The proportion of loss to follow-up from antiretroviral therapy (ART) and its association with age among adolescents living with HIV in sub-Saharan Africa: A systematic review and meta-analysis

Abstract

Background: Human immunodeficiency virus (HIV) remains a global health threat, especially in developing countries. The successful scale-up of antiretroviral therapy (ART) programs to address this threat is hindered by a high proportion of patient loss to follow-up (LTFU). LTFU is associated with poor viral suppression and increased mortality. It is particularly acute among adolescents, who face unique adherence challenges. Although LTFU is a critical obstacle on the continuum of care for adolescents, few regional-level studies report the proportion of LTFU among adolescents receiving ART. Therefore, a systematic review and meta-analysis were conducted to estimate the pooled LTFU in ART programs among adolescents living with HIV in sub-Saharan Africa (SSA).

Methods: We searched five databases (PubMed, Embase (Elsevier), PsycINFO, CINAHL, and Scopus) for articles published between 2005 and 2020 and reference lists of included articles. The PRISMA guidelines for systematic reviews were followed. A standardised checklist to extract data was used. Descriptive summaries were presented using narrative tables and figures. Heterogeneity within the included studies was examined using the Cochrane Q test statistics and I2 test. Random effect models were used to estimate the pooled prevalence of LTFU among ALHIV. We used Stata version 16 statistical software for our analysis.

Results: Twenty-nine eligible studies (n = 285,564) were included. An estimated 15.07% (95% CI: 11.07, 19.07) of ALHIV were LTFU. Older adolescents (15-19 years old) were 43% (AOR = 0.57, 95% CI: 0.37, 0.87) more likely to be LTFU than younger (10-14 years old) adolescents. We find an insignificant relationship between gender and LTFU (AOR = 0.95, 95% CI: 0.87, 1.03). A subgroup analysis found that regional differences in the proportion of adolescent LTFU were not statistically significant. The trend analysis indicates an increasing proportion of adolescent LTFU over time.

Conclusions and recommendations: The proportion of LTFU among HIV-positive adolescents in SSA seems higher than those reported in other regions. Older adolescents in the region are at an increased risk for LTFU than younger adolescents. These findings may help policymakers develop appropriate strategies to retain ALHIV in ART services. Such strategies could include community ART distribution points, appointment spacing, adherence clubs, continuous free access to ART, and community-based adherence support.

Fig 1. PRISMA flow diagram.

Fig 2. Funnel plot of the meta-analysis used to show a visual description of publication bias.

Fig 3. Sensitivity analysis of the pooled prevalence meta-analysis.

Fig 4. Pooled prevalence of estimated loss to follow-up among adolescents living with HIV and on ART follow-up in SSA.

Fig 5. Subgroup analyses by study design on loss to follow-up among adolescents living with HIV and on ART follow-up in SSA.

Fig 6. Subgroup analyses by the broad categories of across national countries on loss to follow-up among adolescents living with HIV and on ART follow-up in SSA.

Fig 7. Forest plot showing the association of age and LTFU in ART treatment.

Fig 8. Forest plot showing the association of gender and LTFU in ART treatment.

Fig 9. The time trend of LTFU among HIV positive adolescents in sub-Saharan Africa from 2005 to 2020.