What Happens to Patients on Antiretroviral Therapy Who Transfer Out to Another Facility? Joseph Kwong-Leung Yu1,2,3,4, Teck-Siang Tok2, Jih-Jin Tsai3, Wu-Shou Chang4, Rose K. Dzimadzi5, Ping- Hsiang Yen2, Simon D. Makombe6, Amon Nkhata6, Erik J. Schouten6,7, Kelita Kamoto6, Anthony D. Harries6,8,9* 1 Taiwan Medical Mission in Malawi, Mzuzu Central Hospital, Mzuzu, Malawi, 2 International Medical Cooperation and Development Center, Pingtung Christian Hospital, Pingtung, Taiwan, 3 College of Medicine, Kaohsiung Medical University Division of Infectious Disease, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, 4 Bureau of International Cooperation, Department of Health, Taipei, Taiwan, 5 Office of the Hospital Director, Mzuzu Central Hospital, Ministry of Health, Mzuzu, Malawi, 6 HIV Unit, Ministry of Health, Lilongwe, Malawi, 7 Management Sciences for Health, Lilongwe, Malawi, 8 Family Health International, Lilongwe, Malawi, 9 London School of Hygiene and Tropical Medicine, London, United Kingdom Abstract Background: Long term retention of patients on antiretroviral therapy (ART) in Africa’s rapidly expanding programmes is said to be 60% at 2 years. Many reports from African ART programmes make little mention of patients who are transferred out to another facility, yet Malawi’s national figures show a transfer out of 9%. There is no published information about what happens to patients who transfer-out, but this is important because if they transfer-in and stay alive in these other facilities then national retention figures will be better than previously reported. Methodology/Principal Findings: Of all patients started on ART over a three year period in Mzuzu Central Hospital, North Region, Malawi, those who transferred out were identified from the ART register and master cards. Clinic staff attempted to trace these patients to determine whether they had transferred in to a new ART facility and their outcome status. There were 805 patients (19% of the total cohort) who transferred out, of whom 737 (92%) were traced as having transferred in to a new ART facility, with a median time of 1.3 months between transferring-out and transferring-in. Survival probability was superior and deaths were lower in the transfer-out patients compared with those who did not transfer. Conclusion/Significance: In Mzuzu Central Hospital, patients who transfer-out constitute a large proportion of patients not retained on ART at their original clinic of registration. Good documentation of transfer-outs and transfer-ins are needed to keep track of national outcomes. Furthermore, the current practice of regarding transfer-outs as being double counted in national cohorts and subtracting this number from the total national registrations to get the number of new patients started on ART is correct. Citation: Kwong-Leung Yu J, Tok T-S, Tsai J-J, Chang W-S, Dzimadzi RK, et al. (2008) What Happens to Patients on Antiretroviral Therapy Who Transfer Out to Another Facility?. PLoS ONE 3(4): e2065. doi:10.1371/journal.pone.0002065 Editor: Beatriz Grinsztejn, Instituto de Pesquisa Clinica Evandro Chagas, FIOCRUZ, Brazil Received November 30, 2007; Accepted March 16, 2008; Published April 30, 2008 Copyright: 2008 Kwong-Leung Yu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This study was supported by funds from an anonymous donor who helped to finance some of the field trips. Competing Interests: The authors have declared that no competing interests exist. * E-mail: adharries@malawi.net Introduction Malawi, a small resource-poor country in Southern Africa, has been making good progress with scaling up antiretroviral therapy (ART): by June 2007, just over 110,000 patients had started free treatment from 109 public sector facilities [1]. Treatment outcomes are monitored every quarter, with patients classified as alive and on treatment, dead, stopped treatment, transferred to another facility or ‘‘lost to follow-up’’. The category of transfer-out is used in both the ART programme and national TB programme to indicate patients who actively seek a transfer to another treatment facility. As new sites are continuously being accredited for ART delivery, many patients who are started on therapy in a distant hospital obviously prefer to continue with therapy from a facility nearer to home and therefore transfer. By June 2006, there were 9,862 patients (9% of the total cohort) who had been recorded as transfer-out in the ART registers from around the country [1]. There is recent concern about the poor retention on therapy in ART programmes in sub-Saharan Africa [2,3]. Reports on treatment outcomes from individual ART clinics in sub-Saharan Africa often raise the problem of loss to follow-up [4–9]. However, surprisingly little mention is made of transfer-outs, with one study from Botswana mentioning a transfer-out rate of 5.2% [4], and one from South Africa mentioning this as a small component of loss to follow-up [5]. We know from the Malawi national quarterly ART reports that transfer-outs are a common cause of patients no longer being retained on therapy in their original ART clinic. However, we have no hard data on whether these patients transfer-in to another facility and we do not know how they fare in terms of treatment outcomes once registered in the new facility. We therefore conducted a study in the Northern Region of Malawi to investigate this issue, and to determine what had happened to patients who transferred out from Mzuzu Central Hospital to other facilities. PLoS ONE | www.plosone.org 1 April 2008 | Volume 3 | Issue 4 | e2065