Background:  The government of Malawi began an antiretroviral program in 2001 consisting of fixed-dose combination tablets of nevirapine/stavudine/lamivudine. Analysis of the program has revealed a high loss to follow-up after 6 months with the vast majority occurring in the first 2 months. The objective of this study was to determine the causes for loss to follow-up.

Methods:  A prospective observation study enrolled patients seeking antiretroviral therapy in the Lighthouse Clinic at Lilongwe Central Hospital in Malawi. Patients followed the general clinic procedures, including payment for their medication, but received free laboratory tests and were actively traced in the event of missed visits. For univariate and bivariate analysis we relied on standard descriptive statistics including Pearson’s chi square and Wilcoxon rank sum test. 

Results:  From January 2003 until June 2003, 179 patients enrolled in the cohort. Baseline characteristics of the cohort include 76% WHO stage 3 or 4 with a median CD4 of 70 cells (IQR 20 to 163). To date, 37 patients have died (21%). Among those who died, median CD4 was lower (28 cells [IQR 9 to 79] vs 83 cells (IQR 30 to 180), p = 0.0006), and AST was higher (72 mg/dL [IQR 48 to 96] vs 39 mg/dL [IQR 30 to 54], p = 0.0001). Median baseline Karnovsky score was significantly lower for those who died (70 [IQR 50 to 85] vs 90 [IQR 80 to 100], p = 0.0001). All patients died either prior to initiating therapy or within the first 3 months of treatment. Reported causes of death included cryptococcal meningitis (3), anemia (7), suspected bacterial pneumonia (7), tuberculosis (5), Kaposi’s sarcoma (3), sepsis (1), renal failure (1), and  unknown (10). In 12 cases, death was only verified after actively tracing the clients. 

Conclusions:  Early mortality secondary to HIV-related disease is the primary contributor to loss to follow-up among Malawians seeking antiretroviral therapy. Identification and initiation of antiretroviral therapy earlier in the course of disease likely will improve outcomes. 

Keywords: Mortality; Antiretroviral Therapy; Developing Countries