Early Mortality and Loss to Follow-up in HIV-Infected Children Starting Antiretroviral Therapy in Southern Africa

• DOI: 10.1097/qai.0b013e3181e0c4cf
• Publication Date: 2010-06-29T07:37:04Z
• Authors: Lukas Fenner; Martin W G Brinkhof; Olivia Keiser; Ralf Weigel; Morna Cornell; Harry Moultrie; Hans Prozesky; Karl Technau; Brian Eley; Paula Vaz; Margaret Pascoe; Janet Giddy; Gilles Van Cutsem; Robin Wood; Matthias Egger; Mary-Ann Davies
• Keywords: childhood mortality; Male; Malawi; nevirapine; HIV Infections; preschool child; 310; Severity of Illness Index; South Africa; 0302 clinical medicine; sensitivity analysis; Risk Factors; Antiretroviral Therapy, Highly Active; Child; Southern; Mozambique; child; lopinavir plus ritonavir; article; Age Factors; efavirenz; Human immunodeficiency virus infected patient; Prognosis; 3. Good health; female; priority journal; risk factor; Child, Preschool; Female; Zimbabwe; Anti-HIV Agents; Antiretroviral Therapy; CD4 lymphocyte percentage; Africa, Southern; 03 medical and health sciences; male; Human immunodeficiency virus infection; follow up; Humans; Highly Active; human; Preschool; Infant; school child; lamivudine plus stavudine; infant; major clinical study; CD4 Lymphocyte Count; adolescent; Africa

Many HIV-infected children in Southern Africa have been started on antiretroviral therapy (ART), but loss to follow up (LTFU) can be substantial. We analyzed mortality in children retained in care and in all children starting ART, taking LTFU into account.Children who started ART before the age of 16 years in 10 ART programs in South Africa, Malawi, Mozambique, and Zimbabwe were included. Risk factors for death in the first year of ART were identified in Weibull models. A meta-analytic approach was used to estimate cumulative mortality at 1 year.Eight thousand two hundred twenty-five children (median age 49 months, median CD4 cell percent 11.6%) were included; 391 (4.8%) died and 523 (7.0%) were LTFU in the first year. Mortality at 1 year was 4.5% [95% confidence interval (CI): 2.8% to 7.4%] in children remaining in care, but 8.7% (5.4% to 12.1%) at the program level, after taking mortality in children and LTFU into account. Factors associated with mortality in children remaining in care included age [adjusted hazard ratio (HR) 0.37; 95% CI: 0.25 to 0.54 comparing > or =120 months with <18 months], CD4 cell percent (HR: 0.56; 95% CI: 0.39 to 0.78 comparing > or =20% with <10%), and clinical stage (HR: 0.12; 95% CI: 0.03 to 0.45 comparing World Health Organization stage I with III/IV).In children starting ART and remaining in care in Southern Africa mortality at 1 year is <5% but almost twice as high at the program level, when taking LTFU into account. Age, CD4 percentage, and clinical stage are important predictors of mortality at the individual level.