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.


METHODS
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.


RESULTS
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).


CONCLUSIONS
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.
Fenner
Lukas
L
Institute of Social and Preventive Medicine, University of Bern, Switzerland. lfenner@ispm.unibe.ch
Brinkhof
Martin W G
MW
Keiser
Olivia
O
Weigel
Ralf
R
Cornell
Morna
M
Moultrie
Harry
H
Prozesky
Hans
H
Technau
Karl
K
Eley
Brian
B
Vaz
Paula
P
Pascoe
Margaret
M
Giddy
Janet
J
Van Cutsem
Gilles
G
Wood
Robin
R
Egger
Matthias
M
Davies
Mary-Ann
MA
D000353:Africa, Southern / Q000453:epidemiology; D000367:Age Factors; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D002648:Child; D002675:Child, Preschool; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000401:mortality*; D006801:Humans; D007223:Infant; D008297:Male; D011379:Prognosis; D012307:Risk Factors; D012720:Severity of Illness Index
D019380:Anti-HIV Agents