Attrition of HIV‐exposed infants from early infant diagnosis services in low‐ and middle‐income countries: a systematic review and meta‐analysis

Abstract

IntroductionIdentification and retention of HIV‐exposed infants in early infant diagnosis (EID) services helps to ensure optimal health outcomes. This systematic review and meta‐analysis examines the magnitude of attrition from EID services in low‐ and middle‐income countries (LMICs).MethodsWe performed a comprehensive database search through April 2016. We included original studies reporting retention/attrition data for HIV‐exposed infants in LMICs. Outcomes included loss to follow‐up (LTFU), death and overall attrition (LTFU + death) at time points along the continuum of EID services. At least two authors determined study eligibility, performed data extraction and made quality assessments. We used random‐effects meta‐analytic methods to aggregate effect sizes and perform meta‐regression analyses. This study adhered to PRISMA reporting guidelines.ResultsWe identified 3040 unique studies, of which 92 met eligibility criteria and were included in the quantitative synthesis. The included studies represent data from 110,805 HIV‐exposed infants, the majority of whom were from Africa (77%). LTFU definitions varied widely, and there was significant variability in outcomes across studies. The bulk of attrition occurred in the first six months of follow‐up, with additional losses over time. Overall, 39% of HIV‐exposed infants were no longer in care at 18 months. When restricted to non‐intervention studies, 43% were not retained at 18 months.ConclusionsThese findings underscore the high attrition of HIV‐exposed infants from EID services in LMICs and the urgent need for implementation research and resources to improve retention among this vulnerable population.

HIV-exposed infant follow-up in Mozambique: Formative research findings for the design of a cluster randomized controlled trial to improve testing and ART initiation

“…The interview results revealed that waiting time for the consultations, lack of understanding of how to follow-up, compounded by stigma and fear of disclosure to partners, contributed to LTFU especially at the PCR results stage and the follow-up to ART initiation. These finding tend to corroborate results from other studies and trials in low resources contexts (10)(11)(12)(13)(14) . HIV testing and ART initiation coverage for mothers tends be quite high, but EID and pediatric HIV care and treatment coverage are hampered by lack of patient tracking mechanisms, long waiting times for test results, and inadequate counseling and support for mothers to help them understand and navigate each step in the care cascade.…”

HIV-exposed infant follow-up in Mozambique: formative research findings for the design of a cluster randomized controlled trial to improve testing and ART initiation

“…The interview results revealed that waiting time for clinic visits, and lack of understanding of how to followup added to stigma and fear of disclosure to partners, and contributed to LTFU especially at the PCR results stage and the follow-up to ART initiation. These findings tend to corroborate results from other studies and trials in low resources contexts [10][11][12][13][14]. HIV testing and maternal ART initiation coverage tends be quite high, but EID and pediatric HIV care and treatment coverage are hampered by lack of patient tracking mechanisms, long waiting times for test results, and inadequate counseling and support for mothers to help them understand and navigate each step in the care cascade.…”

“…The EID care and treatment cascade has proven challenging in many developing countries, including Mozambique [1,[9][10][11][12][13][14]. Loss-to-follow-up (LTFU) can occur at multiple steps and effective EID is further impeded by human resource constraints, lack of parental understanding for how to navigate care, laboratory stock-outs, and difficulty with patient tracking [9][10][11][12][13][14]. One recent meta-analysis indicated that most attrition occurs in the first 6 months of follow-up and 39% of exposed infants were not in care after 18 months, therefore interventions early in the EID cascade might have greater impact on LTFU [14].…”

“…Loss-to-follow-up (LTFU) can occur at multiple steps and effective EID is further impeded by human resource constraints, lack of parental understanding for how to navigate care, laboratory stock-outs, and difficulty with patient tracking [9][10][11][12][13][14]. One recent meta-analysis indicated that most attrition occurs in the first 6 months of follow-up and 39% of exposed infants were not in care after 18 months, therefore interventions early in the EID cascade might have greater impact on LTFU [14]. To reach the UNAIDS 90-90-90 targets by 2020 improvements in the pediatric HIV treatment cascade are urgently needed [15].…”

Review article: direct‐acting antivirals for the treatment of HCV during pregnancy and lactation ‐ implications for maternal dosing, foetal exposure, and safety for mother and child

“…Unfortunately, there will be no treatment available prior to the age of 3 in the near future as this is not requested by the European Medicines Agency (EMA). Therefore, treatment of children with vertically acquired HCV may be complicated as loss to follow‐up in healthcare later in life is likely to be high, as is the case in some settings for HIV …”