Loss to follow-up among youth accessing outpatient HIV care and treatment services in Kisumu, Kenya

Abstract

Youth are particularly vulnerable to acquiring HIV, yet reaching them with HIV prevention interventions and engaging and retaining those infected in care and treatment remains a challenge. We sought to determine the incidence rate of loss to follow-up (LTFU) and explore socio-demographic and clinical characteristics associated with LTFU among HIV-positive youth aged 15–21 years accessing outpatient care and treatment clinics in Kisumu, Kenya. Between July 2007 and September 2010, youth were enrolled into two different HIV care and treatment clinics, one youth specific and the other family oriented. An individual was defined as LTFU when absent from the HIV treatment clinic for ≥ 4 months regardless of their antiretroviral treatment status. The incidence rate of LTFU was calculated and Cox regression analysis used to identify factors associated with LTFU. A total of 924 youth (79% female) were enrolled, with a median age of 20 years (IQR 18-21). Over half, (529 (57%)), were documented as LTFU, of whom 139 (26%) were LTFU immediately after enrolment. The overall incidence rate of LTFU was 52.9 per 100 person-years (p-y). Factors associated with LTFU were pregnancy during the study period (crude HR 0.68, 95% CI 0.53–0.89); CD4 cell count ≥350 (adjusted hazard ratios (AHR) 0.59, 95% CI 0.39–0.90); not being on antiretroviral therapy (AHR 4.0, 95% CI 2.70–5.88); and nondisclosure of HIV infection status (AHR 1.43, 95% CI 1.10–1.89). The clinic of enrolment, age, marital status, employment status, WHO clinical disease stage and education level were not associated with LTFU. Interventions to identify and enrol youth into care earlier, support disclosure, and initiate ART earlier may improve retention of youth and need further investigation. Further research is also needed to explore the reasons for LTFU from care among HIV-infected youth and the true outcomes of these patients.

Retention and adherence

“…Another study in Kenya evaluated factors associated with LTFU in a cohort of 15-21 year-olds enrolled at a youth-dedicated clinic and a family oriented clinic. While there was a high proportion LTFU (57%), with 26% LTFU immediately, enrollment in a youth-specific clinic was not associated with reduced LTFU [76].…”

“…It is possible that provision of AFS may be insufficient to mitigate the causes of LTFU for many AYALHIV. In some contexts, there may be high initial attrition from HIV care prior to engagement with AFS [8,53,54,76,80,81]. Furthermore, stigma, psychosocial issues, family and community factors may be central to disengagement, and must be mitigated to realize optimal adolescent HIV outcomes [9,58,59,75].…”

Improving retention in HIV care among adolescents and adults in low- and middle-income countries: A systematic review of the literature

“…The only study in this review conducted exclusively with youth examined youth-friendly clinic services. This good-quality retrospective cohort study compared LTFU among youths (15–21 years) enrolled in HIV services at a youth-friendly clinic (where 30.4% of the patients were youth) with youths enrolled in care at a family-oriented clinic (where only 3.4% of the patients were youth) [ 54 ]. Overall, LTFU among youth was extremely high: 61% of youth were LTFU at the youth-friendly clinic and 51% were LTFU at the family-oriented clinic.…”

Rapid antiretroviral initiation among Thai youth living with HIV in the National AIDS programme in the era of treatment at any CD4 cell count: a national registry database study

“…Studies indicate that loss to follow up (LTFU) is high before people start antiretroviral therapy (ART) and more likely in these pre-ART patients with high CD4 counts and less advanced clinical stage [2][3][4], due to waiting times for ART eligibility [5]. Youth living with HIV (YLHIV) have traditionally had poor outcomes, with high LTFU and death rates before ART initiation, and even lower proportions achieve the final endpoint of viral suppression in the cascade of care [6][7][8]. Evidence from Africa and Thailand suggests that the rate of LTFU before ART initiation in young people (age 15 to 24 years) is higher than the rates observed in adults (age ≥25 years) and early adolescents (age <15 years) [3,9,10].…”