title: Factors associated with long-term antiretroviral therapy attrition among adolescents in rural Uganda: a retrospective study.
abstract: As access to antiretroviral therapy (ART) increases, the success of treatment programmes depends on ensuring high patient retention in HIV care. We examined retention and attrition among adolescents in ART programmes across clinics operated by The AIDS Support Organization (TASO) in Uganda, which has operated both facility- and community-based distribution models of ART delivery since 2004.
  
  
  
  Using a retrospective cohort analysis of patient-level clinical data, we examined attrition and retention in HIV care and factors associated with attrition among HIV-positive adolescents aged 10-19 years who initiated ART at 10 TASO clinics between January 2006 and December 2011. Retention in care was defined as the proportion of adolescents who had had at least one facility visit within the six months prior to 1 June 2013, and attrition was defined as the proportion of adolescents who died, were lost to follow-up, or stopped treatment. Descriptive statistics and Cox proportional hazards regression models were used to determine the levels of retention in HIV care and the factors associated with attrition following ART initiation.
  
  
  
  A total of 1228 adolescents began ART between 2006 and 2011, of whom 57% were female. The median duration in HIV care was four years (IQR=3-6 years). A total of 792 (65%) adolescents were retained in care over the five-year period; 36 (3%) had died or transferred out and 400 (32%) were classified as loss to follow-up. Factors associated with attrition included being older (adjusted hazard ratio (AHR)=1.38, 95% confidence interval (CI) 1.02-1.86), having a higher CD4 count (250+ cells/mm(3)) at treatment initiation (AHR=0.49, 95% CI 0.34-0.69) and HIV care site with a higher risk of attrition among adolescents in Gulu (AHR=2.26; 95% CI 1.27-4.02) and Masindi (AHR=3.30, 95% CI 1.87-5.84) and a lower risk of attrition in Jinja (AHR=0.24, 95% CI 0.08-0.70). Having an advanced WHO clinical stage at initiation was not associated with attrition.
  
  
  
  We found an overall retention rate of 65%, which is comparable to rates achieved by TASO's adult patients and adolescents in other studies in Africa. Variations in the risk of attrition by TASO treatment site and by clinical and demographic characteristics suggest the need for early diagnosis of HIV infection, use of innovative approaches to reach and retain adolescents living with HIV in treatment and identifying specific groups, such as older adolescents, that are at high risk of dropping out of treatment for targeted care and support.
authors.affiliation: The AIDS Support Organization (TASO), Kampala, Uganda; stephenokoboi@yahoo.co.ukokobois@tasouganda.org.
authors.forename: Stephen
authors.initials: S
authors.lastname: Okoboi
authors.affiliation: The AIDS Support Organization (TASO), Kampala, Uganda.
authors.forename: Livingstone
authors.initials: L
authors.lastname: Ssali
authors.affiliation: Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development (USAID), Arlington, VA, USA.
authors.forename: Aisha I
authors.initials: AI
authors.lastname: Yansaneh
authors.affiliation: The AIDS Support Organization (TASO), Kampala, Uganda.
authors.forename: Celestin
authors.initials: C
authors.lastname: Bakanda
authors.affiliation: The AIDS Support Organization (TASO), Kampala, Uganda.
authors.forename: Josephine
authors.initials: J
authors.lastname: Birungi
authors.affiliation: The AIDS Support Organization (TASO), Kampala, Uganda.
authors.forename: Sophie
authors.initials: S
authors.lastname: Nantume
authors.affiliation: The AIDS Support Organization (TASO), Kampala, Uganda.
authors.forename: Joanne Lyavala
authors.initials: JL
authors.lastname: Okullu
authors.affiliation: Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor, MI, USA.
authors.forename: Alana R
authors.initials: AR
authors.lastname: Sharp
authors.affiliation: BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.|Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
authors.forename: David M
authors.initials: DM
authors.lastname: Moore
authors.affiliation: HIVCore/Population Council Washington, DC, USA.
authors.forename: Samuel
authors.initials: S
authors.lastname: Kalibala
mesh_terms: D000293:Adolescent; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012424:Rural Population; D014454:Uganda; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents
keywords: HIV treatment; Uganda; adolescents; antiretroviral therapy; attrition; community-based delivery; retention