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

Background

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.

Patients and methods

Children who started ART before the age of 16 years in ten 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 one year.

Results

8225 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 one year was 4.5% (95% CI 2.8–7.4%) in children remaining in care, but 8.7% (5.4–12.1%) 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 0.25–0.54 comparing ≥120 months with <18 months), CD4 cell percent (HR 0.56; 95% CI 0.39–0.78 comparing ≥ 20% with <10%), and clinical stage (HR 0.12; 95% CI 0.03–0.45 comparing WHO stage I with III/IV).

Conclusions

In children starting ART and remaining in care in Southern Africa mortality at one 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.