title: Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement.
abstract: BACKGROUND
  Residents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15-49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting.
  
  
  METHODS
  We studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006-July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk.
  
  
  RESULTS
  Of 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3-8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001).
  
  
  CONCLUSIONS
  We found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.
authors.affiliation: Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Friends in Global Health, Quelimane and Maputo, Mozambique.
authors.forename: Sten H
authors.initials: SH
authors.lastname: Vermund
authors.affiliation: Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
authors.forename: Meridith
authors.initials: M
authors.lastname: Blevins
authors.affiliation: Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Friends in Global Health, Quelimane and Maputo, Mozambique.
authors.forename: Troy D
authors.initials: TD
authors.lastname: Moon
authors.affiliation: Friends in Global Health, Quelimane and Maputo, Mozambique.
authors.forename: Eurico
authors.initials: E
authors.lastname: José
authors.affiliation: Friends in Global Health, Quelimane and Maputo, Mozambique.
authors.forename: Linda
authors.initials: L
authors.lastname: Moiane
authors.affiliation: Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Friends in Global Health, Quelimane and Maputo, Mozambique.
authors.forename: José A
authors.initials: JA
authors.lastname: Tique
authors.affiliation: School of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique.
authors.forename: Mohsin
authors.initials: M
authors.lastname: Sidat
authors.affiliation: Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Ciampa
authors.affiliation: Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
authors.forename: Bryan E
authors.initials: BE
authors.lastname: Shepherd
authors.affiliation: Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Friends in Global Health, Quelimane and Maputo, Mozambique.
authors.forename: Lara M E
authors.initials: LM
authors.lastname: Vaz
mesh_terms: D000293:Adolescent; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology* / Q000401:mortality; D006295:Health Resources / Q000600:supply & distribution; D006301:Health Services Needs and Demand; D006801:Humans; D007223:Infant; D059012:Lost to Follow-Up; D008297:Male; D009073:Mozambique / Q000453:epidemiology; D058996:Quality Improvement; D012111:Residence Characteristics; D012424:Rural Population / Q000706:statistics & numerical data*; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents