Mortality and loss to follow-up in the first year of ART

Abstract

Objectives To analyse mortality, loss to follow-up (LTFU) and retention on antiretroviral treatment (ART) in the first year of ART across all age-groups in the Malawi national ART programme. Design Cohort study including all patients who started ART in Malawi’s public sector clinics between 2004 and 2007. Methods ART registers were photographed, information entered into a database and merged with data from clinics with electronic records. Rates per 100 patient-years and cumulative incidence of retention were calculated. Subhazard ratios (sHR) of outcomes adjusted for patient and clinic level characteristics were calculated in multivariate analysis, applying competing risk models. Results A total of 117,945 patients contributed 85,246 person-years: 1.0% were infants <2 years, 7.4 % children 2–14, 7.5% young people 15–24, and 84.2% adults 25 years and above. Sixty percent of patients were female: women outnumbered men from age 14 to 35 years. Mortality and LTFU were higher in men from age 20 years. Infants and young people had the highest rates per 100 person-years for mortality (23.0 and 19.4) and LTFU (24.7 and 19.3), and the highest adjusted relative risks compared to age group 25–34 years: sHRs were 1.37 (95%CI 1.17–1.60) and 1.17 (95%CI 1.10–1.25) for death and 1.37 (95%CI 1.18–1.59) and 1.27 (95%CI 1.19–1.35) for LTFU, respectively. Conclusion In this country-wide study patients aged 0–1 and 15–24 years had the highest risk of death and LTFU, and from age 20 and older men were at higher risk than women. Interventions to improve outcomes in these patient groups are required.

High attrition before and after ART initiation among youth (15–24 years of age) enrolled in HIV care

“…Eighty-five percent of youth in our study population were female, on par with the sex distribution observed among adolescents and young adults in other studies in Africa [11,13,19,20]. In our study, 19% of female youth were pregnant at enrollment into HIV care, and 20% enrolled through PMTCT, highlighting an important point of entry into clinical care for this population.…”

Incidence of World Health Organization Stage 3 and 4 Events, Tuberculosis and Mortality in Untreated, HIV-infected Children Enrolling in Care Before 1 Year of Age

“…We chose to censor follow-up time at ART initiation, in order to report clinical event risks among untreated children. Alternative approaches, such as competing-risk analysis, 37,38 would permit creation of survival curves and partial adjustment of clinical event risks for the impact of ART initiation over follow-up periods expanded to include time on ART, but would not permit an analysis focused only on events among children prior to ART initiation. These data thus provide an estimate of HIV disease progression in the current ART era, but prior to universal access to ART for HIV-infected infants.…”

The Association between Quality of HIV Care, Loss to Follow-Up and Mortality in Pediatric and Adolescent Patients Receiving Antiretroviral Therapy in Nigeria

“…[20]–[22] Reports describing clinical outcomes in this age group have documented significant challenges, with numerous studies noting high rates of loss to follow-up and early mortality. [23]–[28] Many factors—including late presentation, malnutrition, lack of caregiver involvement, nondisclosure, and HIV-related stigma—contribute to these findings. [27], [29], [30] Whether the quality of care received by children and young adults is associated with loss to follow-up or mortality has not been assessed.…”