Urgent need to strengthen active tracing of lost to follow up cases: a prospective cohort study of newly diagnosed HIV clients in rural districts, Zambia Paul Nambala 1, Shinsuke Miyano 2, Kenichi Komada 2,3, Francis Hadunka 1, Vincent Chipeta 4, Kenneth Chibwe 4, Albert Mwango 5 1 Kazungula District Community Medical Office, Zambia 2 National Center for Global Health and Medicine, Japan 3 SHIMA project, JICA, Lusaka, Zambia 4 Kalomo District Community Medical Office, Zambia 5 Ministry of Health, Lusaka, Zambia

Background: HIV in Zambia Zambia has a population of 13.2 million (2010) New infection rate in % among males % among females HIV Prevalence in adults: 14.3% (2007 ZDHS) - Rural 10.3 % - Urban 19.7%

Kazungula and Kalomo District 480 & 360km south west of Lusaka (Capital city) Share borders with Zimbabwe, Namibia, Botswana by the Zambezi river. Total population: 396,390 (2013) Area: 30,000 km 2 The mainstay is agriculture and animal husbandly with few industry.

HIV in Kazungula/Kalomo Adult HIV prevalence rate -13.4%. ART services started in a few selected health facilities in 2005 and have been scaling up. Number of HIV infected adults on ARVs – 8200.

Objectives To assess the retention among HIV testing, care and treatment. To evaluate active tracing for lost to follow up cases in rural districts in Zambia.

Methods A Prospective Cohort Study Newly diagnosed HIV clients from April 2012 to March 2013 in 8 health facilities in Kazungula and Kalomo has been enrolled. The data have been collected through clients’ records and interviews Assessed at June 2013 The retention rates were estimated by Kaplan-Meier method

Result Table 1. Baseline characteristics of enrolled cases Number% Study site District Hospital Rural Health Centres HIV test entry points OPD/IPD VCT ANC/MCH TB121.5 Others ART eligibility at base line Eligible (ART) Not eligible (Pre-ART)

Number% Gender Male Female WHO stage Stage Ⅰ Stage Ⅱ Stage Ⅲ Stage Ⅳ 61.0 Discordant couples Known as discordant698.4 MedianIQR Age (years) CD4 cell count (cells/mm 3 ) Table 1. Baseline characteristics of enrolled cases (cont’d)

Result Figure 1. Continuum of HIV care in enrolled cases Pre-ART 240 clients (36.7%) ART 414 clients (63.3%) No access to HIV care 168 / 822 clients (20.4%) LTFU at 12 months 139 / 654 clients (21.3%) HIV Positive Total 822 clients OPD/IPD253 VCT320 ANC/MCH99 TB12 Others138 Enrolled in HIV Care Total 654 clients (79.6%) OPD/IPD221 (87.4%) VCT266 (83.1%) ANC/MCH74 (74.7%) TB12 (100%) Others81 (58.7%)

Result Figure 2. Pre-ART and ART retention rate (Kaplan-Meier estimates) 12 months retention ART 75.4% Pre-ART 75.9%

Result Figure 3. The LTFU cases traced by phone Lost to Follow up at 12 months n = 139 n = 139 Have phone number 53 / 139 ( 38.1%) 53 / 139 ( 38.1%) No phone number 86 / 139 ( 61.9%) 86 / 139 ( 61.9%)

Figure 3. The LTFU cases traced by phone Lost to Follow up at 12 months n = 139 Have phone number 53 / 139 ( 38.1%) 53 / 139 ( 38.1%) No phone number 86 / 139 ( 61.9%) Reachable to Clients 17 / 53 (32.1%) Not Reachable 14 / 53 (26.4%) Invalid/Wrong number 22 / 53 (41.5%) Result

Figure 3. The LTFU cases traced by phone Lost to Follow up at 12 months n = 139 Have phone number 53 / 139 ( 38.1%) No phone number 86 / 139 ( 61.9%) Reachable to Clients 17 / 53 (32.1%) Not Reachable 14 / 53 (26.4%) Invalid/Wrong number 22 / 53 (41.5%) Returned to the original facility 3 / 17 (17.6%) Self transfer out to other facility 4 / 17 (23.5%) Not returned on the care 10 /17 (58.9%) Result

Figure 3. The LTFU cases traced by phone Lost to Follow up at 12 months n = 139 Have phone number 53 / 139 ( 38.1%) No phone number 86 / 139 ( 61.9%) 86 / 139 ( 61.9%) Reachable to Clients 17 / 53 (32.1%) Not Reachable 14 / 53 (26.4%) Invalid/Wrong number 22 / 53 (41.5%) Returned to the original facility 3 / 17 (17.6%) Self transfer out to other facility 4 / 17 (23.5%) Not returned on the care 10 /17 (58.9%) 122 / 139 (87.8%) need physical follow-up Result

Discussions (1) The reasons for Many LTFU cases were maybe; - long distances to access ART services. - bad road condition in the rainy season. - not enough attention by staff and supporters. - still have some stigma among HIV clients. - many seasonal migrants (fishermen) in some sites. The linkage between diagnosis and care should be strengthened. There is need to conduct adequate counseling soon after HIV diagnosis

Discussions (2) Tracing LTFU case by phone is not feasible in rural area of Zambia because, - most clients do not have Mobile phones - some clients give wrong phone numbers - poor accessibility of phone networks in rural area Adherence counseling at every visit and physical tracing should be strengthened. Need to consider how to motivate treatment supporters.

Conclusions Despite having successful scaled up HIV services to many rural health facilities, we still have a big number of LTFU cases. There is urgent need to strengthen active tracing of LTFU cases.

Acknowledgement Our patients Treatment supporters District Community Medical Offices JICA-SHIMA project NCGM MCDMCH- Zambia MOH- Zambia