High attrition before and after ART initiation among youth (15–24 years of age) enrolled in HIV care

Abstract

Objectives To compare pre and post-ART attrition between youth (15–24 years) and other patients in HIV care, and to investigate factors associated with attrition among youth. Design Cohort study utilizing routinely collected patient-level data from 160 HIV clinics in Kenya, Mozambique, Tanzania, and Rwanda. Methods Patients at least 10 years of age enrolling in HIV care between 01/05 and 09/10 were included. Attrition (loss to follow-up or death 1 year after enrollment or ART initiation) was compared between youth and other patients using multivariate competing risk (pre-ART) and traditional (post-ART) Cox proportional hazards methods accounting for within-clinic correlation. Among youth, patient-level and clinic-level factors associated with attrition were similarly assessed. Results A total of 312 335 patients at least 10 years of age enrolled in HIV care; 147 936(47%) initiated ART, 17% enrolling in care and 10% initiating ART were youth. Attrition before and after ART initiation was substantially higher among youth compared with other age groups. Among youth, nonpregnant women experienced lower pre-ART attrition than men [sub-division hazard ratio=0.90, 95% confidence interval (CI): 0.86–0.94], while both pregnant [adjusted hazard ratio (AHR) = 0.85, 95% CI: 0.74–0.97] and nonpregnant (AHR = 0.79, 95% CI: 0.73–0.86) female youth experienced lower post-ART attrition than men. Youth attending clinics providing sexual and reproductive health services including condoms (AHR = 0.47, 95% CI: 0.32–0.70) and clinics offering adolescent support groups (AHR = 0.73, 95% CI: 0.52–1.0) experienced significantly lower attrition after ART initiation. Conclusion Youth experienced substantially higher attrition before and after ART initiation compared with younger adolescents and older adults. Adolescent-friendly services were associated with reduced attrition among youth, particularly after ART initiation.

HIV treatment and care services for adolescents: a situational analysis of 218 facilities in 23 sub‐Saharan African countries

“…Moreover, facilities reported insufficient protocols for determining and managing both non‐adherence and LTFU, as well as limited use of counselling tools to inform their interventions. This is problematic as research indicates that adolescents and young people are at high risk of LTFU, especially those aged 15–19 years [7,8,19,20]. …”

Living and dying to be counted: What we know about the epidemiology of the global adolescent HIV epidemic

“…Compared to HIV‐infected children and adults, HIV‐infected adolescents have poorer retention in care, lower rates of virologic suppression and higher rates of mortality [7–9]. Different risks and barriers experienced during the stages of younger (age 10–14 years) and older (age 15–19 years) adolescence may impact on these HIV‐related outcomes as well as on the risk for HIV acquisition.…”

Experiences along the HIV care continuum: perspectives of Kenyan adolescents and caregivers

“…For example, adolescent HIV testing in Kenya is well below the World Health Organization 90% target at 35% and 27% among females and males aged 15–19, respectively (UNICEF, 2016). Additionally, a growing number of studies in southern and eastern sub-Saharan countries have found that youth ages 15–24 years are less likely to enrol in care after HIV diagnosis and more likely to be lost to care after enrolment compared to either older or younger groups (Auld et al, 2014; Bygrave et al, 2012; Evans et al, 2013; Genberg et al, 2015; Hatcher et al, 2012; Koech et al, 2014; Lamb et al, 2014; Naik et al, 2015). They are also less likely than adults to adhere to ART after initiation and subsequently experience shorter time to viral rebound and lower rates of virological suppression and immunological recovery (Nachega et al, 2009).…”

“…This suggests that adolescents are less likely to rebound after interruptions in care. Studies also indicate that young males are less likely to be in care than females and more likely to be lost to care if ART is initiated (Hatcher et al, 2012; Lamb et al, 2014; Ndiayeet al, 2013). …”