Abstract
IntroductionGlobal scale up of anti‐retroviral therapy (ART) has led to expansion of HIV treatment and prevention across sub‐Saharan Africa. However, age and gender‐specific disparities persist leading to failures in fulfillment of Sustainability Development Goals, including SDG3 (achieving healthy lives and wellbeing for all, at all ages) and SDG5 (gender equality). We assessed ART initiation and adherence, loss to follow‐up, all‐cause death and early death, according to SDG3 and SDG5 indicators among a cohort of HIV‐infected children and adolescents enrolled in care in Dar‐es‐Salaam, TanzaniaMethods SDG3 indicators included young (<5 years) and older paediatric children (5 to <10 years), early adolescent (10 to <15 years) and late adolescent (15 to <20 years) age group divisions and the SDG5 indicator was gender. Associations of age group and gender with ART initiation, loss to follow‐up and all‐cause death, were analysed using Cox proportional hazards regression and with adherence, using generalized estimating equations (GEE) with the Poisson distribution. Associations of age group and gender with early death were analysed, using log‐Poisson regression with empirical variance.ResultsA total of 18,315 enrollees with at least one clinic visit were included in this cohort study. Of these 7238 (40%) were young paediatric , 4169 (23%) older paediatric, 2922 (16%) early adolescent and 3986 (22%) late adolescent patients at enrolment. Just over half of paediatric and early adolescents and around four fifths of the late adolescents were female. Young paediatric patients were at greater risk of early death, being almost twice as likely to die within 90 days. Males were at greater risk of early death once initiated on ART (HR 1.35, 95% CI 1.09, 1.66)), while females in late adolescence were at greatest risk of late death (HR 2.44 [1.60, 3.74] <0.01). Late adolescents demonstrated greater non‐engagement in care (RR 1.21 (95% CI 1.16, 1.26)). Among both males and females, early paediatric and late adolescent groups experienced significantly greater loss to follow‐up.ConclusionThese findings highlight equity concerns critical to the fulfillment of SDG3 and SDG5 within services for children and adolescents living with HIV in sub‐Saharan Africa. Young paediatric and late adolescent age groups were at increased risk of late diagnosis, early death, delayed treatment initiation and loss of continuity of care. Males were more likely to die earlier. Special attention to SDG3 and SDG5 disparities for children and adolescents living with HIV will be critical for fulfillment of the 2030 SDG agenda.
Highlights
Global scale up of anti-retroviral therapy (ART) has led to expansion of HIV treatment and prevention across sub-Saharan Africa
Failure to address the age and genderspecific needs of children and adolescents infected with HIV in sub-Saharan Africa leads to failure to fulfill SDG3 and SDG5, with further interdependent failings in several Sustainability Development Goals (SDGs) [10]
Utilizing SDG3 and SDG5 age and gender-specific indicators, we sought to assess disparities in access to treatment, continuity of care and outcomes, among children and adolescents enrolled in a large subSaharan African HIV care service in Tanzania
Summary
Global expansion of anti-retroviral therapy (ART) has led to the marked success of prevention of mother-to-child transmission (PMTCT) programmes and increased enrolment into HIV care programmes across sub-Saharan Africa [1]. Shortfalls in approaches to HIV treatment and care and attendant age and gender-specific disparities in treatment, health outcomes, and continuity of care within the health services of sub-Saharan African countries have been increasingly well described over the past several years [8,9,13,14,15,16,17,18,19] This establishes a precedent for greater measurement of the impacts of these deficits on fulfillment of the SDGs as we move towards 2030. It is important to further understand the varying failures in the continuity of care of HIV-positive children and adolescents enroled in services in high disease prevalence and impoverished settings [21] This prospective cohort study assesses early death and late all-cause death, ART initiation, non-attendance as a form of non-engagement in care and loss to follow-up. Utilizing SDG3 and SDG5 age and gender-specific indicators, we sought to assess disparities in access to treatment, continuity of care and outcomes, among children and adolescents enrolled in a large subSaharan African HIV care service in Tanzania
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