Adolescent pregnancy at antiretroviral therapy (ART) initiation: a critical barrier to retention on ART

Abstract

IntroductionAdolescence and pregnancy are potential risk factors for loss to follow‐up (LTFU) while on antiretroviral therapy (ART). We compared adolescent and adult LTFU after ART initiation to quantify the impact of age, pregnancy, and site‐level factors on LTFU.MethodsWe used routine clinical data for patients initiating ART as young adolescents (YA; 10 to 14 years), older adolescents (OA; 15 to 19 years) and adults (≥20 years) from 2000 to 2014 at 52 health facilities affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) East Africa collaboration. We estimated cumulative incidence (95% confidence interval, CI) of LTFU (no clinic visit for ≥6 months after ART initiation) and identified patient and site‐level correlates of LTFU, using multivariable Cox proportional hazards models for all patients as well as individual age groups.ResultsA total of 138,387 patients initiated ART, including 2496 YA, 2955 OA and 132,936 adults. Of these, 55%, 78% and 66%, respectively, were female and 0.7% of YA, 22.3% of OA and 8.3% of adults were pregnant at ART initiation. Cumulative incidence of LTFU at five years was 26.6% (24.6 to 28.6) among YA, 44.1% (41.8 to 46.3) among OA and 29.3% (29.1 to 29.6) among adults. Overall, compared to adults, the adjusted hazard ratio, aHR, (95% CI) of LTFU for OA was 1.54 (1.41 to 1.68) and 0.77 (0.69 to 0.86) for YA. Compared to males, pregnant females had higher hazard of LTFU, aHR 1.20 (1.14 to 1.27), and nonpregnant women had lower hazard aHR 0.90 (0.88 to 0.93). LTFU hazard among the OA was primarily driven by both pregnant and nonpregnant females, aHR 2.42 (1.98 to 2.95) and 1.51 (1.27 to 1.80), respectively, compared to men. The LTFU hazard ratio varied by IeDEA program. Site‐level factors associated with overall lower LTFU hazard included receiving care in tertiary versus primary‐care clinics aHR 0.61 (0.56 to 0.67), integrated adult and adolescent services and food ration provision aHR 0.93 (0.89 to 0.97) versus nonintegrated clinics with food ration provision, having patient support groups aHR 0.77 (0.66 to 0.90) and group adherence counselling aHR 0.61 (0.57 to 0.67).ConclusionsOlder adolescents experienced higher risk of LTFU compared to YA and adults. Interventions to prevent LTFU among older adolescents are critically needed, particularly for female and/or pregnant adolescents.

Retention in care for adolescents who were newly initiated on antiretroviral therapy in the Cape Metropole in South Africa

“…These findings correspond to those of Nuwagaba-Biribonwoha et al who found a greater rate of LTFU amongst pregnant and non-pregnant female adolescents, compared with male adolescents. 29 The current study reports lower RiC rates, compared with the 76.4% RiC at 12 months noted in a recent systematic review of pregnant and post-partum women in Africa. 30 This report found younger age and same-day ART initiation to be risk factors for poor retention, as was initiating during pregnancy, particularly late pregnancy.…”

Poor retention and care-related sex disparities among youth living with HIV in rural Mozambique

“…Many cohort studies have identified PL females as a particularly vulnerable group for attrition from HIV care [ 30 , 31 ]. Unfortunately, these studies also suggest that LTFU in this group has worsened despite increased numbers of pregnant women initiating ART under the Option B+ policy, which promotes lifelong ART for PL females regardless of CD4 count [ 31 ].…”

Adolescent mothers affected by HIV and their children: A scoping review of evidence and experiences from sub-Saharan Africa

“…Included research suggests that amongst pregnant and parenting adolescents, additional challenges may emerge relating to HIV infection. Many adolescent mothers find out about their HIV status at the same time as their pregnancies are confirmed, often after their first trimester (Nuwagaba-Biribonwoha et al, 2018;Ronen et al, 2016), which may also be linked to delayed ART initiation for PMTCT. Two studies report that adolescent mothers living with HIV have less antenatal and postnatal care engagement, and are less likely to access programming that has shown to be effective among older mothers (Orne-Gliemann et al, 2017;Ronen et al, 2016).…”