High Incidence and Predictors of Loss to Follow-up among Children and Adolescents on Life Long Antiretroviral Therapy in the Conflict-affected Northwest and Southwest Regions of Cameroon: A Retrospective Cohort Study

Abstract

Background: Retention in care and transition to adulthood are critical for children and adolescents living with HIV on Antiretroviral Therapy (ART) in HIV treatment programs in Sub Sahara, Africa. Objective: This study aimed to determine the incidence and predictors of loss-to-follow-up (LTFU) in the context of the ongoing crisis caused by an armed conflict in the Northwest and Southwest Regions of Cameroon, where staff in HIV treatment programs faced unique challenges of retention of children/adolescents. Methods: We employed a multi-stage mixed method design in which we conducted a retrospective cohort study to determine incidence and risk factors for LTFU through data abstraction from medical records of children and adolescents from five (5) ART treatment centers, followed by seventeen (17) key informant interviews conducted with healthcare workers to gain further insights into the reasons for LTFU among children and adolescents enrolled between January 2018 to December 2021. Kaplan–Meier plots were used to determine the probability of LTFU as a function of time. The Cox regression model was used to measure predictors of LTFU. Endpoint-recorded interviews were transcribed, translated, and analyzed using Atlas-ti Version 9. Results: A total of 1,030 children and adolescents (p-y) were enrolled for follow-up. 138 (13.4%) were LTFU, with an overall incidence rate of 33.0 LTFU per 1000 person years. Survival probability decreased for younger children and older adolescents. Receiving care in a rural health facility (AHR:2.14 (1.23-3.76), non-biological caregivers (AHR: 2.44; 95% CI: 1.59-3.74), short duration on ART, being on a sub-optimal regimen (AHR: 17.83; 95% CI: 11.00-29.00) and long distances to health facility (AHR:2.05; 95% CI: 1.10-3.20) were significant predictors of LTFU. Multiple Caregivers (94.1%), long distances/cost of transportation (88.2%), socio-political crises (75.5%), peer pressure, refusal, dating and marriage among adolescents (70.5%), stigma (64.7%), competitive life activities (58.8%), lack of timely disclosure (53%), poverty/lack of partner/family support (48.2%), lack of understanding on the disease process (47.0%), alternative forms of health care (29.4%), and shortage of ARVs (13.8%) were reasons for poor retention from the interviews. Conclusion: The overall incidence rate of LTFU was 33.0 per 1000 person years for children and adolescents initiated on lifelong ART over a period of four (4) years in the conflict-affected areas. The study portrays the need for innovative, multifaceted strategies to mitigate the predictors of this high-risk LTFU in displaced populations in the context of a sociopolitical crisis.