Young people (15 to 24 years) especially likely to drop out of HIV care

Patients aged between 15 and 24 years are significantly more likely to drop out of HIV care compared to individuals in other age groups, research published in the online edition of AIDS shows. The research was conducted in four sub-Saharan African countries and involved patients newly entered HIV care or initiating antiretroviral therapy (ART) between 2005 and 2010. Patients in the 15- to 24-years age group were significantly more likely to be lost to follow-up compared to both younger and older age groups.

“This study provides important insights on program outcomes previously not sufficiently described,” comment the authors. “In addition to confirming attrition 1 year after starting ART…we found that youth were substantially more likely than young adolescents and older adults to die or be lost to follow-up before initiating ART.”

Approximately 20% of all HIV-positive people in sub-Saharan Africa are aged between 15 and 24 years (youth), and 40% of incident infections are in this age group. Previous research has shown that there is a high attrition rate among young people in sub-Saharan Africa in the first year after starting HIV therapy.

An international team of investigators wanted to see if this was also the case for young people newly entering HIV care.

They therefore collected data from 160 HIV clinics in Kenya, Mozambique, Tanzania and Rwanda. Between 2005 and 2010, these clinics provided care to 312,335 patients who newly entered care or who started treatment.

The investigators compared attrition rates (death or loss to follow-up) between youth and other age groups (10 to 14 years; 25 to 54 years; 55 years and over) in the first year after entry into HIV care pre-ART and in the first year after the initiation of HIV therapy. The factors associated with loss to follow-up were also explored.

Young people account for 17% of patients entering care and 10% of patients starting HIV therapy.

Young people had higher median CD4 cell counts when entering care compared to other age groups (383 cells/mm³ vs 348 cells/mm³ [10 to 14 years]; 251 cells/mm³ [25 to 54 years); 232 cells/mm³ [55 years and over]).

Analysis of patients starting HIV therapy showed that patients aged between 15 and 24 years had a median CD4 cell count of 184 cells/mm³, which was lower than patients aged between 10 and 14 years (204 cells/mm³) but higher than individuals in the older age groups (161 cells/mm³ and 169 cells/mm³, respectively).

Overall, approximately a third (32%) of pre-ART patients had died or were lost to follow-up in the first year after entering HIV care. The rate of attrition among young patients was 48%.

The rate of attrition in the first year after starting HIV therapy was 17% overall and 27% among young people.

The vast majority of cases of attrition, both before (98%) and after (87%) the initiation of ART, among patients aged between 15 and 24 were due to loss to follow-up rather than death.

“Youth may be becoming LTF [lost to follow-up] for reasons other than illness,” comment the authors. “High levels of migration for work, and lack of belief in the benefits of attending clinic and initiating ART among youth, particularly if healthy and not yet eligible to initiate ART, are two possible explanations.”

Young people were between 50 and 100% more likely to die or drop out of HIV care before and after treatment, compared to other age groups.

Attrition rates among young people pre-ART were significantly lower among pregnant women than in men. Among young people starting therapy, both pregnant and non-pregnant women had a lower risk of attrition compared to men.

The provision of youth-friendly services reduced the risk of loss to follow-up after starting HIV treatment.

Young people attending clinics providing sexual and reproductive health services, including condom provision, had a significantly lower risk of attrition (AHR = 0.47; 95% CI, 0.32-0.70), as did 15- to 24-year-olds attending clinics that offered adolescent support (AHR = 0.73; 95% CI, 0.52-1.0).

“We suggest that youth-friendly interventions be implemented and evaluated for their effectiveness in improving retention,” conclude the investigators.