Higher Loss to Follow-Up After ART Initiation Among Older Adolescents

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Older adolescents initiating antiretroviral therapy have a high risk for loss to follow-up.

Older adolescents initiating antiretroviral therapy (ART) have a high risk for loss to follow-up (LTFU), particularly among female and/or pregnant adolescents, according to results published in the Journal of the International AIDS Society.

The study included participants initiating ART as young adolescents (YA; 10 to 14 years), older adolescents (OA; 15 to 19 years), and adults (≥20 years) from 2000 to 2014 at 52 health facilities affiliated with the International epidemiology Databases to Evaluate AIDS East Africa collaboration. The researchers estimated cumulative incidence of LTFU using multivariable Cox proportional hazards models.

A total of 138,387 participants initiated ART during the study period, with 2496 YA, 2955 OA, and 132,936 adults. Participants were 55%, 78%, and 66% female, respectively; 0.7% of YA, 22.3% of OA, and 8.3% of adult participants were pregnant at ART initiation.

The researchers found that the cumulative rate of LTFU at 5 years was 26.6% among YA, 44.1% among OA, and 29.3% among adults. Compared with adults, the adjusted hazard ratio (aHR) of LTFU was 1.54 among OA and 0.77 among YA.

After stratifying by participant characteristics, the researchers found that compared with males, pregnant females had an aHR of 1.20 for LTFU, while nonpregnant females had an aHR of 0.90.

In the OA group, risk for LTFU was driven by pregnant and nonpregnant females, who had aHRs of 2.42 and 1.51, respectively, compared with males.

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The LTFU hazard ratio varied by individual program, with different factors affecting the sites. Some site-level factors that were associated with overall lower LTFU hazard ratios were receiving care in tertiary vs primary-care clinics (aHR, 0.61), integrated adult and adolescent services and food ration provision (aHR, 0.93) vs nonintegrated clinics with food ration provision, having patient support groups (aHR, 0.77), and group adherence counselling (aHR 0.61).

“This analysis highlights the need to develop, test, and assess interventions designed to retain older adolescents on ART, particularly girls and women initiating ART while pregnant,” the researchers wrote.


Nuwagaba-Biribonwoha H, Kiragga AN, Yiannoutsos CT, et al. Adolescent pregnancy at antiretroviral therapy (ART) initiation: a critical barrier to retention on ART. J Int AIDS Soc. 2018;21:e25178.