Outcomes among <scp>HIV</scp>‐infected children initiating <scp>HIV</scp> care and antiretroviral treatment in Ethiopia

Melaku, Zenebe; Lulseged, Sileshi; Wang, Chunhui; Lamb, Matthew R.; Gutema, Yoseph; Teasdale, Chloe A; Ahmed, Solomon; Gadisa, Tsigereda; Habtamu, Zelalem; Bedri, A; Fayorsey, Ruby; Abrams, Elaine J.

doi:10.1111/tmi.12834

Cited by 18 publications

(33 citation statements)

References 22 publications

(28 reference statements)

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“…Our findings confirm the importance of the child’s age [ 9 , 10 , 13 ] and presence of baseline anaemia [ 9 , 12 ] as reliable predictors of attrition from HIV care in a setting with limited resources. Furthermore, children enrolled in HIV care and treatment in our study facilities and coming from rural areas due to their caregivers’ residence were found to have greater risk of attrition than those from urban settings, which we identified as an additional caregiver-associated predictor of attrition.…”

Section: Discussionsupporting

confidence: 80%

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Rates and predictors of attrition among children on antiretroviral therapy in Ethiopia: A prospective cohort study

et al. 2018

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IntroductionAttrition from antiretroviral therapy (ART) programmes is a critical challenge among children receiving care in resource-limited settings. Our objective was to determine the rates and predictors of attrition among children on ART in Ethiopia.MethodsBetween December 2014 and September 2016, we conducted a prospective cohort study in eight health facilities in Ethiopia. Eligibility criteria included age 3 months–14 years; being on ART for not more than a month. Outcome was attrition due to death and/or loss to follow-up. Predictor variables were child clinical and socio-demographic characteristics, and caregiver socio-demographic characteristics. We used Cox Regression analyses to examine the association between predictors and outcome.ResultsOf 309 children, 304 were included, 52% were male. Their median age was 9 years (Inter-quartile range, IQR, 6–12). At ART initiation, their median CD4 was 362 cells/mm3 (IQR 231–499); and 74.3% had WHO stage 1 or 2 disease. During 287.7 person-years of observation (PYO), 24 attritions were recorded, yielding an attrition rate of 8.3 per 100 PYO (95% CI 5.4–12.1). Of these, six children were reported dead, leading to a mortality rate of 2.1 per 100 PYO (95% CI 0.8–4.3). Eighteen were lost to follow-up (LTFU) leading to LTFU rate of 6.26 per 100 PYO (95% CI: 3.83–9.70). The majority, 14 (58%) of attrition occurred during the first six months of treatment.Age below three years [aHR] = 5.14 (95% CI: 2.07–12.96), rural residence (aHR = 3.97, 95% CI: 1.34–11.78) and baseline Hgb in g/dl < 10 g/dl [aHR] = 5.68 (95% CI: 2.03–6.23) predicted higher risk of attrition. Baseline Hgb < 10 g/dl (aHR = 16.63, 95% CI: 1.64–168.4) and WHO stage III or IV (aHR = 12.25, 95% CI: 1.26–119.05) predicted the death of the child. Higher attrition was documented among children of both biological parents alive and biologically related close family caregivers.ConclusionYounger children, those from rural areas, and children with anaemia were at higher risk of attrition, especially during the early months of treatment, and therefore should be prioritized during treatment follow-up. Further studies should examine underlying reasons for higher attrition.

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Section: Discussionsupporting

confidence: 80%

“…A few studies from Ethiopia provided important insights about rates and predictors of attrition in children on ART [ 10 – 13 ]. However, none of these studies used a prospective study design.…”

Section: Introductionmentioning

confidence: 99%

Rates and predictors of attrition among children on antiretroviral therapy in Ethiopia: A prospective cohort study

et al. 2018

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“…Our review found that care in a rural area was associated with higher levels of attrition. This is likely due to rural areas not benefiting from the relatively higher resources and services available in more urban areas . Higher rural attrition is almost certainly also related to transportation, fiscal, and logistical constraints for rural mothers, fathers, and their children .…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2018

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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.

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“…Children with advanced disease at ART initiation are less likely to achieve VS and have higher mortality . While countries have expanded early infant diagnosis (EID) services, many children continue to be missed and are enrolling late in care . In addition to late enrolment, differences have also been observed in rates of VS by age at ART initiation.…”

Section: Introductionmentioning

confidence: 99%

HIV viral suppression and longevity among a cohort of children initiating antiretroviral therapy in Eastern Cape, South Africa

et al. 2018

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IntroductionThere are limited data on viral suppression (VS) in children with HIV receiving antiretroviral therapy (ART) in routine care in low‐resource settings. We examined VS in a cohort of children initiating ART in routine HIV care in Eastern Cape Province, South Africa.MethodsThe Pediatric Enhanced Surveillance Study enrolled HIV‐infected ART eligibility children zero to twelve years at five health facilities from 2012 to 2014. All children received routine HIV care and treatment services and attended quarterly study visits for up to 24 months. Time to VS among those starting treatment was measured from ART start date to first viral load (VL) result <1000 and VL <50 copies/mL using competing risk estimators (death as competing risk). Multivariable sub‐distributional hazards models examined characteristics associated with VS and VL rebound following suppression among those with a VL >30 days after the VS date.ResultsOf 397 children enrolled, 349 (87.9%) started ART: 118 (33.8%) children age <12 months, 122 (35.0%) one to five years and 109 (31.2%) six to twelve years. At study enrolment, median weight‐for‐age z‐score (WAZ) was −1.7 (interquartile range (IQR):−3.1 to −0.4) and median log VL was 5.6 (IQR: 5.0 to 6.2). Cumulative incidence of VS <1000 copies/mL at six, twelve and twenty‐four months was 57.6% (95% CI 52.1 to 62.7), 78.7% (95% CI 73.7 to 82.9) and 84.0% (95% CI 78.9 to 87.9); for VS <50 copies/mL: 40.3% (95% CI 35.0 to 45.5), 63.9% (95% CI 58.2 to 69.0) and 72.9% (95% CI 66.9 to 78.0). At 12 months only 46.6% (95% CI 36.6 to 56.0) of children <12 months had achieved VS <50 copies/mL compared to 76.9% (95% CI 67.9 to 83.7) of children six to twelve years (p < 0.001). In multivariable models, children with VL >1 million copies/mL at ART initiation were half as likely to achieve VS <50 copies/mL (adjusted sub‐distributional hazards 0.50; 95% CI 0.36 to 0.71). Among children achieving VS <50 copies/mL, 37 (19.7%) had VL 50 to 1000 copies/mL and 31 (16.5%) had a VL >1000 copies/mL. Children <12 months had twofold increased risk of VL rebound to VL >1000 copies/mL (adjusted relative risk 2.03, 95% CI: 1.10 to 3.74) compared with six to twelve year olds.ConclusionsWe found suboptimal VS among South African children initiating treatment and high proportions experiencing VL rebound, particularly among younger children. Greater efforts are needed to ensure that all children achieve optimal outcomes.

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Outcomes among HIV‐infected children initiating HIV care and antiretroviral treatment in Ethiopia

Abstract: Over the last decade large numbers of HIV-infected children have been successfully enrolled in HIV care and initiated on ART in Ethiopia. Retention prior to and after ART initiation remains a major challenge.

Cited by 18 publications

References 22 publications

Rates and predictors of attrition among children on antiretroviral therapy in Ethiopia: A prospective cohort study

Rates and predictors of attrition among children on antiretroviral therapy in Ethiopia: A prospective cohort study

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

HIV viral suppression and longevity among a cohort of children initiating antiretroviral therapy in Eastern Cape, South Africa

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