Retention of HIV-Infected Children on Antiretroviral Treatment in HIV Care and Treatment Programs in Kenya, Mozambique, Rwanda, and Tanzania

McNairy, Margaret L.; Lamb, Matthew R.; Carter, Rosalind J.; Fayorsey, Ruby; Tene, Gilbert; Mutabazi, Vincent; Gusmão, Eduarda Pimentel De; Panya, Millembe F; Sheriff, Muhsin; Abrams, Elaine J.

doi:10.1097/qai.0b013e318278bcb0

Cited by 71 publications

(86 citation statements)

References 40 publications

(58 reference statements)

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“…These improvements include reductions inage at initiation, 21,39 baseline disease severity and mortality. 9,21 Our results are also comparable to more recent studies of immunological 40,41 and anthropometric responses 21,42 as well as mortality 43 in infants on ART within sub-Saharan Africa. However, our findings regarding virological suppression differ considerably from previous studies such as Kay et al (2012) who described a 45% 12 month probability of virological suppression (defined as two consecutive viral load <400copies/ml) and Tukei et al (2013) who described a 72%12 month probability of virological suppression in a cohort of infants with at least 6 months of ART.…”

Section: Discussionsupporting

confidence: 90%

Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004–2012

Porter

Davies

Mapani

et al. 2015

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background There is limited published data on the outcomes of infants starting antiretroviral therapy (ART) in routine care in Southern Africa. This study aimed to examine the baseline characteristics and outcomes of infants initiating ART. Methods We analysed prospectively collected cohort data from routine ART initiation in infants from 11 cohorts contributing to the International Epidemiologic Database to Evaluate AIDS in Southern Africa. We included ART naïve HIV-infected infants <12 months of age initiating ≥ three antiretroviral drugs between 2004 and 2012. Kaplan-Meier estimates were calculated for mortality, loss to follow-up (LTFU), transfer out and virological suppression. We used Cox Proportional Hazards models stratified by cohort to determine baseline characteristics associated with outcomes mortality and virological suppression. Results The median (interquartile range) age at ART initiation of 4945 infants was 5.9 months (3.7-8.7) with follow-up of 11.2 months (2.8-20.0). At ART initiation 77% had WHO clinical stage 3 or 4 disease and 87% were severely immunosuppressed. Three-year mortality probability was 16% and LTFU 29%. Severe immunosuppression, WHO stage 3 or 4, anaemia, being severely underweight and initiation of treatment before 2010 were associated with higher mortality. At 12 months after ART initiation 17% of infants were severely immunosuppressed and the probability of attaining virological suppression was 56%. Conclusion Most infants initiating ART in Southern Africa had severe disease with high probability of LTFU and mortality on ART. Although the majority of infants remaining in care showed immune recovery and virological suppression, these responses were suboptimal.

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Section: Discussionsupporting

confidence: 90%

Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004–2012

Porter

Davies

Mapani

et al. 2015

JAIDS Journal of Acquired Immune Deficiency Syndromes

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“…Regardless of the reason(s), the high proportion of patients with optimal outcomes observed from the data from Rwanda is consistent with findings from other studies. 29–31 …”

Section: Discussionmentioning

confidence: 99%

Use of a Comprehensive HIV Care Cascade for Evaluating HIV Program Performance

McNairy

Lamb

Abrams

et al. 2015

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background The traditional HIV treatment cascade has been noted to have limitations. A proposed comprehensive HIV care cascade that uses cohort methodology offers additional information as it accounts for all patients. Using data from 4 countries, we compare patient outcomes using both approaches. Methods Data from 390,603 HIV-infected adults (>15 years) enrolled at 217 facilities in Kenya, Mozambique, Rwanda, and Tanzania from 2005 to 2011 were included. Outcomes of all patients at 3, 6, and 12 months after enrollment were categorized as optimal, suboptimal, or poor. Optimal outcomes included retention in care, antiretroviral therapy (ART) initiation, and documented transfer. Suboptimal outcomes included retention in care without ART initiation among eligible patients or those without eligibility data. Poor outcomes included loss to follow-up and death. Results The comprehensive HIV care cascade demonstrated that at 3, 6 and 12 months, 58%, 51%, and 49% of patients had optimal outcomes; 22%, 12%, and 7% had suboptimal outcomes, and 20%, 37% and 44% had poor outcomes. Of all patients enrolled in care, 56% were retained in care at 12 months after enrollment. In comparison, the traditional HIV treatment cascade found 89% of patients enrolled in HIV care were assessed for ART eligibility, of whom 48% were determined to be ART-eligible with 70% initiating ART, and 78% of those initiated on ART retained at 12 months. Conclusions The comprehensive HIV care cascade follows outcomes of all patients, including pre-ART patients, who enroll in HIV care over time and uses quality of care parameters for categorizing outcomes. The comprehensive HIV care cascade provides complementary information to that of the traditional HIV treatment cascade and is a valuable tool for monitoring HIV program performance.

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“…6,8,22-24 In 2010, 70% of children <2 years started cART with severe immunodeficiency despite WHO guidelines recommending early cART regardless of immunologic or clinical thresholds for all children in this age group. 7 This may be partly due to delayed country-level implementation of WHO guidelines as well as poor access to early infant diagnosis (EID), slow turn-around time of test results, and limited cART availability for infants and young children.…”

Section: Discussionmentioning

confidence: 99%

Immunodeficiency in Children Starting Antiretroviral Therapy in Low-, Middle-, and High-Income Countries

Koller

Patel

Benjamin

et al. 2015

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background The CD4 cell count or percent (CD4%) at the start of combination antiretroviral therapy (cART) are important prognostic factors in children starting therapy and an important indicator of program performance. We describe trends and determinants of CD4 measures at cART initiation in children from low-, middle- and high-income countries. Methods We included children aged <16 years from clinics participating in a collaborative study spanning sub-Saharan Africa, Asia, Latin America and the United States of America (USA). Missing CD4 values at cART start were estimated through multiple imputation. Severe immunodeficiency was defined according to World Health Organization criteria. Analyses used generalized additive mixed models adjusted for age, country and calendar year. Results 34,706 children from nine low-income, six lower middle-income, four upper middle-income countries and one high-income country (United States of America, USA) were included; 20,624 children (59%) had severe immunodeficiency. In low-income countries the estimated prevalence of children starting cART with severe immunodeficiency declined from 76% in 2004 to 63% in 2010. Corresponding figures for lower middle-income countries were from 77% to 66% and for upper middle-income countries from 75% to 58%. In the USA, the percentage decreased from 42% to 19% during the period 1996 to 2006. In low- and middle-income countries infants and children aged 12-15 years had the highest prevalence of severe immunodeficiency at cART initiation. Conclusions Despite progress in most low- and middle-income countries, many children continue to start cART with severe immunodeficiency. Early diagnosis and treatment of HIV-infected children to prevent morbidity and mortality associated with immunodeficiency must remain a global public health priority.

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Retention of HIV-Infected Children on Antiretroviral Treatment in HIV Care and Treatment Programs in Kenya, Mozambique, Rwanda, and Tanzania

Abstract: Retention was lowest in young children and differed across country programs. Young children and those with advanced disease are at highest risk for LTF and death. Further evaluation of patient- and program-level factors is needed to improve health outcomes.

Cited by 71 publications

References 40 publications

Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004–2012

Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004–2012

Use of a Comprehensive HIV Care Cascade for Evaluating HIV Program Performance

Immunodeficiency in Children Starting Antiretroviral Therapy in Low-, Middle-, and High-Income Countries

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