Research Article: HIV prevalence and determinants of loss-to-follow-up in adolescents and young adults with tuberculosis in Cape Town

Date Published: February 5, 2019

Publisher: Public Library of Science

Author(s): Pancho Mulongeni, Sabine Hermans, Judy Caldwell, Linda-Gail Bekker, Robin Wood, Richard Kaplan, Richard John Lessells.


TB remains a leading cause of mortality and morbidity in sub-Saharan Africa, due to the HIV epidemic. As TB treatment is lengthy, the completion of the full course of treatment may be especially challenging for young people. We therefore aimed to identify the extent of and reasons underlying loss to follow-up from TB treatment among young people in Cape Town. Accordingly, we reviewed the outcomes of young people treated for TB in Cape Town during 2009–2013, across three age groups: younger adolescents (10–14 years); older adolescents; (15–19 years) and young adults (20–24 years). We employed logistic regression analysis to identify risk factors for loss from TB care. 23,737 patients aged 10–24 were treated for drug sensitive TB over the study period. Of these, the HIV co-infection prevalence was 18.5% for younger adolescents, 12.9% for older adolescents and 33.1% for young adults. From age 16, HIV prevalence increased disproportionately among young women: by age 22, over 50% of women were TB/HIV co-infected compared to 14% of men. TB treatment success (cure plus completion) was 84.4%, while 1.7% of patients died, 9.5% were lost-to follow-up and 0.4% failed treatment. Being an older adolescent (aOR 1.75 [95% CI: 1.38–2.21]) or young adult (aOR: 1.96 [95% CI: 1.57–2.45]) increased the risk of loss-to-follow up, relative to being a younger adolescent. Further risk factors for loss from TB care were male gender (aOR: 1.33 [95% CI:1.20–1.46]), being a TB/HIV co-infected young person (aOR 1.74 [95% CI: 1.57–1.93]) and having had prior treatment for TB (aOR 3.17 [95% CI 2.87–3.51]). We identified risk factors for loss to follow-up and highlighted the need to focus on HIV prevention and retention in TB care among young people. TB care tailored to the needs of young people could improve patient retention, similar to improved outcomes reported by youth friendly HIV clinics.

Partial Text

In South Africa, tuberculosis (TB) remains one of the biggest causes of death during the productive years of life [1]. As human immunodeficiency virus-1 (HIV) infection became widespread in South Africa, the fraction of the population with immunosuppression expanded, resulting in a rise in TB disease [2]. In order to treat TB patients successfully, the health services need to successfully identify and treat TB/HIV co-infection. There has been some progress in this regard, with HIV testing among TB patients increasing from 59% to 93% over the course of 2009–14 [3]. However, successful TB treatment outcomes from 2012 to 2013 remained at roughly 77–78%, which is below the national target of 82% and far from the international targets of 85–90% [3].

We have presented data on the burden of TB disease, TB treatment outcomes and the degree of TB/HIV co-infection among young people in Cape Town, during 2009–2013. In addition, our study elucidates risk factors for loss to follow-up from TB care among this vulnerable population. Outside South Africa there are few studies from resource-limited settings on TB treatment outcomes among young people. Studies from Brazil and India have assessed clinical features of young people with TB [23–25], with little reference to treatment outcomes. Our study follows on that of young people with TB in the Western Cape to provide a population-level analysis of TB treatment outcomes and TB/HIV co-infection among adolescents with active TB disease [15]. However, unlike the former study, we conducted an exhaustive analysis to illustrate both sex and age distribution of TB/HIV coinfection, as well as elucidating possible pathways through which adolescents and young adults become vulnerable to loss from TB care.




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