Open Access Research article

What happens to ART-eligible patients who do not start ART? Dropout between screening and ART initiation: a cohort study in Karonga, Malawi

Nuala McGrath12*, Judith R Glynn1, Jacqueline Saul1, Katharina Kranzer1, Andreas Jahn3, Frank Mwaungulu4, Msenga HC Ngwira5, Hazzie Mvula4, Fipson Munthali5, Venance Mwinuka4, Lorren Mwaungulu4, Paul EM Fine1 and Amelia C Crampin14

Author Affiliations

1 London School of Hygiene and Tropical Medicine, London, UK

2 Africa Centre for Health and Population Studies, University of KwaZulu Natal, Mtubatuba, South Africa

3 HIV Department, Ministry of Health, Lilongwe, Malawi

4 Karonga Prevention Study, Chilumba, Malawi

5 Karonga District Hospital, Karonga, Malawi

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BMC Public Health 2010, 10:601  doi:10.1186/1471-2458-10-601

Published: 12 October 2010



Routine ART programme statistics generally only provide information about individuals who start treatment. We aimed to investigate the outcome of those who are eligible but do not start ART in the Malawi programme, factors associated with this dropout, and reasons for not starting treatment, in a prospective cohort study.


Individuals having a first screening visit at the ART clinic at Karonga District Hospital, northern Malawi, between September 2005 and July 2006 were interviewed. Study follow-up to identify treatment outcomes was conducted at the clinic and in the community. Logistic regression models were used to identify factors associated with dropout before ART initiation among participants identified as clinically eligible for ART.


88 participants eligible for ART at their first screening visit (out of 633, 13.9%) defaulted before starting ART. Participants with less education, difficulties in dressing, a more delayed ART initiation appointment, and mid-upper arm circumference (MUAC) < 22 cm were significantly less likely to have visited the clinic subsequently. Thirty-five (58%) of the 60 participants who defaulted and were tracked at home had died, 21 before their ART initiation appointment.


MUAC and reported difficulties in dressing may provide useful screening indicators to identify sicker ART-eligible individuals at high risk of dropping out of the programme who might benefit from being brought back quickly or admitted to hospital for observation. Individuals with less education may need adapted health information at screening. Deaths of ART-eligible individuals occurring prior to ART initiation are not included in routine programme statistics. Considering all those who are eligible for ART as a denominator for programme indicators would help to highlight this vulnerable group, in order to identify new opportunities for further improving ART programmes.