half of all children having started antiretroviral treatment (ART) at under one
year of age were still in care two years later, according to the largest single
programme multi-country retrospective analysis of children on ART in Kenya,
Mozambique, Rwanda and Tanzania, published in the advance online edition of the
Journal of Acquired Immune Deficiency
the more than 17,000 children (0 to under 15 years of age) having started ART
at 192 facilities in the four countries over the six-year period, overall
retention rates at 12 months and 24 months were 80 and 72%, respectively;
differing considerably by country ranging from 71 to 95% and 62 to 93%, respectively.
overall 16 and 22% were lost to follow-up (LTFU) and 5 and 7% were known to
have died at these respective time points, there were significant differences
among patient populations.
24 months, 18% of those having started ART at under one year of age died.
these estimates can be considered an improvement from the reports in the
pre-ART era (50% mortality at 24 months), the mortality rate remains
unacceptably high in the context of ART” write the authors.
benefits for children on ART should be the same whether in a resource-poor or
-rich setting, yet the death rate among the former is eight times that of the
spite of increased early diagnosis and getting larger numbers of younger
children onto treatment many paediatric HIV programmes in resource-poor
settings have yet to see these benefits.
study builds upon evidence that overall retention, LTFU and death are
suboptimal, and young children and those with advanced disease are at highest
risk for LTFU and death” the authors note.
of paediatric HIV treatment and care in sub-Saharan African, home to over 90%
of children living with HIV, has resulted in over 400,000 children having
in resource-poor settings respond to treatment as well as those in
resource-rich settings. The vast difference in outcomes is the result of both
biomedical and programme factors and include having advanced disease upon
diagnosis, other co-infections, malnutrition, delays in starting ART, and
suboptimal retention in care.
HIV-infected children in care is critical for prevention of HIV-related illness
and death. It means the timely start of ART, monitoring and managing disease
progression and treatment failure, and providing ongoing treatment and
outcomes are to be improved factors that affect retention need to be
authors chose to undertake a retrospective cohort analysis of data of children
having started ART between January 2005 and June 2011 to determine the
proportion of children retained in care, LTFU and died at 12 and 24 months; to
look at the variations by country and identify those individual- and
facility-level associated factors.
192 health facilities received support from the International Center for AIDS
Care and Treatment Programs (ICAP), a PEPFAR implementing partner supporting
HIV treatment and care in sub-Saharan Africa since 2005.
for starting ART followed national guidelines reflecting World Health
Organization (WHO) recommendations.
was defined as the proportion of children known to be alive and getting care at
the health facility where treatment was started; LTFU was defined as no clinic
visit for more than six months.
factors included: CD4 count or percentage, according to WHO guidelines, to
determine disease severity when starting ART; malnourishment; “severe illness” (a new category because of the high proportion of missing CD4 measurements and
WHO stage); WHO definition of severe immunodeficiency or WHO Stage 4 at the time
of starting ART.
level factors were defined as primary and secondary/tertiary; the former any
health centre and the latter district, regional or national hospitals.
Locations were categorised as urban, semi-urban and rural.
the 37,514 children enrolled in HIV services, 17,712 started ART; Mozambique
had the largest number (7226) and Rwanda the smallest (2170).
year, the numbers starting ART increased, from 585 in 2005 to 3653 in 2010 with
the number of facilities increasing from 75 to 192.
half of all facilities were in rural areas.
starting ART the median age was 4.6 years (IQR: 1.9-8.3), the median CD4
percentage for children under five years of age was 15% (IQR: 10-20%) and 265
cells/mm3 (IQR: 111-461) for those over five.
over a third of all children were severely ill when starting ART.
proportion of young children under two starting ART increased over time (from
12% in 2005 to 33% in 2011) with a corresponding decrease in the severity of
illness in children under one (from 56 to 18%). Yet contrary to what would be
expected – enrolling healthier children and the benefits of getting them on
treatment earlier – no improvements were seen in retention or death over time.
children under one year of age the adjusted hazard ratio for LTFU and death was
aHR=2.0, 95% CI: 1.7-2.4 and aHR=3.4, 95% CI: 2.6-4.6, respectively.
to children with less advanced illness those with severe illness had higher
death rates HR=1.6, 95% CI: 1.1-1.9, but similar LTFU rates, HR=0.99, 95% CI:
highlighting the continued need to pay special attention for infants to be
diagnosed promptly, started on treatment and kept in care, these findings also
show the need for more research to identify those factors affecting health
outcomes among this highly vulnerable group, the authors note.
all facilities receiving technical support through ICAP, having the same model
of care in place with an emphasis on early infant diagnosis, family-focussed
care, peer educators and active follow-up, there were considerable differences
in outcomes across country programmes as well as within country.
to children in Rwanda, children in Mozambique were over 16 times more likely to
be lost to follow-up (aHR: 16.8, 95% CI: 8.9-32.0) and children in Tanzania had more than
twice the death rate (aHR: 2.6, 95% CI: 1.8-3.6).
authors suggest these differences result from a combination of factors
including national leadership, access to care, HIV prevalence, patient-provider
ratios, caseload and decentralisation.
had the highest retention rate consistent with other findings. However, they
also had the smallest proportion of young children (15.6% compared to 38.7% in
Mozambique) and the smallest proportion of severely ill children, (18.6%
compared to 44.5% in Mozambique).
Rwanda had a smaller programme with a lower caseload, a factor linked to lower
LTFU in resource-poor settings. This may be the result of higher
staff-to-patient ratios, shorter wait times, more staff and active follow-up,
factors shown to reduce LTFU, the authors note.
the exception of Rwanda, the proportion of LTFU was higher than the proportion
of known death for all age groups and time periods.
results are encouraging as they illustrate what is achievable in public
programmes and suggest that improvement is obtainable,” the authors comment.
is the largest single programme multi-country analysis on outcomes among
children reflecting the scale up of HIV care and treatment in sub-Saharan
Africa and can probably be generalised to other PEPFAR-supported paediatric HIV
analysis is limited by the large amount of missing data at the start of ART.
Missing data – a separate category in the regression analyses – showed that
children with missing data appeared at greater risk for LTFU or death.
authors conclude “The vast differences across country programmes illustrate
that improved retention is achievable…additional attention to prompt diagnosis,
early ART initiation, active follow-up of children who miss appointments and
improved documentation of known transfers and death are urgent priorities for
paediatric HIV programmes.”