Date Published: May 4, 2018
Publisher: Public Library of Science
Author(s): Sophie Desmonde, Franck Tanser, Rachel Vreeman, Elom Takassi, Andrew Edmonds, Pagakrong Lumbiganon, Jorge Pinto, Karen Malateste, Catherine McGowan, Azar Kariminia, Marcel Yotebieng, Fatoumata Dicko, Constantin Yiannoutsos, Mwangelwa Mubiana-Mbewe, Kara Wools-Kaloustian, Mary-Ann Davies, Valériane Leroy, Lynne Meryl Mofenson
Abstract: IntroductionAccess to antiretroviral therapy (ART) is a global priority. However, the attrition across the continuum of care for HIV-infected children between their HIV diagnosis and ART initiation is not well known. We analyzed the time from enrollment into HIV care to ART initiation in HIV-infected children within the International Epidemiology Databases to Evaluate AIDS (IeDEA) Global Cohort Consortium.Methods and findingsWe included 135,479 HIV-1-infected children, aged 0–19 years and ART-naïve at enrollment, between 1 January 2004 and 31 December 2015, in IeDEA cohorts from Central Africa (3 countries; n = 4,948), East Africa (3 countries; n = 22,827), West Africa (7 countries; n = 7,372), Southern Africa (6 countries; n = 93,799), Asia-Pacific (6 countries; n = 4,045), and Latin America (7 countries; n = 2,488). Follow-up in these cohorts is typically every 3–6 months. We described time to ART initiation and missed opportunities (death or loss to follow-up [LTFU]: last clinical visit >6 months) since baseline (the date of HIV diagnosis or, if unavailable, date of enrollment). Cumulative incidence functions (CIFs) for and determinants of ART initiation were computed, with death and LTFU as competing risks. Among the 135,479 children included, 99,404 (73.4%) initiated ART, 1.9% died, 1.4% were transferred out, and 20.4% were lost to follow-up before ART initiation. The 24-month CIF for ART initiation was 68.2% (95% CI: 67.9%–68.4%); it was lower in sub-Saharan Africa—ranging from 49.8% (95% CI: 48.4%–51.2%) in Central Africa to 72.5% (95% CI: 71.5%–73.5%) in West Africa—compared to Latin America (71.0%, 95% CI: 69.1%–72.7%) and the Asia-Pacific (78.3%, 95% CI: 76.9%–79.6%). Adolescents aged 15–19 years and infants <1 year had the lowest cumulative incidence of ART initiation compared to other ages: 62.2% (95% CI: 61.6%–62.8%) and 66.4% (95% CI: 65.7%–67.0%), respectively. Overall, 49.1% were ART-eligible per local guidelines at baseline, of whom 80.6% initiated ART. The following children had lower cumulative incidence of ART initiation: female children (p < 0.01); those aged <1 year, 2–4 years, 5–9 years, and 15–19 years (versus those aged 10–14 years, p < 0.01); those who became eligible during follow-up (versus eligible at enrollment, p < 0.01); and those receiving care in low-income or lower-middle-income countries (p < 0.01). The main limitations of our study include left truncation and survivor bias, caused by deaths of children prior to enrollment, and use of enrollment date as a proxy for missing data on date of HIV diagnosis, which could have led to underestimation of the time between HIV diagnosis and ART initiation.ConclusionsIn this study, 68% of HIV-infected children initiated ART by 24 months. However, there was a substantial risk of LTFU before ART initiation, which may also represent undocumented mortality. In 2015, many obstacles to ART initiation remained, with substantial inequities. More effective and targeted interventions to improve access are needed to reach the target of treating 90% of HIV-infected children with ART.
Partial Text: By the end of 2016, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that 2.1 million children aged <15 years were living with HIV worldwide . Despite effective interventions for the prevention of mother-to-child transmission, the pediatric epidemic persists, and an estimated 160,000 children were newly infected with HIV in 2016 . Furthermore, the incidence of HIV remains alarmingly high in adolescents and young people aged 15–24 years. According to UNAIDS, 37% of new HIV infections occurring in sub-Saharan African adults in 2016 were among this population . This pooled analysis from the IeDEA Global Cohort Consortium documents time to ART initiation since enrollment in HIV programs treating HIV-infected children and adolescents between the ages of 0 and 19 years within multiple geographic regions, between 2004 and 2015. We report 3 major findings. First, in HIV-infected children and adolescents, the cumulative incidence of initiating ART within 24 months of enrollment into a program or HIV diagnosis was 68%, with a substantial risk for mortality or LTFU before ART initiation (19%), representing multiple missed opportunities for ART initiation. Second, among children eligible for ART initiation and followed up, 19% did not initiate treatment within the first 24 months of follow-up. Third, we report a number of inequities in ART access: female sex, children <10 years at baseline (and those <1 year in particular), adolescents aged 15–19 years at baseline (compared to those aged 10–14 years), those becoming eligible during follow-up (compared to those eligible at baseline), and those living in sub-Saharan Africa compared to other regions were all less likely to initiate treatment. Source: http://doi.org/10.1371/journal.pmed.1002565