ART Patients Who Transfer Out Results There were 4175 patients registered for ART, of whom 805 (19%) had transferred out to another facility, 65 patients transferring to the Central and Southern Regions and 740 to the Northern Region. Altogether, 737 (92%) of these patients were traced. Tracing was successful in 16 (25%) of 65 patients who transferred to the Central and South region and 721 (98%) 740 patients who transferred to the Northern Region. Characteristics and treatment outcome status of patients who transferred out and were traced compared with those who did not transfer out are shown in Table 1. There was a trend for those transferring out to have less advanced clinical stage of disease (WHO Clinical Stage 1,2 or 3 together) compared with those who did not transfer out. The proportion of transfer-out patients who died was significantly less than those who did not transfer out [OR Table 1. Characteristics and treatment outcomes of patients who transferred out and those who did not transfer out from Mzuzu Central Hospital, Malawi, between June 2004 and December 2006. Patients Patients not transferring transferring out out Materials and Methods Background Details of how ART in Malawi is delivered and monitored have previously been described [10]. When patients start ART, their details are entered into ART patient master cards and an ART register, and patients are given a unique ART identification number. Every month patients come for clinic reviews, at which time their outcome status is entered into the master card and they are given another supply of ART drugs for a month. If a patient wishes to transfer to another facility, the name of the new facility to which the patient will move is indicated in the ART register and the treatment outcome is changed to transfer-out. The patient is given his/her ART master card, a transfer out letter and a month’s supply of drugs to take to the new facility. A copy of the original master card is made and kept in the usual numerical order in the arch-back files in the original clinic [10]. Thus, ART staff and staff from supervising teams can see who has transferred out from each clinic by going through the ART patient master cards and the register. At the new facility, the patient is registered with a new ART identification number related to that facility. The patient hands over his/her master card from the previous site, and on this master card the ART identification number is changed to the new number. This master card is then filed in the usual way and used until the end of the year, at which time a new master card is issued to the patient. In both the ART register and the ART master card it is clearly written that the patient is a ‘‘transfer-in’’. Data collection and Analysis The master cards and the ART register of all new patients registered at Mzuzu Central Hospital, Northern Region, Malawi, between June 2004 and December 2006 were reviewed, and a record was made of those who had transferred out to another facility. For patients who had transferred out within the Northern Region, active visits were made to all the ART clinics in that region to determine whether patients had in fact transferred-in, the date of the transfer-in and their latest treatment outcome with the date. Treatment outcomes of patients transferring in were censored on March 31st 2007. Patients alive and on ART on March 31st, 2007, were recorded as such. However, those who had died, were lost to follow-up, stopped therapy or transferred-out again before this date were recorded as such with the date of this outcome. For patients transferring to the Central or Southern Region, active follow-up was confined to making a phone call to the new site to try and obtain data similar to that obtained during Northern Region site visits. Categorical variables between patients who transferred out and who did not transfer out were analyzed and compared using the chi-squared test with odds ratios (OR) and the chi-squared test for trend. The probability of survival between patients who trans- ferred out and were traced and patients who did not transfer-out was estimated using the Kaplan-Meier method, and comparisons made using the Cox-Mantel (Log rank test). The level of significance was set at P = 0.05 or less, and 95% confidence intervals (CI) were used throughout. Data analysis was carried out using SAS system for Windows (Version 8.01). Ethical Approval The Malawi National Health Science Research Committee provides general oversight and approval for the collection and use of routine programmatic data for monitoring and evaluation, as was the case with this study. PLoS ONE | www.plosone.org 2 April 2008 | Volume 3 | Issue 4 | e2065 Number of patients started on ART Female patients Children (aged,15 years) Median age in years Indication for ART: WHO Stage 1 or 2 with low CD4 56 (7%) count WHO Clinical Stage 3 WHO Clinical Stage 4 Patients transferring out and not 68 traced Patients transferring out and traced Median time (range) in months between transfer out and transfer in those traced Treatment outcome statusa Alive and on ART Dead Lost to follow-up Stopped treatment Transferred out again Month 1 Month 2 Month 3 After month 3 805 491 (61%) 81 (10%) 36 620 (77%) 129 (16%) 737 1.3 (0.03–3.53) 634 (86%) 40 (5%) 22 (4%) 0 0 4 (10%) 5 (12.5%) 31 (77.5%) 41 (5%) Not applicable Month of death after start of ART in the original or the new facility for those who had transferred out: atreatment outcomes censored on March 31st, 2007, and for those who transferred out these refer to those who were traced. bchi-squared test for trend = 5.8. cchi-squared test for trend = 42.3. WHO = World Health Organization; ART = antiretroviral therapy. doi:10.1371/journal.pone.0002065.t001 3370 1977 (59%) 396 (12%) 37 530 (16%) 2186 (65%) 654 (19%) P value NS NS NS p = 0.016b 2826 (84%) 423 (12.5%) 120 (3.5%) 1 NS NS NS p,0.001 180 (42.5%) 74 (17.5%) 43 (10%) 126 (30%) p = ,0.001c