No 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.

Efforts to scale-up HIV care and treatment have been successful at initiating large numbers of patients onto antiretroviral therapy (ART), although persistent challenges remain to optimizing scale-up effectiveness in both resource-rich and resource-limited settings. Among the most important are very high rates of ART initiation in the advanced stages of HIV disease, which in turn drive morbidity, mortality, and onward transmission of HIV. With a focus on sub-Saharan Africa, this review article presents a conceptual framework for a broader discussion of the persistent problem of late ART initiation, including a need for more focus on the upstream precursors (late HIV diagnosis and late enrollment into HIV care) and their determinants. Without additional research and identification of multilevel interventions that successfully promote earlier initiation of ART, the problem of late ART initiation will persist, significantly undermining the long-term impact of HIV care scale-up on reducing mortality and controlling the HIV epidemic.

Intensified efforts are needed to identify and link HIV-infected individuals to care earlier and to retain them in continuous pre-ART care to facilitate more timely ART initiation.