title: Early mortality and loss to follow-up in HIV-infected children starting antiretroviral therapy in Southern Africa.
abstract: 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.
authors.affiliation: Institute of Social and Preventive Medicine, University of Bern, Switzerland. lfenner@ispm.unibe.ch
authors.forename: Lukas
authors.initials: L
authors.lastname: Fenner
authors.forename: Martin W G
authors.initials: MW
authors.lastname: Brinkhof
authors.forename: Olivia
authors.initials: O
authors.lastname: Keiser
authors.forename: Ralf
authors.initials: R
authors.lastname: Weigel
authors.forename: Morna
authors.initials: M
authors.lastname: Cornell
authors.forename: Harry
authors.initials: H
authors.lastname: Moultrie
authors.forename: Hans
authors.initials: H
authors.lastname: Prozesky
authors.forename: Karl
authors.initials: K
authors.lastname: Technau
authors.forename: Brian
authors.initials: B
authors.lastname: Eley
authors.forename: Paula
authors.initials: P
authors.lastname: Vaz
authors.forename: Margaret
authors.initials: M
authors.lastname: Pascoe
authors.forename: Janet
authors.initials: J
authors.lastname: Giddy
authors.forename: Gilles
authors.initials: G
authors.lastname: Van Cutsem
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
authors.forename: Mary-Ann
authors.initials: MA
authors.lastname: Davies
mesh_terms: 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
chemical_list: D019380:Anti-HIV Agents