Camlin Carol S, Neilands Torsten B, Odeny Thomas A, Lyamuya Rita, Nakiwogga-Muwanga Alice, Diero Lameck, Bwana Mwebesa, Braitstein Paula, Somi Geoffrey, Kambugu Andrew, Bukusi Elizabeth A, Glidden David V, Wools-Kaloustian Kara K, Wenger Megan, Geng Elvin H
aDepartment of Obstetrics, Gynecology and Reproductive SciencesbCenter for AIDS Prevention Studies, University of California, San Francisco, California, USAcResearch Care and Training Program, Center for Microbiology Research and the Family AIDS Care and Education Services Program, Kenya Medical Research Institute, Nairobi, KenyadNational AIDS Control Program, Dar es Salaam, TanzaniaeInfectious Diseases Institute, Kampala, UgandafKenya Academic Model Providing Access to Healthcare (AMPATH), Moi University, Eldoret, KenyagMbarara University of Science and Technology, Mbarara, UgandahDivision of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, CanadaiDepartment of Epidemiology and Biostatistics, University of California, San Francisco California USA.jDivision of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IndianakDivision of HIV/AIDS, Department of Medicine, University of California, San Francisco General Hospital, San Francisco, California, USA.
AIDS. 2016 Jan 28;30(3):495-502. doi: 10.1097/QAD.0000000000000931.
Engagement in care is key to successful HIV treatment in resource-limited settings; yet little is known about the magnitude and determinants of reengagement among patients out of care. We assessed patient-reported reasons for not returning to clinic, identified latent variables underlying these reasons, and examined their influence on subsequent care reengagement.
We used data from the East Africa International Epidemiologic Databases to Evaluate AIDS to identify a cohort of patients disengaged from care (>3 months late for last appointment, reporting no HIV care in preceding 3 months) (n = 430) who were interviewed about reasons why they stopped care. Among the 399 patients for whom follow-up data were available, 104 returned to clinic within a median observation time of 273 days (interquartile range: 165-325).
We conducted exploratory and confirmatory factor analyses (EFA, CFA) to identify latent variables underlying patient-reported reasons, then used these factors as predictors of time to clinic return in adjusted Cox regression models.
EFA and CFA findings suggested a six-factor structure that lent coherence to the range of barriers and motivations underlying care disengagement, including poverty, transport costs, and interference with work responsibilities; health system 'failures,' including poor treatment by providers; fearing disclosure of HIV status; feeling healthy; and treatment fatigue/seeking spiritual alternatives to medicine. Factors related to poverty and poor treatment predicted higher rate of return to clinic, whereas the treatment fatigue factor was suggestive of a reduced rate of return.
Certain barriers to reengagement appear easier to overcome than factors such as treatment fatigue. Further research will be needed to identify the easiest, least expensive interventions to reengage patients lost to HIV care systems. Interpersonal interventions may continue to play an important role in addressing psychological barriers to retention.
在资源有限的环境中，参与治疗是成功进行艾滋病毒治疗的关键；然而，对于失访患者重新参与治疗的程度和决定因素知之甚少。我们评估了患者报告的未返回诊所的原因，确定了这些原因背后的潜在变量，并研究了它们对随后重新参与治疗的影响。
我们使用东非国际流行病学数据库评估艾滋病的数据，确定一组失访患者（上次预约迟到超过3个月，在前3个月内未接受艾滋病毒治疗）（n = 430），并就他们停止治疗 的原因进行访谈。在有随访数据的399名患者中，104人在中位观察时间273天内（四分位间距：165 - 325天）返回诊所。
我们进行了探索性和验证性因素分析（EFA，CFA），以确定患者报告原因背后的潜在变量，然后在调整后的Cox回归模型中使用这些因素作为返回诊所时间的预测因子。
EFA和CFA结果表明存在一个六因素结构，该结构使失访背后的一系列障碍和动机具有连贯性，包括贫困、交通成本和对工作职责的干扰；卫生系统“失灵”，包括提供者治疗不当；担心艾滋病毒感染状况被披露；感觉健康；以及治疗疲劳/寻求医学的精神替代方法。与贫困和治疗不当相关的因素预测返回诊所的比率较高，而治疗疲劳因素表明返回比率降低。
某些重新参与治疗的障碍似乎比治疗疲劳等因素更容易克服。需要进一步研究以确定使艾滋病毒治疗系统中失访患者重新参与治疗的最简单、成本最低的干预措施。人际干预可能在解决留存的心理障碍方面继续发挥重要作用。
