1. REASONS FOR LONG-TERM LOSS TO FOLLOW UP OF ADULT ART PATIENTS IN SOUTH AFRICA: A PROSPECTIVE, QUALITATIVE STUDY METHODS RESULTS POLICY RECOMMENDATIONS We enrolled a random sample of adult patients who had been on ART for 6 months to 3 years at two treatment sites in South Africa: a public sector urban hospital and an NGO clinic serving a rural population. At enrollment, subjects provided detailed contact information to allow later follow-up. Subjects in default 12 months after study enrollment were contacted by study coordinator. –Defaulting was defined as > 1 month late for an appointment or medication pickup. Qualitative interviews were conducted with defaulting subjects regarding reasons for default and experience taking ART. –Assistance was offered to help subjects return to care, where appropriate. Data were analyzed using qualitative methods. –Interviews read multiple times to identify major themes and ideas; these were coded and analyzed using NVIVO 8 software –Coded text examined to understand similarities and differences within each category and quantify the frequency with which ideas occurred. –Consistency of ideas and experiences was examined within individual transcripts to understand why some reports and actions were disparate. Contact: Candace Miller Center for International Health and Development, Boston University School of Public Health 801 Massachusetts Ave, Boston, MA 02118 USA Tel: 617-414-1216 Email: candace@bu.edu@bu.edu Extend clinic hours on evenings and weekends to accommodate patient work schedules. Simplify processes for referral and scheduling for patient convenience. Improve communication between treatment facilities to ensure continuity of care. Improve tracking of patients who transfer between facilities to allow focus on patients who discontinue treatment, rather than merely changing sites. Where possible, employ a loss-to-follow-up counselor who can offer assistance with small barriers to returning to care, such as paperwork, scheduling, disclosure to families, etc. Antiretroviral therapy (ART) requires a lifelong commitment; successful treatment requires motivated patients and providers. Retention of patients in treatment is essential for the long-term success of ART, but retaining asymptomatic patients in treatment is a challenge worldwide Patient default on medication is thought to be a major problem in the developing world Research on patient attrition in South Africa has yielded mixed results and has focused on patients who still attend clinic visits. Better research is needed to identify reasons for patient attrition and methods to improve adherence as South Africa continues to roll out free ART. BACKGROUND Subjects universally expressed positive attitudes towards treatment Subjects demonstrated knowledge of the health effects of ART Not all defaulters reported negative consequences of stopping ART Stigma, side effects, and traditional medicine were not widely reported and were not major contributors to attrition Health systems complaints (long queues, inadequate provider time, etc.) were prevalent Subjects reported universal willingness to recommend ART to HIV positive friends and family members Subjects expressed unwillingness to reveal their own status in discussion about ART Candace M. Miller 1, Mpefe Ketlhapile 2, Heather Rybasack-Smith 1, Sydney Rosen 1,2 1 Boston University Center for International Health and Development, Boston, USA 2 Health Economics and Epidemiology Research Office, Johannesburg, South Africa OBJECTIVES The overall objective of this study was to investigate the situation of patients who default from ART programs after successfully remaining on treatment for at least the first six months. Specific objectives were: 1.To identify major themes and contributors to patient attrition from ART programs in South Africa. 2.To make policy and practice recommendations that will facilitate better long- term retention in care. Descriptive Findings KEY RESULTS Major reasons for default for 9 of 13 subjects were logistical issues related to employment, limited clinic hours, paperwork, and travel. Stigma was not reported as a major reason for default, but it affected patients interactions with others. Traditional medicine was not a major reason for default. Many patients reported by study sites as lost to follow up said that they had actually transferred to different facilities. Most transfers were due to lack of resources for transportation to the original clinic. 11/13 defaulters wished to resume ART but needed help returning to treatment. Study coordinator was able to facilitate the return to treatment of several patients by helping to make new appointments, consulting clinic staff, providing referrals, and/or providing transport funds for first visit. Cohort Outcomes 12 Months After Enrollment Reasons for Default CONTACT DETAILS Many barriers to ART adherence in this sample are resolvable with simple solutions. Logistical issues such as lost paperwork, restrictive clinic operating hours, and inability to obtain adequate supply of medication during travel were the main cause for attrition in this sample. Nine out of 13 patients in default blamed logistical issues for their attrition. Only three patients stopped ART purely for personal reasons (e.g. desire to take traditional medicine, feeling that ART did not improve health). Patients demonstrated a high level of motivation to remain on treatment but needed assistance to do so. CONCLUSIONS