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High attrition before and after ART initiation among youth (15–24 years of age) enrolled in HIV care

Lamb, Matthew R.a,b; Fayorsey, Rubya; Nuwagaba-Biribonwoha, Harrieta; Viola, Violantea; Mutabazi, Vincentc; Alwar, Teresaa; Casalini, Caterinaa; Elul, Batyaa,b

doi: 10.1097/QAD.0000000000000054
Epidemiology and Social

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.

aICAP-Columbia University

bDepartment of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA

cRwanda Biomedical Center, Kigali, Rwanda.

Correspondence to Matthew Lamb, ICAP-Columbia University, 60 Haven, Room B-112 New York, NY 10032, USA. Tel: +1 212 304 7135; e-mail:

Received 10 June, 2013

Accepted 20 August, 2013

Preliminary analysis of data included in this article was presented at the 19th Conference on Retroviruses and Opportunistic Infections. Factors associated with high loss to follow-up among 15- to 24-year-olds enrolled in HIV care: sub-Saharan Africa (Paper #1149). Seattle, Washington. March 5–8, 2012.

Copyright © 2014 Wolters Kluwer Health, Inc.