiwot Hospital                                                                                                                   pre-ART patients and HIV-exposed infants.
providing pediatric antiretroviral therapy                        was one of five sites in this project.                                                                                                                               Transportation problems were another major
                                                                                                                                   Health Improvement

(ART).                                                                When outreach workers were able to find a                                                                                                                     reason for default (7.2% of families). Transport
    Felige Hiwot Hospital, a major referral                       family, they asked a series of questions about                                                                                                  Death
                                                                                                                                                                                                                                    support may be a stopgap intervention to ease
                                                                                                                                        Transport Problems
hospital in Northwestern Ethiopia, serves a                       the child’s HIV care and the family’s reasons for                                                                                                                 this problem, but decentralization of HIV care and
patient population of several million. More                       defaulting for care. Outreach workers then filled                                                                                                                 pediatric ART will be the primary solution to this
                                                                                                                                              Misunderstanding or
than 7,000 patients have started antiretroviral                   out a form detailing their conversations and                                Unclear Instructions                                                                  problem
                                                                                                                                                                                Moved or Transferred Out
treatment at this facility, and it was one of the                 provided health education and peer support
first facilities in Ethiopia to provide pediatric                 encouraging families to return to HIV care.                       Figure 2: The most common reasons for default included                                          Conclusion
HIV/AIDS treatment and follow-up.                                     Outreach workers were able to locate 52% of                      reporting error, death, and moving/transferring out.                                             We found an alarmingly high rate of LTFU in
                                                                  families residing outside of Bahir Dar and 32% of                                                                                                                 this pediatric population, much higher than those
                                                                  those residing within city limits.                    Discussion                                                                                                  reported in studies of adults. Retention in care
                                                                                                                                                                                                                                    must be a priority for facilities providing
                                                                                                                            The fact that death of the child is one of the
                                                                  Results                                                                                                                                                           antiretroviral therapy. Timely and accurate
                                                                                                                        major reasons for default from care should be
                                                                    The chart review revealed that 47.6% of the 842                                                                                                                 tracing of patients lost to follow-up is an
                                                                                                                        seen as a red flag. Of all families contacted,
                                                                                                                                                                                                                                    important part of maintaining a high quality of
                                                                  pediatric patients examined had been LTFU.            18.7% reported non-attendance because of
                                                                                                                                                                                                                                    care. Many of the patients traced during this pilot
                                                                                                                        death. High mortality could reflect late access to
                                                                                                                                                                                                                                    project were lost to follow-up more than two
                                                                   ART Patients                                         care and poor ascertainment of eligibility for
                                                                                                                                                                                                                                    years ago. It is vital that records be made,
                                                                         288 charts reviewed: 50 (17.4%) LTFU.          ARV treatment.
                                                                                                                                                                                                                                    updated, and examined to identify children lost
                                                                     Pre-ART Patients                                      The use of holy water is another interesting
                                                                                                                                                                                                                                    to follow-up, and that resources be allocated to
                                                                         313 charts reviewed: 198 (63.3%) LTFU.         finding. Nearly seven percent of families
                                                                                                                                                                                                                                    encouraging families of defaulting children to
                                                                     HIV-exposed Infants                                reported the use of holy water or Eucharist as a
                                                                                                                                                                                                                                    bring them back to care. Further linkages to
                                                                         241 charts reviewed: 153 (63.5%) LTFU.         primary reason for defaulting from care. Health
                                                                                                                                                                                                                                    community-based organizations and social and
                                                                                                                        care providers should be sensitized to this issue
                                                                                                                                                                                                                                    economic support can ease the problem of LTFU.
                                                                                                                        and should take initiative to ask patients about
                                                                                                                                                                                                                                    Continued health education and adherence
                                                                  Of the 401 children identified, 322 were tracked.     their use of religious treatments in conjunction
                                                                                                                                                                                                                                    counseling are also vital. Rapid decentralization
  Figure 1: Felige Hiwot Referral Hospital, Bahir Dar, Ethiopia
                                                                  Tracking took place over a period of three and a      with medical care.
                                                                                                                                                                                                                                    of pediatric HIV care and integration of HIV
                                                                  half months. Outreach workers traced 125
                                                                                                                                                                                                                                    services with primary health care facilities will
                                                                  children residing outside of Bahir Dar, and 197                                                                               Percent of
                                                                                                                                                                            Overall             Families          Percent of        further ameliorate the problem of LTFU.
    Despite the dramatic scale-up of ART at                       children within the city.                                                                                 Percentage of       Outside of        Families Within
                                                                                                                                                                            Families            Bahir Dar         Bahir Dar
 the facility, loss to follow-up (LTFU) has                                                                                                                                 Reporting this      Reporting this    Reporting this    Acknowledgements
                                                                                                                      Reason                                                Reason              Reason            Reason
 been one of the major barriers to the                               Reported reasons for default were multiple,                                                                                                                       This project was funded by CHAI Ethiopia,
                                                                                                                      Reporting Error                                                   20.9               10.8              32.3
 successful provision of both adult and                           and varied greatly. The reported reasons also       Death                                                             18.7               28.4               7.7   and was conducted in collaboration with
 pediatric ART. While adult LTFU has been                         varied significantly between families residing      Moved or Transferred Out                                          18.0               21.6              13.9
                                                                                                                                                                                                                                    International Training and Education Center on
                                                                                                                      Misunderstanding or Unclear Instructions                            7.9               0.0              16.9
 documented at approximately 25% in                               within city limits and those residing away from     Transport Problems                                                  7.2              10.8               3.1   HIV (I-TECH), Mekdim Ethiopia, and Felige
 Ethiopia, little research has been conducted                     the city.                                           Health Improvement                                                  6.5               2.7              10.8   Hiwot Referral Hospital. The project would not
 on LTFU in a pediatric population.                                                                                   Holy Water                                                          6.5               4.0               9.2
                                                                                                                      Death or Illness of Parent                                          4.3               6.8               1.5
                                                                                                                                                                                                                                    have been possible without the support of the
    This pilot project aimed to assess the                          Figures 2 and 3 detail the reasons families       Denies HIV/Unwilling to Continue Care                               2.2               2.7               1.5   Program Director, Sarah Pasternak, hospital
 extent of LTFU at Felige Hiwot Referral                          stated as primary reasons for having difficulty     Other                                                               7.9              12.2               3.1   staff, and the seven outreach workers.
 Hospital, to evaluate families’ reasons for                      getting to the hospital for appointments.
 defaulting from care, and to encourage                                                                               Figure 3: Reasons for defaulting from care, by place of residence;
                                                                                                                                                                                                                                    Contact Information:
                                                                                                                      reported reasons differed for patients living within and outside the
 defaulting patients to return to care, either                                                                                                city of Bahir Dar.
 at Felige Hiwot or at another health facility.

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