Figure 1. Probability of Survival in Patients on ART who Transfer Out and who do not Transfer Out. doi:10.1371/journal.pone.0002065.g001 0.4, 95% CI 0.3–06], and of those transfer-out patients who did die, there was a significant trend towards later deaths compared with those who did not transfer out. There was a significantly higher survival probability in patients transferring out and traced compared with those who did not (Figure 1). Discussion This study shows first of all that almost one fifth of patients transferred out from a central hospital institution over a 30-month period as new ART sites were set up in the country and started to deliver therapy closer to patients’ homes. For geographical reasons more patients transferred out to new sites in the Northern Region compared to the other 2 regions in the country. Second, we were able to document that over 90% of these patients transferred in to a new facility. Tracing was more successful in the Northern Region where active follow-up was conducted to sites compared with the other 2 regions of the country where only telephone calls could be made. The median time for the transfer process was just over 1 month, which suggests References 1. HIV Unit, Ministry of Health, Malawi (2006) ARV therapy in Malawi–up to 30th June, 2006. Quarterly Report. 2. Rosen S, Fox MP, Gill CJ (2007) Patient retention in antiretroviral therapy programs in sub-Saharan Africa: a systematic review. PLoS Medicine 4: e298. 3. Boulle A, Ford N (2007) Scaling up antiretroviral therapy in developing countries: what are the benefits and challenges? Sex Transm Inf 83: 503–505. 4. Wester CW, Kim S, Bussmann H, Avalos A, Ndwapi N, et al. (2005) Initial response to highly active antiretroviral therapy in HIV-1C-infected adults in a public sector treatment program in Botswana. J Acquir Immune Defic Syndr 40: 336–343. 5. Lawn SD, Myer L, Orrell C, Bekker L-G, Wood R (2005) Early mortality among adults accessing a community-based antiretroviral service in South Africa: implications for programme design. AIDS 19: 2141–2148. 6. Wools-Kaloustian K, Kimaiyo S, Diero L, Siika A, Sidle J, et al. (2006) Viability and effectiveness of large-scale HIV treatment initiatives in sub-Saharan Africa: experience from Western Kenya. AIDS 20: 41–48. 7. Calmy A, Pinoges L, Szumilin E, Zachariah R, Ford N, et al. (2006) Generic fixed-dose combination antiretroviral treatment in resource-poor settings: multicentric observational cohort. AIDS 20: 1163–1169. ART Patients Who Transfer Out that patients who usually move with a new 1-month’s supply of drugs probably do not experience drug interruptions during the transfer process, an important factor in reducing the development of drug resistance. The reasons for not finding what happened to some transfer out patients are speculative. These patients may have transferred to a different site altogether either within or outside of Malawi, they may have used a different name to transfer to another site, or they may have died or decided to stop therapy. Third, the probability of survival in patients transferring out was better than those who remained at the central hospital, suggesting that transfers occur after patients have stabilised on therapy and after the first three months when a large proportion of ART deaths occur [5,9]. There are two important lessons from this study. First, two recent published reports have emphasised that there is poor retention on therapy in Africa’s ART programmes, citing loss to follow-up and death as the principal reasons for attrition [2,3]. We feel that these reports are potentially misleading, and that one of the important reasons for poor ART clinic retention is the transfer out of patients who move to another site yet continue to successfully take ART. In Malawi’s well organised tuberculosis programme, there were poor quality data on transfers [11], and in Malawi’s national ART programme we are well aware that patients may transfer-out without informing the original clinic, and these patients will be counted as ‘‘losses to follow-up’’ unless active tracing is conducted [12]. Second, in Malawi we have thought for some time that patients who transfer out may be double counted, in their original ART site as a transfer-out and in the new site with a new number as alive and on therapy. To allow for this at national level, when we count the number of new patients starting on therapy we subtract the transfer-outs from the total national registrations. The current study validates this approach, as over 90% of patients who transfer-out are indeed registered at a new site and the majority of those registered are subsequently found alive and on ART. Author Contributions Conceived and designed the experiments: AH SM JK ES KK AN TT JT WC RD PY. Performed the experiments: JK. Analyzed the data: AH JK. Contributed reagents/materials/analysis tools: AH JK. Wrote the paper: AH SM JK ES KK AN TT JT WC RD PY. 8. Ferradini L, Jeannin A, Pinoges L, Izopet J, Odhiambo D, et al. (2006) Scaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment. Lancet 367: 1335–1342. 9. The Antiretroviral Therapy in Lower Income Countries (ART-LINC) Collaboration and ART Cohort Collaboration (ART-CC) groups (2006) Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries. Lancet 367: 817–824. 10. Libamba E, Makombe S, Harries AD, Chimzizi R, Salaniponi FM, et al. (2005) Scaling up antiretroviral therapy in Africa: learning from tuberculosis control programmes–the case of Malawi. Int J Tuberc Lung Dis 9: 1062–1071. 11. Meijnen S, Weismuller MM, Claessens NJM, Kwanjana JH, Salaniponi FM, et al. (2002) Outcome of patients with tuberculosis who transfer between reporting units in Malawi. Int J Tuberc Lung Dis 6: 666–671. 12. Yu JK-L, Chen SC-C, Wang K-Y, Chang C-S, Makombe SD, et al. (2007) True outcomes for patients on antiretroviral therapy who are ‘‘lost to follow-up’’ in Malawi. Bulletin World Health Organization 85: 550–554. PLoS ONE | www.plosone.org 3 April 2008 | Volume 3 | Issue 4 | e2065