Outcomes of Antiretroviral Therapy in Children in Asia and Africa

Abstract

Background We investigated 18-month incidence and determinants of death and loss-to-follow-up of children after antiretroviral therapy (ART) initiation in a multiregional collaboration in lower-income countries. Methods HIV-infected children (positive PCR <18 months or positive serology ≥18 months) from IeDEA cohorts, <16 years, initiating ART were eligible. A competing risk regression model was used to analyze the independent risk of two failure types: death and loss-to-follow-up (>6 months). Findings Data on 13611 children, from Asia (N=1454), East-Africa (N=3114), Southern-Africa (N=6212) and West-Africa (N=2881) contributed 20,417 person-years of follow-up. At 18 months, the adjusted risk of death was 4.3% in East-Africa, 5.4% in Asia, 5.7% in Southern-Africa and 7.4% in West-Africa (P=0.01). Age<24 months, WHO stage 4, CD4<10%, attending a private sector clinic, larger cohort size and living in West-Africa were independently associated with poorer survival. The adjusted risk of loss-to-follow-up was 4.1% in Asia, 9.0% in Southern-Africa, 14.0% in East-Africa, and 21.8% in West-Africa (P <0.01). Age<12 months, non NNRTI-based ART regimen, WHO stage 4 at ART start, ART initiation after 2005, attending a public sector or a non-urban clinic, having to pay for laboratory tests or antiretroviral drugs, larger cohort size, and living in East or West-Africa were significantly associated with higher loss-to-follow-up. Conclusion Findings differed substantially across regions but raise overall concerns about delayed ART start, low access to free HIV-services for children, and increased workload on program retention in lower-income countries. Universal free access to ART services and innovative approaches are urgently needed to improve pediatric outcomes at program level.

Viral load versus CD4+ monitoring and 5-year outcomes of antiretroviral therapy in HIV-positive children in Southern Africa

“…It was not our intention to examine programme-level outcomes and include outcomes in children lost to follow-up. Interestingly, our results are closely similar to a recent multiregional analysis of paediatric outcomes of ART in Africa and Asia [48]. Leroy and colleagues used a competing risk model of death and loss to follow-up [48].…”

Living and dying to be counted: What we know about the epidemiology of the global adolescent HIV epidemic

“…Based on an updated review (produced by Lynne Mofenson and commissioned by UNAIDS, and detailed in Annex 2 of reference [21]), on the probability of HIV transmission during pregnancy, delivery and breastfeeding, the number of children estimated to have become HIV infected was revised downward for current and historical years. Based on multiregional analyses performed by the International Epidemiologic Database to Evaluate AIDS (IeDEA), improvements were also made to more accurately reflect at what age children initiate ART [23,24]. Rather than assuming that a constant proportion of children less than age 15 years initiate ART as they become eligible as done in previous models, the current model uses age‐specific assumptions of the proportion of children starting on ART [3,20].…”

Determinants of durability of first-line antiretroviral therapy regimen and time from first-line failure to second-line antiretroviral therapy initiation

“…Furthermore, a high proportion of children are lost to follow-up (LTFU). In the context of paediatric HIV care in West Africa where very few children were transferred out to decentralized centres, there is reason to believe that LTFU is associated with disease progression and that a significant proportion of those children are actually in failure and/or deceased [22]. Consequently, the validity of our results could be adversely affected: first, the number of children in failure is underestimated, thus overestimating the probability of switching in case of failure; second, these LTFU children are censored in our model and therefore the risks of death are underestimated.…”