Pediatric Antiretroviral Therapy Coverage and AIDS Deaths in the “Treat All” Era

Abstract

OBJECTIVES: In 2015, CD4-based clinical staging criteria for antiretroviral therapy (ART) initiation were removed, expanding ART eligibility (“Treat All”) for children, who shoulder an outsized burden of HIV-related deaths. To quantify the impact of “Treat All” on pediatric HIV outcomes, we examined shifts in pediatric ART coverage and AIDS mortality before and after “Treat All” implementation. METHODS: We abstracted country-level ART coverage (proportion of children <15 years on ART) and AIDS mortality (deaths per 100 000 population) estimates over 11 years. For 91 countries, we also abstracted the year “Treat All” was incorporated into national guidelines. We used multivariable 2-way fixed effects negative binomial regression to estimate changes in pediatric ART coverage and AIDS mortality potentially attributable to “Treat All” expansion, reported as adjusted incidence rate ratios (adj.IRR) with 95% confidence intervals (95% CI). RESULTS: From 2010 to 2020, pediatric ART coverage tripled (16% to 54%), and AIDS-related deaths were halved (240 000 to 99 000). Compared with the pre-implementation period, observed ART coverage continued increasing after “Treat All” adoption, but this rate of increase declined by 6% (adj.IRR = 0.94, 95% CI: 0.91–0.98). AIDS mortality continued declining after “Treat All” adoption, but this rate of decline decreased by 8% (adj.IRR = 1.08, 95% CI: 1.05–1.11) in the post-implementation period. CONCLUSIONS: Although “Treat All” called for increased HIV treatment equity, ART coverage continues lagging in children and comprehensive approaches that address structural issues, including family-based services and intensified case-finding, are needed to close pediatric HIV treatment gaps.

Electronic Medical Record Data Missingness and Interruption in Antiretroviral Therapy Among Adults and Children Living With HIV in Haiti: Retrospective Longitudinal Study

“…Pediatric populations living with HIV have unique care needs, and poorer engagement for pediatric patients across the HIV care cascade is a multifaceted issue, involving behavioral, psychosocial, pharmacokinetic, and structural factors [ 17 46 ]. The literature has identified a number of key barriers to pediatric ART adherence, including stigma among caregivers to seek or continue care for children; lack of education or training for caregivers on caring for a child living with HIV; complexities inherent to a patient-caregiver-provider relationship; limited patient agency due to age and patient-caregiver power structures; patient-led treatment refusal, sometimes due to a lack of palatable formulations for younger patients; and lack of providers trained in pediatric HIV care or family-based service delivery [ 17 47 48 ]. Relevant to this analysis, prior research has shown direct links between quality of care, care engagement, and patient outcomes for this population.…”

Cardioprotective effects of antiretroviral treatment in adolescents with perinatal HIV infection are heterogeneous depending on age at treatment initiation

“…In contrast, subclinical cardiac abnormalities remain prevalent in their peers in sub-Saharan Africa (SSA) [4], [5], [6] where 90% of global pediatric HIV patients reside [7]. Here, pediatric ART coverage is neither universal (54% in 2020) [8] 9 nor is it started early (median age at initiation 7.9 years (2018)) [7], [8] before substantial immunosuppression and cardiac damage set in [3]. The concern is that these cardiac abnormalities in early life will likely be a substrate for symptomatic cardiovascular dysfunction in adulthood, particularly as maturing APHIV are cumulatively exposed to traditional cardiovascular risk factors [9].…”

The Impact of Normal Aging Out on Continuity of Treatment among Children and Adolescents Living with HIV in the PEPFAR Supported Program in Kenya

“…Optimized case-finding and enhanced linkage to treatment are needed to close gaps in ART coverage and HIV-related morbidity and mortality for C/ALHIV [9]. While HIV continuity of treatment (CoT) is essential for VLS, prevention of disease progression and mortality, and further transmission; data is limited on impact of aging on CoT proxies used for programmatic evaluation and improvement.…”