Risk factors for loss to follow‐up among at‐risk HIV negative men who have sex with men participating in a research cohort with access to pre‐exposure prophylaxis in coastal Kenya

Abstract

Introduction: Retention in preventive care among at-risk men who have sex with men (MSM) is critical for successful prevention of HIV acquisition in Africa. We assessed loss to follow-up (LTFU) rates and factors associated with LTFU in an HIV vaccine feasibility cohort study following MSM with access to pre-exposure prophylaxis (PrEP) in coastal Kenya. Methods: Between June 2017 and June 2019, MSM cohort participants attending a research clinic 20 km north of Mombasa were offered daily PrEP and followed monthly for risk assessment, risk reduction counselling and HIV testing. Participants were defined as LTFU if they were late by >90 days for their scheduled appointment. Participants who acquired HIV were censored at diagnosis. Cox proportional hazards models were used to estimate adjusted Hazard Ratio (aHR) of risk factors for LTFU. Results and discussion: A total of 179 participants with a median age of 25.0 years (interquartile range [IQR]: 23.0 to 30.0) contributed a median follow-up time of 21.2 months (IQR: 6.5 to 22.1). Of these, 143 (79.9%) participants started PrEP and 76 (42.5%) MSM were LTFU, for an incidence rate of 33.7 (95% confidence interval [CI], 26.9 to 42.2) per 100 person-years. Disordered alcohol use (aHR: 2.3, 95% CI, 1.5 to 3.7), residence outside the immediate clinic catchment area (aHR: 2.5, 95% CI, 1.3 to 4.6 for Mombasa Island; aHR: 1.8, 95% CI, 1.0 to 3.3 for south coast), tertiary education level or higher (aHR: 2.3, 95% CI, 1.1 to 4.8) and less lead-in time in the cohort prior to 19 June 2017 (aHR: 3.1, 95% CI, 1.8 to 5.6 for zero to three months; aHR: 2.4, 95% CI, 1.2 to 4.7 for four to six months) were independent predictors of LTFU. PrEP use did not differ by LTFU status (HR: 1.0, 95% CI, 0.6 to 1.5). Psychosocial support for men reporting disordered alcohol use, strengthened engagement of recently enrolled participants and focusing recruitment on areas close to the research clinic may improve retention in HIV prevention studies involving MSM in coastal Kenya. Conclusions: About one in three participants became LTFU after one year of follow-up, irrespective of PrEP use. Research preparedness involving MSM should be strengthened for HIV prevention intervention evaluations in coastal Kenya.

Stopping and restarting PrEP and loss to follow‐up among PrEP‐taking men who have sex with men and transgender women at risk of HIV‐1 participating in a prospective cohort study in Kenya

“…We found that being LTFU was most frequent among individuals who were on PrEP, although we did not find significant differences in LTFU rates according to PrEP state. Determinants of becoming LTFU while on PrEP were: alcohol use disorder, residing further from the research clinic and having a secondary level of education or higher, consistent with recent findings in this study [24]. In addition, we found that being LTFU while on PrEP was more likely among men who resided in the area for 1 year or less.…”

“…In the present study, we did not identify predictors for being LTFU while off PrEP, possibly owing to the lack of statistical power in identifying determinants from the small number of participants. However, our results suggest that linking MSM who have recently moved into an area to local MSM‐friendly services for social support and PrEP care services, screening for mental health and strengthened engagement may improve both retention in HIV‐1 prevention services and adherence to PrEP [24–26].…”

Feasibility of a community‐based delivery model for HIV pre‐exposure prophylaxis among bar patrons in rural South Africa

“…Frequency, type and quantity of alcohol use may be more influential for adherence and retention in PrEP care. Despite restrictions imposed by the COVID‐19 pandemic and potential resulting changes in risk behaviour, short‐term retention in PrEP care was in line with other published data [30]. Since predictors of retention were not identified in our small study, larger studies to explore barriers to retention among young men and women who drink are NEEDED.…”

“I wish to remain HIV negative”: Pre-exposure prophylaxis adherence and persistence in transgender women and men who have sex with men in coastal Kenya

“…In addition, alternative PrEP dispensing venues in Kenya including the use of community pharmacies can potentially expand the reach of PrEP to individuals and communities with discomfort seeking services at government-run facilities. PrEP-taking individuals may also benefit from a peer support model which has recently been shown to improve ART adherence among MSM in a pilot study in coastal Kenya [ 30 , 31 ].…”