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

Abstract

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.

Survival of Children Living With HIV on Art in Zambia: A 13-Years Retrospective Cohort Analysis

“…Our mortality rates over the first 2 years on ART were higher than those reported in a 2 year follow up study in Addis Ababa, Ethiopia (1.2 per 100 person-years), a 1 year follow up study in Makurdi, Nigeria (3.0 per 100 person-years), and a 2 year follow up study in Eastern Ethiopia (2.1 per 100 years). However, our overall mortality rate was lower than those reported in a 7 year South African study (4.7 per 100 person-years) and an eight-year study in Jos, Nigeria (14,16,17). The variation in mortality rates could be due to larger sample size in our study compared to other studies used in the comparison.…”

“…The variation in mortality rates could be due to larger sample size in our study compared to other studies used in the comparison. Another reason could be the year in which the study was conducted as WHO guidelines being used at that time could have affected time to ART initiation, drug regimen and in turn mortality (10,14).…”

“…Studies have shown that initiating children on ART early (birth-7 weeks) reduced mortality by 76% compared to postponing ART until progression to advanced HIV disease or CD4 count thresholds are reached (11,12). However, other studies have shown that WHO clinical stage 3 or 4 and young age at the time of ART initiation were associated with a 5-fold increased risk of death, while absolute CD4 counts of <350 cells/mm 3 at ART initiation and underweight (weightfor-age Z-score <-2) were associated with 3.6 and 3,5 times increase in mortality among CLHIV (5,(13)(14)(15). In addition, overall mortality rates among CLHIV on ART vary from country to country depending on several factors.…”

“…In addition, overall mortality rates among CLHIV on ART vary from country to country depending on several factors. In a 7-year study in South Africa, a mortality rate of 4.7 per 100 person-years was reported (16), whereas in Ethiopia a mortality rate of 1.2 per 100 person-years was reported in Addis Ababa and 2.1 per 100 person-years in Eastern Ethiopia after a 2 year follow up (14). Furthermore, a mortality rate of 3.0 per 100 person-years was reported in a 1 year follow up study in Nigeria (17).…”

Reengagement of HIV-infected children lost to follow-up after active mobile phone tracing in a rural area of Mozambique

“…Older children had higher probabilities of RIC in our study (AOR 1.11, 95% CI 1.01-1.24; p-value 0.036). Taking into account these findings as well as those from several studies (20)(21)(22) that indicate that younger children have a higher risk of LTFU and death, retention efforts should be increased in young children.…”