title: Risk of death among those awaiting treatment for HIV infection in Zimbabwe: adolescents are at particular risk.
abstract: BACKGROUND
  Mortality among HIV-positive adults awaiting antiretroviral therapy (ART) has previously been found to be high. Here, we compare adolescent pre-ART mortality to that of adults in a public sector HIV care programme in Bulawayo, Zimbabwe.
  
  
  METHODS
  In this retrospective cohort study, we compared adolescent pre-ART outcomes with those of adults enrolled for HIV care in the same clinic. Adolescents were defined as those aged 10-19 at the time of registration. Comparisons of means and proportions were carried out using two-tailed sample t-tests and chi-square tests respectively, for normally distributed data, and the Mann-Whitney U-tests for non-normally distributed data. Loss to follow-up (LTFU) was defined as missing a scheduled appointment by three or more months.
  
  
  RESULTS
  Between 2004 and 2010, 1382 of 1628 adolescents and 7557 of 11,106 adults who registered for HIV care met the eligibility criteria for ART. Adolescents registered at a more advanced disease stage than did adults (83% vs. 73% WHO stage III/IV, respectively, p<0.001), and the median time to ART initiation was longer for adolescents than for adults [21 (10-55) days vs. 15 (7-42) days, p<0.001]. Among the 138 adolescents and 942 adults who never commenced ART, 39 (28%) of adolescents and 135 (14%) of adults died, the remainder being LTFU. Mortality among treatment-eligible adolescents awaiting ART was significantly higher than among adults (3% vs. 1.8%, respectively, p=0.004).
  
  
  CONCLUSIONS
  Adolescents present to ART services at a later clinical stage than adults and are at an increased risk of death prior to commencing ART. Improved and innovative HIV case-finding approaches and emphasis on prompt ART initiation in adolescents are urgently needed. Following registration, defaulter tracing should be used, whether or not ART has been commenced.
authors.affiliation: Médecins Sans Frontières, Harare, Zimbabwe; amir.shroufi@doctors.org.uk.
authors.forename: Amir
authors.initials: A
authors.lastname: Shroufi
authors.affiliation: Mpilo OI/ART Clinic, Bulawayo, Zimbabwe.|Faculty of Medicine, National University of Science and Technology, Bulawayo, Zimbabwe.
authors.forename: Wedu
authors.initials: W
authors.lastname: Ndebele
authors.affiliation: Mpilo OI/ART Clinic, Bulawayo, Zimbabwe.
authors.forename: Mary
authors.initials: M
authors.lastname: Nyathi
authors.affiliation: Mpilo OI/ART Clinic, Bulawayo, Zimbabwe.|Faculty of Medicine, National University of Science and Technology, Bulawayo, Zimbabwe.
authors.forename: Hilary
authors.initials: H
authors.lastname: Gunguwo
authors.affiliation: Mpilo OI/ART Clinic, Bulawayo, Zimbabwe.|Faculty of Medicine, National University of Science and Technology, Bulawayo, Zimbabwe.
authors.forename: Mark
authors.initials: M
authors.lastname: Dixon
authors.affiliation: Médecins Sans Frontières, Harare, Zimbabwe.
authors.forename: Jean F
authors.initials: JF
authors.lastname: Saint-Sauveur
authors.affiliation: Médecins Sans Frontières, Harare, Zimbabwe.
authors.forename: Fabian
authors.initials: F
authors.lastname: Taziwa
authors.affiliation: Médecins Sans Frontières, Harare, Zimbabwe.
authors.forename: Mari C
authors.initials: MC
authors.lastname: Viñoles
authors.affiliation: Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Rashida A
authors.initials: RA
authors.lastname: Ferrand
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012306:Risk; D015030:Zimbabwe
chemical_list: D019380:Anti-HIV Agents
keywords: ART; Africa; HIV/AIDS; adolescent; pre-ART