The epidemiology of adolescents living with perinatally acquired HIV: A cross-region global cohort analysis

Abstract

BackgroundGlobally, the population of adolescents living with perinatally acquired HIV (APHs) continues to expand. In this study, we pooled data from observational pediatric HIV cohorts and cohort networks, allowing comparisons of adolescents with perinatally acquired HIV in “real-life” settings across multiple regions. We describe the geographic and temporal characteristics and mortality outcomes of APHs across multiple regions, including South America and the Caribbean, North America, Europe, sub-Saharan Africa, and South and Southeast Asia.Methods and findingsThrough the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER), individual retrospective longitudinal data from 12 cohort networks were pooled. All children infected with HIV who entered care before age 10 years, were not known to have horizontally acquired HIV, and were followed up beyond age 10 years were included in this analysis conducted from May 2016 to January 2017. Our primary analysis describes patient and treatment characteristics of APHs at key time points, including first HIV-associated clinic visit, antiretroviral therapy (ART) start, age 10 years, and last visit, and compares these characteristics by geographic region, country income group (CIG), and birth period. Our secondary analysis describes mortality, transfer out, and lost to follow-up (LTFU) as outcomes at age 15 years, using competing risk analysis. Among the 38,187 APHs included, 51% were female, 79% were from sub-Saharan Africa and 65% lived in low-income countries. APHs from 51 countries were included (Europe: 14 countries and 3,054 APHs; North America: 1 country and 1,032 APHs; South America and the Caribbean: 4 countries and 903 APHs; South and Southeast Asia: 7 countries and 2,902 APHs; sub-Saharan Africa, 25 countries and 30,296 APHs). Observation started as early as 1982 in Europe and 1996 in sub-Saharan Africa, and continued until at least 2014 in all regions. The median (interquartile range [IQR]) duration of adolescent follow-up was 3.1 (1.5–5.2) years for the total cohort and 6.4 (3.6–8.0) years in Europe, 3.7 (2.0–5.4) years in North America, 2.5 (1.2–4.4) years in South and Southeast Asia, 5.0 (2.7–7.5) years in South America and the Caribbean, and 2.1 (0.9–3.8) years in sub-Saharan Africa. Median (IQR) age at first visit differed substantially by region, ranging from 0.7 (0.3–2.1) years in North America to 7.1 (5.3–8.6) years in sub-Saharan Africa. The median age at ART start varied from 0.9 (0.4–2.6) years in North America to 7.9 (6.0–9.3) years in sub-Saharan Africa. The cumulative incidence estimates (95% confidence interval [CI]) at age 15 years for mortality, transfers out, and LTFU for all APHs were 2.6% (2.4%–2.8%), 15.6% (15.1%–16.0%), and 11.3% (10.9%–11.8%), respectively. Mortality was lowest in Europe (0.8% [0.5%–1.1%]) and highest in South America and the Caribbean (4.4% [3.1%–6.1%]). However, LTFU was lowest in South America and the Caribbean (4.8% [3.4%–6.7%]) and highest in sub-Saharan Africa (13.2% [12.6%–13.7%]). Study limitat...

Stunting and growth velocity of adolescents with perinatally acquired HIV: differential evolution for males and females. A multiregional analysis from the IeDEA global paediatric collaboration

“…In El Salvador, 48% of children with HIV over 12 years of age were stunted . In the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) including cohorts of APH from IeDEA and other networks in low‐, middle‐ and high‐income countries, median HAZ at ART initiation and at 10 years of age were similar to our study; however, APH living in high‐income countries had higher HAZ than in low‐and‐middle‐income countries (LMICs) .…”

Mortality and losses to follow‐up among adolescents living with HIV in the IeDEA global cohort collaboration

“…Receiving care in rural settings was associated with higher LTFU, but protective against death, which may suggest under ascertainment of mortality in rural areas where out migration in sub‐Saharan Africa has been common . The reasons for the associations with regional cohort are unclear, and could be due to varying proportions of perinatally infected youth, local patient case mix, or other socio‐economic or demographic factors . In addition, regional cohorts with sites within areas with a high density of ART programmes may see more “silent transfers,” where patients move between clinics without formal referrals.…”

“…In addition, infections acquired through risk behaviours are not modelled in the UNAIDS Spectrum model to occur among those entering HIV care before the age of 15 years . We conducted a sensitivity analysis to examine the impact of differentiating patients by age <10 versus ≥10 years at entry into care as a comparison .…”

Characterizing the double‐sided cascade of care for adolescents living with HIV transitioning to adulthood across Southern Africa

“…Characteristics of AYLH for each analysis were described by frequencies for categorical variables and as medians and inter‐quartile ranges for continuous variables. As the mode of infection was not available in our data, we considered adolescents who had enrolled into HIV care before the age of 10 years as likely perinatally infected . We investigated whether there were any differences in the proportion of patients with no gap in care and proportion virally suppressed before and after each respective age threshold which we termed as the pre‐ and post‐transition periods.…”