Factors associated with long‐term antiretroviral therapy attrition among adolescents in rural Uganda: a retrospective study

Abstract

IntroductionAs access to antiretroviral therapy (ART) increases, the success of treatment programmes depends on ensuring high patient retention in HIV care. We examined retention and attrition among adolescents in ART programmes across clinics operated by The AIDS Support Organization (TASO) in Uganda, which has operated both facility- and community-based distribution models of ART delivery since 2004.MethodsUsing a retrospective cohort analysis of patient-level clinical data, we examined attrition and retention in HIV care and factors associated with attrition among HIV-positive adolescents aged 10–19 years who initiated ART at 10 TASO clinics between January 2006 and December 2011. Retention in care was defined as the proportion of adolescents who had had at least one facility visit within the six months prior to 1 June 2013, and attrition was defined as the proportion of adolescents who died, were lost to follow-up, or stopped treatment. Descriptive statistics and Cox proportional hazards regression models were used to determine the levels of retention in HIV care and the factors associated with attrition following ART initiation.ResultsA total of 1228 adolescents began ART between 2006 and 2011, of whom 57% were female. The median duration in HIV care was four years (IQR=3–6 years). A total of 792 (65%) adolescents were retained in care over the five-year period; 36 (3%) had died or transferred out and 400 (32%) were classified as loss to follow-up. Factors associated with attrition included being older (adjusted hazard ratio (AHR)=1.38, 95% confidence interval (CI) 1.02–1.86), having a higher CD4 count (250+ cells/mm3) at treatment initiation (AHR=0.49, 95% CI 0.34–0.69) and HIV care site with a higher risk of attrition among adolescents in Gulu (AHR=2.26; 95% CI 1.27–4.02) and Masindi (AHR=3.30, 95% CI 1.87–5.84) and a lower risk of attrition in Jinja (AHR=0.24, 95% CI 0.08–0.70). Having an advanced WHO clinical stage at initiation was not associated with attrition.ConclusionsWe found an overall retention rate of 65%, which is comparable to rates achieved by TASO's adult patients and adolescents in other studies in Africa. Variations in the risk of attrition by TASO treatment site and by clinical and demographic characteristics suggest the need for early diagnosis of HIV infection, use of innovative approaches to reach and retain adolescents living with HIV in treatment and identifying specific groups, such as older adolescents, that are at high risk of dropping out of treatment for targeted care and support.

Transition from paediatric to adult care of adolescents living with HIV in sub‐Saharan Africa: challenges, youth‐friendly models, and outcomes

“…A recent study conducted in Canada reported that a quarter of transitioned patients were no longer engaged in care [55]. Although these data are from high-income settings, we may expect similar findings in low-resource settings where report of transition outcomes are less common [48,50]. Descriptions of ongoing research efforts to capture transition outcomes in African settings and how they differ from high- and middle-income settings are necessary in order to identify key steps in the HIV cascade for interventions.…”

“…Support groups and greater involvement of adolescent healthcare providers have been suggested by healthcare providers themselves to facilitate transition [22,30]. Teen clinics have also been found in a small number of studies to improve retention compared to the standard model of care which is the most prevalent [48,50]. Although these youth-focused health services may improve their retention in HIV care, it is difficult to generalize study results due to their limited numbers, sample sizes, and short follow-up.…”

“…Significantly higher retention rates in adolescents attending the dedicated teen clinic (97%) versus adolescents in standard care (85%) ( p  = 0.0005)Teasdale, C.J.Aquir Immune Defic Syndr2016 [49]Nyanza, KenyaRetrospective analysis comparing LTFU pre-YAFS (youth- adolescent-friendly services) to LTFU post YAFS in 6 YAFS. In addition LTFU outcomes were examined in the pre (03–12/2011) and post YAFS periods (312/2013) at 28 health facilities that did not implement YAFS to examine changes in LTFU in the same periods which were unrelated to YAFS.The analysis examined LTFU before ART and LTFU after ART2321 HIV-infected adolescents and young adults 10–24 yearsICAP-funded YAFS with(1) training and mentorship for health care providers on care for adolescent/youth(2) one day per month at least about sexually and reproductive health, gynaecologic examination condoms, contraception (3) groups and education programmePre ART:– we observed decrease in LTFU between the pre- and post-YAFS but the difference was no significant p  = 0.15– no difference in LTFU between YAFS and non-YAFS facilities in pre YAFS period ( p  = 0.08) and no significant difference post ( p  = 0.87) YAFS period.Post ART:– no significant difference in LTFU in the before and after YAFS p  = 0.19– no significant difference in LTFU between YAFS and non-YAFS facilities in pre ( p  = 0.73) or post ( p  = 0.77) YAFS period– for health facilities that did not have YAFS, LTFU observed in the after period was significantly higher than the before period p  = 0.04– Data from the YAFS were evaluated immediately after implementation of the programme– may be a difference in the impact of YAFS on retention for adolescent compared with older youth– other factors may also contribute to the retention of this groupNyabigambo A, Value Health 2014 [46]Kampala, UgandaCross-sectional analysis looking at the association between adherence to clinic visits (attended all or missed 1 or more) and general wellbeing (measured with General Well Being Schedule, 18 point scale)379 youth 15–24 years living with HIV who completed the general wellbeing schedule in 2012Care in “HIV transition clinic” within infectious disease instituteMean age 22 years, mean CD4 + 402.3, 60.9% currently on ART, 32.4% attended all clinic visits, no relationship between reported wellbeing and attending all clinical visits (compared to missing at least one visit)Okoboi S, AIDS 2016 [50]Uganda (TASO clinics)Retrospective cohort analysis to examine retention of adolescents after ART and clinical factors associated with non-retention after ART617 adolescents 10–19 years starting ART 2006–2011 at 6 TASO sitesNot specifiedOverall retention: 90% at 12 months, 83% at 24 months and 76% at 36 months and 70% at 48 monthsNon-retention at 12-month associated:Clinic-based vs. community-based ART delivery (AHR 2.58, 95%CI 1.26–5.29)CD4 > 100 at ART initiation (AHR 1.38, 95%CI 1.01–1.90)15–19 years (vs. 10–14) at ART initiation (AHR 1.88, 95%CI 1.01–3.48)…”

“…Other factors such as socio-economic factors (food supplementation, schooling, employment and enhanced social support) or clinical (adherence) factors may also contribute to retention of this group and should be further understood [49]. There is a need to examine community-based approaches to reach and retain adolescents and youth to support treatment adherence, and to identify sub-groups that are at highest risk of dropping out for targeted care and support [50]. …”

Lessons learned and study results from HIVCore: an HIV implementation science initiative

“…In Uganda, Okoboi et al . describe how retention in care was better among younger adolescents (aged 10–14 years) than older adolescents, adolescents who initiated ART in earlier years of the programme when it had a stronger community focus and adolescents who had higher CD4 counts at ART initiation [20]. …”