Description of the cascade of care and factors associated with attrition before and after initiating antiretroviral therapy of HIV infected children in a cohort study in India

Gerardo Alvarez-Uria

doi:10.7717/peerj.304

Abstract

In low- and middle-income countries, the attrition across the continuum of care of HIV infected children is not well known. The aim of this study was to investigate predictors of mortality and loss to follow up (LTFU) in HIV infected children from a cohort study in India and to describe the cascade of care from HIV diagnosis to virological suppression after antiretroviral therapy (ART) initiation. Multivariable analysis was performed using competing risk regression. The cumulative incidence of attrition due to mortality or LTFU after five year of follow-up was 16% from entry into care to ART initiation and 24.9% after ART initiation. Of all children diagnosed with HIV, it was estimated that 91.9% entered into care, 77.2% were retained until ART initiation, 58% stayed in care after ART initiation, and 43.4% achieved virological suppression on ART. Approximately half of the attrition occurred before ART initiation, and the other half after starting ART. Belonging to socially disadvantaged communities and living >90 min from the hospital were associated with a higher risk of attrition. Being >10 years old and having higher 12-month risk of AIDS (calculated using the absolute CD4 lymphocyte count and the age) were associated with an increased risk of mortality. These findings indicate that we should consider placing more emphasis on promoting research and implementing interventions to improve the engagement of HIV infected children in pre-ART care. The results of this study can be used by HIV programmes to design interventions aimed at reducing the attrition across the continuum of care of HIV infected children in India.

Highlights

By the end of 2011, 99% of the 3.3 million HIV infected children worldwide were living in low- or middle-income countries (UNAIDS, 2012)
We present factors associated with mortality and loss to follow up (LTFU) that could be used to reduce the attrition of HIV programmes in India
This study shows that fewer than half of the children diagnosed with HIV in our setting follow all stages of care up to the achievement of virological suppression after antiretroviral therapy (ART) initiation

Summary

Introduction

By the end of 2011, 99% of the 3.3 million HIV infected children worldwide were living in low- or middle-income countries (UNAIDS, 2012). How to cite this article Alvarez-Uria (2014), Description of the cascade of care and factors associated with attrition before and after initiating antiretroviral therapy of HIV infected children in a cohort study in India. After the HIV diagnosis is made, they need to engage in HIV medical care (Alvarez-Uria et al, 2013a) Once they enter into care, children are followed up until they meet clinical or immunological criteria to start ART (World Health Organization, 2010). All children infected with HIV should be retained across the continuum of care and remain virologically suppressed after initiating ART. Studies performed in HIV infected adults have demonstrated that the attrition across the continuum of care is high in both developed and developing countries (Alvarez-Uria et al, 2013b; Centers for Disease Control and Prevention, 2011; Fox & Rosen, 2010; Mugglin et al, 2012; Rosen & Fox, 2011). Data about programme attrition in HIV infected children before and after ART initiation are scarce, especially outside sub-Saharan Africa (KIDS-ART-LINC Collaboration, 2008; Munyagwa et al, 2012; Okomo et al, 2012; Tene et al, 2013)

Objectives

Methods

Results

Discussion

Conclusion