Abstract
BackgroundHIV infection among children, particularly those under 24 months of age, is often rapidly progressive; as a result guidelines recommend earlier access to combination antiretroviral therapy (cART) for HIV infected children. Losses to follow-up (LTFU) and death in the interval between diagnosis and initiation of ART profoundly limit this strategy. This study explores correlates of LTFU and death prior to ART initiation among children.MethodsThe study is based on 337 HIV-infected children enrolled into care at an urban centre in The Gambia, including those alive and in care when antiretroviral therapy became available and those who enrolled later. Children were followed until they started ART, died, transferred to another facility, or were LTFU. Cox proportional hazards regression models were used to determine the hazard of death or LTFU according to the baseline characteristics of the children.ResultsOverall, 223 children were assessed as eligible for ART based on their clinical and/or immunological status among whom 73 (32.7%) started treatment, 15 (6.7%) requested transfer to another health facility, 105 (47.1%) and 30 (13.5%) were lost to follow-up and died respectively without starting ART. The median survival following eligibility for children who died without starting treatment was 2.8 months (IQR: 0.9 - 5.8) with over half (60%) of all deaths occurring at home. ART-eligible children less than 2 years of age and those in WHO stage 3 or 4 were significantly more likely to be LTFU when compared with their respective comparison groups. The overall pre-treatment mortality rate was 25.7 per 100 child-years of follow-up (95% CI 19.9 - 36.8) and the loss to programme rate was 115.7 per 100 child-years of follow-up (95% CI 98.8 - 137). In the multivariable Cox proportional hazard model, significant independent predictors of loss to programme were being less than 2 years of age and WHO stage 3 or 4. The Adjusted Hazard Ratio (AHR) for loss to programme was 2.06 (95% CI 1.12 – 3.83) for being aged less than 2 years relative to being 5 years of age or older and 1.92 (95% CI 1.05 - 3.53) for being in WHO stage 3 or 4 relative to WHO stage 1 or 2.ConclusionsEarlier enrolment into HIV care is key to achieving better outcomes for HIV infected children in developing countries. Developing strategies to ensure early diagnosis, elimination of obstacles to prompt initiation of therapy and instituting measures to reduce losses to follow-up, will improve the overall outcomes of HIV-infected children.
Highlights
Human Immunodeficiency virus (HIV) infection among children, those under 24 months of age, is often rapidly progressive; as a result guidelines recommend earlier access to combination antiretroviral therapy for HIV infected children
A systematic review of adult ART programmes in sub-Saharan Africa reported that retention is as low as 60% after 2 years [11], which is consistent with our observation of one-third of ART-eligible adults who died or were lost to follow-up prior to initiation of treatment [12]
Follow-up and ART eligibility A total of 411 HIV infected children attended the Medical Research Council (MRC) paediatric HIV clinic at least once between June 1993 and January 2010; of these, 74 were excluded from the analysis because they had either died or were Losses to follow-up (LTFU) prior to June 2004 when pre-ART sensitization and screening began (Figure 1)
Summary
HIV infection among children, those under 24 months of age, is often rapidly progressive; as a result guidelines recommend earlier access to combination antiretroviral therapy (cART) for HIV infected children. The majority of HIV-infected children in sub-Saharan Africa are diagnosed late with advanced clinical disease and immunosuppression, and are usually 5 years of age or older at initiation of therapy [2,4]. This is due to, among other reasons, the fact that health systems in resource limited settings still face considerable challenges in their efforts to scale-up access to early paediatric HIV diagnosis and treatment, among children aged < 18 months in whom a definitive diagnosis requires sophisticated laboratory techniques. There is a paucity of data on mortality and loss to followup experiences of ART-eligible HIV-infected children who fail to initiate treatment because this information is not routinely assessed as part of program evaluations [13,14,15]
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