title: Temporal trends in mortality and loss to follow-up among children enrolled in Côte d'Ivoire's national antiretroviral therapy program.
abstract: BACKGROUND
  During 2004-2008, >2000 children (<15 years old) initiated antiretroviral therapy (ART) in Côte d'Ivoire. Nationally representative outcomes, temporal trends in outcomes during 2004-2008 and site-level outcome determinants have not been investigated.
  
  
  METHODS
  Incidence rates of death, loss to follow-up (LTFU) and attrition (death or LTFU) were evaluated in a nationally representative, retrospective cohort study among 2,110 children, who initiated ART at 29 facilities in Côte d'Ivoire during 2004-2008.
  
  
  RESULTS
  At ART initiation, 54% were male, 1% was HIV-2-infected and median age was 5.1 years. Median CD4% was 11%, and 61% had weight-for-age Z-score (WAZ) ≤-2. Vaccination completion was documented for 9% of children. Eleven of 29 facilities had an integrated nutrition program. Over 4585 person-years of ART, 237 children died and 427 became LTFU. Twelve-month attrition was 22% overall, but increased from 4% to 34% during 2004-2008, due to increases in 12-month mortality (from 3-11%) and 12-month LTFU (from 2% to 23%). In adjusted analysis, compared with enrollees in 2004, enrollees in 2008 had nearly 4-fold higher mortality and 8-fold higher LTFU. World Health Organization stage III/IV, CD4% <10%, WAZ ≤ 2 and hemoglobin <8 g/dL, were predictive of mortality. Incomplete vaccination was predictive of mortality and LTFU. Facilities with nutrition programs had lower LTFU and mortality rates. Clinics reporting nurse dissatisfaction with working conditions had higher LTFU rates.
  
  
  CONCLUSIONS
  Investigation of causes of increasing mortality and LTFU is needed. Ensuring earlier ART initiation, vaccination completion, scale-up of site-level nutrition programs and nurse work-environment satisfaction, could improve pediatric ART program outcomes.
authors.affiliation: From the *Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, GA; †Ministry of Health, National Program for Medical Care of Persons Living with HIV/AIDS; ‡Division of Global HIV/AIDS, Centers for Disease Control and Prevention; §Elizabeth Glazer Pediatric AIDS Foundation; ¶Directorate General of Budget and Finance, Department of Economy and Finance, Abidjan, Côte d'Ivoire; and ‖Elizabeth Glazer Pediatric AIDS Foundation, Los Angeles, CA.
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Auld
authors.forename: Moise Z
authors.initials: MZ
authors.lastname: Tuho
authors.forename: Kunomboa A
authors.initials: KA
authors.lastname: Ekra
authors.forename: Ray W
authors.initials: RW
authors.lastname: Shiraishi
authors.forename: Fayama
authors.initials: F
authors.lastname: Mohamed
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Kouakou
authors.forename: Virginie
authors.initials: V
authors.lastname: Ettiègne-Traoré
authors.forename: Jennifer
authors.initials: J
authors.lastname: Sabatier
authors.forename: Joseph
authors.initials: J
authors.lastname: Essombo
authors.forename: Emilia D
authors.initials: ED
authors.lastname: Rivadeneira
authors.forename: Georgette
authors.initials: G
authors.lastname: Adjorlolo-Johnson
authors.forename: Richard
authors.initials: R
authors.lastname: Marlink
authors.forename: Tedd V
authors.initials: TV
authors.lastname: Ellerbrock
mesh_terms: D000293:Adolescent; D000554:Ambulatory Care Facilities / Q000458:organization & administration / Q000639:trends; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D002648:Child; D002675:Child, Preschool; D007560:Cote d'Ivoire / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality* / Q000821:virology; D015497:HIV-1; D015498:HIV-2; D006454:Hemoglobins / Q000378:metabolism; D006801:Humans; D007223:Infant; D007588:Job Satisfaction; D059012:Lost to Follow-Up; D008297:Male; D009726:Nurses / Q000523:psychology; D011320:Primary Health Care / Q000639:trends*; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D019380:Anti-HIV Agents; D006454:Hemoglobins
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