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Background: Scale-up and expansion of antiretroviral therapy (ART) for people living with HIV (PLHIV) have been a global priority for more than 15 years. Methods: We describe PLHIV at enrollment in care and ART initiation in Ethiopia, Kenya, Mozambique and Tanzania from 2005–2014 and report on enrollment location, CD4 count and loss to follow-up (LTF), death, and combined attrition (LTF and death) pre- and post-ART initiation over time. Pre-ART outcomes were estimated using competing risk and post-ART using Kaplan-Meier estimators; LTF defined as no visit within six months pre-ART and 12 months after ART start. Results: From 2005–2014, 884,328 PLHIV enrolled in care at 350 health facilities, median age was 32.0 years (interquartile range [IQR] 26.0–42.0), and majority were female (66.5%). The proportion of PLHIV enrolled at primary and rural facilities increased from 12.9% and 15.3% in 2005–2006 to 43.5% and 41.7% in 2013–2014 (p<0.0001). Median CD4+ cell count at enrollment increased from 171 cell/mm3 in 2005–2006 (IQR 71–339) to 289 cell/mm3 in 2013–2014 (IQR 133–485) (p<0.0001). A total of 460,758 (57.4%) PLHIV initiated treatment. Cumulative risk of LTF for PLHIV prior to ART initiation 12 months after enrollment was 33.5% (95%CI 33.36–33.58) and 21.98% (95%CI 21.9–22.1) after ART initiation. Pregnant women and the youngest PLHIV group had the highest attrition after ART initiation, at 24 months 40.8% (95%CI 40.1–41.6) of pregnant women and 47.4% (95%CI 46.4–48.4) of PLHIV 15–19 years were not retained. Attrition at 12 months after enrollment among PLHIV regardless of ART status was 38.5% (95%CI 38.4–38.6). Conclusion: Over 10 years of HIV scale-up in four sub-Saharan African countries, close to a million PLHIV were enrolled in care increasingly at rural and primary facilities with increasing CD4 count. Loss to follow-up from HIV care remains alarmingly high, particularly among pregnant women and younger PLHIV. [ABSTRACT FROM AUTHOR]

Background: Retention of mothers and infants across the prevention of mother-to-child HIV transmission (PMTCT) continuum remains challenging. We assessed the effectiveness of a lay worker administered combination intervention compared with the standard of care (SOC) on mother-infant attrition., Methods: HIV-positive pregnant women starting antenatal care at 10 facilities in western Kenya were randomized using simple randomization to receive individualized health education, retention/adherence support, appointment reminders, and missed visit tracking vs. routine care per guidelines. The primary endpoint was attrition of mother-infant pairs at 6 months postpartum. Attrition was defined as the proportion of mother-infant pairs not retained in the clinic at 6 months postpartum because of mother or infant death or lost to follow-up. Intent-to-treat analysis was used to assess the difference in attrition. This trial is registered with ClinicalTrials.gov; NCT01962220., Results: From September 2013 to June 2014, 361 HIV-positive pregnant women were screened, and 340 were randomized to the intervention (n = 170) or SOC (n = 170). Median age at enrollment was 26 years (interquartile range 22-30); median gestational age was 24 weeks (interquartile range 17-28). Overall attrition of mother-infant pairs was 23.5% at 6 months postpartum. Attrition was significantly lower in the intervention arm compared with SOC (18.8% vs. 28.2%, relative risk (RR) = 0.67, 95% confidence interval: 0.45 to 0.99, P = 0.04). Overall, the proportion of mothers who were retained and virally suppressed (<1000 copies/mL) at 6 months postpartum was 54.4%, with no difference between study arms., Conclusions: Provision of a combination intervention by lay counselors can decrease attrition along the PMTCT cascade in low-resource settings.

Background: The number of youth and adolescents (10-24 years) with HIV infection has increased substantially presenting unique challenges to effective health service delivery., Methods: We examined routinely collected patient-level data for antiretroviral treatment (ART)-naive HIV-infected patients, aged 10-24 years, enrolled in care during 2006-2011 at 109 ICAP-supported health facilities in three provinces in Kenya. Loss to follow-up (LTF) was defined as having no clinic visit for 12 months prior to ART initiation (pre-ART) and 6 months for ART patients. Competing risk and Kaplan-Meier estimators were used to calculate LTF and death rates. Sub-distributional and Cox proportional-hazards models were used to identify potential predictors of death and LTF., Results: Overall 22 832 patients were enrolled in care at 10-24 years of age, 69.5% were aged 20-24 years, and 82% were female. Median CD4(+) cell count was 332 cells/μl (interquartile range 153-561); 70.8% were WHO stage I/II. Young adolescents (10-14 years) had more advanced WHO stage and lower median CD4(+) cell count compared to youth (15-24 years) at enrollment (284 vs. 340 cells/μl; P < 0.0001). Cumulative incidence of LTF and death at 24 months for pre-ART patients was 46.1% [95% confidence interval (CI) 45.4-46.8%) and 2.1% (95% CI 1.9-2.3%), respectively. For those on ART, 32.2% (95% CI 31.1-33.3%) were LTF and 3.9% (95% CI 1.7-2.3%) died within 24 months. LTF among pre-ART and ART patients was twice as high among youth compared to young adolescents., Conclusion: LTF of young people with HIV in this Kenyan cohort was high and notably greater among youth compared to young adolescents. Novel strategies targeting these populations are urgently needed to improve retention., Competing Interests: The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of PEPFAR or the CDC.

Background: Since 2006, the government of Kenya began decentralizing HIV care from secondary health facilities (SHF) to an expanded network, including primary health facilities (PHF). We evaluated the impact of this strategy on enrollment, care, and outcomes among adult patients in Central Province, Kenya, from 2006 to 2010., Methods: We analyzed electronic patient-level data for 26,690 patients at 15 SHF and 22 PHF. Enrollment, patient, and facility characteristics and patterns in CD4 testing, World Health Organization staging, and antiretroviral treatment (ART) initiation were compared between SHF and PHF. Survival analysis was used to estimate cumulative death and loss to follow-up (LTF) rates in PHF and SHF. Multivariate competing risks regression and Cox proportional hazards models were constructed to identify correlates of LTF and death., Results: Enrollment in PHF increased mainly between 2007 and 2009, representing 5% and 25% of all new enrollments, respectively. CD4 test provision and World Health Organization staging, time to ART initiation, and CD4 count at ART initiation were for the most part similar between PHF and SHF. In multivariate analyses, pre-ART patients enrolled in PHF had a lower risk of LTF than those enrolled in SHF (SHR = 0.77, 95% confidence interval: 0.61 to 0.96). No differences in risk of death among pre-ART patients or in LTF or death among ART patients were observed., Conclusions: Enrollment at PHF increased substantially during the period; death rates were comparable between PHF and SHF, whereas LTF among pre-ART patients was lower at PHF. This suggests that decentralization can be a successful strategy for expanding HIV care., Competing Interests: The authors have no conflicts of interest to disclose.