More HIV-infected Youth Lost to Rx Follow-up

December 2, 2014

Younger antiretroviral therapy enrollees differ from older ones in demographic and clinical characteristics and are at higher risk for loss to follow-up. But interventions could reduce mortality and incidence.

Adolescent and young adult patients with HIV who receive antiretroviral therapy (ART) differ significantly from older adults in demographic and clinical characteristics and are at higher risk for loss to follow-up (LTFU).

LTFU rates tended to be higher in adolescents and young adults in a recent study. Documented mortality rates were higher in adults age 50 years and older in some countries.

To evaluate age-related ART retention challenges, Auld and associates1 analyzed data from retrospective cohort studies conducted in 7 African countries among 16,421 patients aged 15 years and older at enrollment who initiated ART during 2004–2012. ART enrollment and outcome data were compared among the following 3 groups: adolescents and young adults (aged 15 to 24 years), middle-aged adults (aged 25 to 49 years), and older adults (aged 50 years and older). Enrollees aged 15 to 24 years were predominantly female (81% to 92%), often pregnant (3% to 32% of females), and typically unmarried (54% to 73%). In 4 countries that had employment data, enrollees were mainly unemployed (53% to 86%). Older adults were more likely to be male, employed, and married.

LTFU rates were higher in adolescents and young adults than in older adults in all 7 countries. Statistical significance was reached in 3 countries in crude and multivariable analyses.

Available data suggest that this group of predominantly female adolescent and young adult ART enrollees represents a socially vulnerable population, the investigators stated. Although rates of HIV-related mortality and HIV incidence have declined globally since 2005, mortality has increased and HIV incidence remained relatively stable among adolescents; most adolescent deaths and new HIV infections occurred in sub-Saharan Africa.

In African countries with generalized epidemics, being young, female, and unemployed increases the risk of voluntary or coerced sexual contact with older, HIV-infected men, it was noted. Factors that might explain high LTFU rates among adolescent and young adult ART enrollees include stigma, lack of money for transport, child care responsibilities, and migration for work.

LTFU from ART is associated with significant increases in mortality risk. A recent meta-analysis suggested that 20% to 60% of patients lost to follow-up die and most of the deaths occur after default from ART. Therefore, difficulties in preventing LTFU among adolescent and young adults on ART might contribute to HIV-related mortality in this age group. Suboptimal ART adherence among adolescents also might contribute to adolescent mortality.

From a prevention perspective, patients who are LTFU are at risk for transmitting HIV to seronegative partners once ART is discontinued and viral load is no longer suppressed. High rates of LTFU among young women, among whom the prevalence of pregnancy is high, also increases the likelihood of mother-to-child HIV transmission.

HIV incidence and HIV-related deaths have declined by about 30% globally since 2005. Increased use of ART has contributed to those declines, but estimated annual HIV-related deaths among adolescents have increased by about 50%.

Effective interventions to reduce LTFU for adolescent and young adult ART enrollees could help reduce mortality and HIV incidence in this age group, the study authors suggested.

The study was reported on November 28, 2014, on Morbidity and Mortality Weekly Report.

World AIDS Day was December 1. This year’s theme is “Focus, Partner, Achieve: An AIDS-free Generation.”


1. Auld AF, Agolory SG, Shiraishi RW, et al. Antiretroviral therapy enrollment characteristics and outcomes among HIV-infected adolescents and young adults compared with older adults - seven African countries, 2004-2013. MMWR Morb Mortal Wkly Rep. 2014;63:1097-1103.