1. No Success without Retension John F. Kennedy Medical Center 11-Jun-16 JFK-ESTHER1

2. 9:30am Interventions to Decrease LFU Rate in JFK Medical Center Monrovia, Liberia Dr.Abraham Borbor-JFK Medical Center Dr. JM Chapplain -Rennes Hospital Dr. S. Brisbane-JFK Medical Center Ms. Coco Vaneway -JFK Hospital -Mr. P Mendiharat -Esther 11-Jun-16 2

3. Liberia Population of Liberia : 3,4 million, –1/3 living in and around Monrovia HIV prevalence in 2008 = 1.7% –in Monrovia = 2.5% Civil war 1989-2003 11-Jun-16 3JFK-ESTHER

4. in 2009 Rennes Hospital Lille-Tourcoing Hospital, Treichville hospital, Abidjan JFK Hospital, Monrovia,Liberia Redemption Hospital, Monrovia, Liberia 11-Jun-16 4JFK-ESTHER

5. JFK Medical Center in Monrovia –Largest Referral Center; –Teaching Hospital for the Medical College of the University of Liberia; –HIV Care (ART) at the JFK Medical Center started in November 2006. 11-Jun-16 5JFK-ESTHER

6. 11-Jun-16 6JFK-ESTHER

7. HIV Patient Retension Rate in Liberia –In Liberia, 84.1% of patients in care were retained in various ART Programs in 2009, with lost to Follow up of 15.9% (NACP, 2009 Report). 11-Jun-16 7JFK-ESTHER

8. Retension Rate in JFK Medical Center, Monrovia JFK : patients who initiated Care & ART from May 2008 to May 2010 –2112 HIV patients on Care & ART, –651 patients (29.1%) were LTFU *adults (≥18 years old) who had at least one visit and who did not return for follow up visits at least three months after their last visit. 11-Jun-16 8JFK-ESTHER

9. First step intervention A workshop on LFU in Monrovia in March 2010 –JFK medical center – Esther project with the approval of National AIDS and STI Control Program (NACP) 11-Jun-16 9JFK-ESTHER

10. A workshop in Monrovia in March 2010 Review interventions implemented to decrease the rate of lost to follow-up in patients on care : –In Monrovia : JFK Hospital ELWA Hospital Redemption hospital –In other counties : Grand Gedeh (Zwedru) and Maryland (Harper) 2 working groups recommended the following interventions to be implemented to decrease the rate of lost to follow-up –Reach consensus 11-Jun-16 10JFK-ESTHER

11. Planed Interventions to reduce LTFU Conduct a study to find out why patients are lost to follow at the clinic Improve data collection: –detailed description; diagram on where the house is; patients phone number; Update the information Developing a computerized database that alerts on who is LTFU Patient reminder of the appointment: phone call before; To define a “treatment support friend” Set of follow-up team: social workers, PLWHA, including clinical staff Improve the relationship between the HIV team and the patient Improving confidentiality and patient flow (less time spent on the medical site (more space, more clinic days) Increase the manpower (Data manager; Social workers; PA) Nutritional support for needy patients and Infant feeding Transportation for patients coming to clinic-not feasible, not sustainable 11-Jun-16 11JFK-ESTHER

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13. Intervention : –A cross sectional study was done to determine reasons for stopping Treatment and lost to care Care –To find out from patients and or affected family member(s) followed in these clinics causes for stopping Treatment and Care Study Design 11-Jun-16 13JFK-ESTHER

14. To Determine Reasons for Stopping Treatment and Care A first questionnaire used to collect socio- demographic clinical and biological characteristics of these patients (from charts). A second questionnaire administered by one nurse and two social workers collected data on causes of lost to follow-up. –patients were contacted by phone –if non reachable by visits to their habitation. 11-Jun-16 14JFK-ESTHER

15. In JFK –651patients (29.1%) LTFUP out of 2112 patients on ART –177 patients identified with phone or address in their chart during the study period Improve data collection 11-Jun-16 15JFK-ESTHER

16. Patients on ART From 177 LTFU patients with address/phone 157 patients or their relatives reached (90%) –20 patient with wrong address or phone number. From these 157 patients, –84 (54%) had died 36 (43%) before the scheduled visit in the clinic 48 (57%) after; –51 (32%) had moved to another clinic of whom stated in addition having missed appointments at JFK for: –25% (n=13) because of lack of transportation; –20% (n=10) due to child care commitments; –12% (n=6) for work responsibilities –2% (1) for lack of money. 11-Jun-16 16JFK-ESTHER

17. Follow-up 651 patients (29.1%) were LTFU Median of 2 [0-20] visits at the HIV clinic between ART initiation and date of last visit CD4 cell count (IQR) at the last visit = 195 cells/mm 3 (106-334). 11-Jun-16 17JFK-ESTHER

18. Other Reasons for LTFU Child care commitments in 2 (4%) Lack of transportation-2 (4%) Religious intervention- Traditional care-2 (4%) Sick relative 11-Jun-16 JFK-ESTHER18

19. Progress on Interventions to Reduce LTFU Improve data collection: –detailed description; diagram on where the house is; patients phone number; Update the information Developing a computerized database that alerts on who is LTFU Free transportation-not feasible, not sustainable, Patient reminder of the appointment: phone call before; To define a “treatment support friend” Set of follow-up team: social workers, PLWHA, including clinical staff Improve the relationship between the HIV team and the patient Improving confidentiality and patient flow (less time spent on the medical site (more space, more clinic days) Increase the manpower (Data manager; Social workers; PA) Nutritional support for needy patients and Infant feeding Study done and completed 11-Jun-16 19JFK-ESTHER

20. No success Without Reteension Patients lost to care and treatment do not benefit from any intervention, and death rate is high Lost to follow tends to occurs early after starting ART All efforts must be made to trace patients lost to care and treatment 11-Jun-16 JFK-ESTHER20

21. Stages of pre-ART care 11-Jun-16 21JFK-ESTHER

22. Gratitude THANKS FOR LISTENING 11-Jun-16 JFK-ESTHER22

23. Acknowledgement institutions Ministry of Health, Republic of Liberia ESTHER, Paris, France National AIDS Control Program of Liberia John F. Kennedy Medical Center personnel Dr. Wvaniscott McDonald Dr. Samuel Brisbane Doctors Nurses PAs 11-Jun-16 23JFK-ESTHER