title: Implementation of antiretroviral therapy guidelines for under-five children in Tanzania: translating recommendations into practice.
abstract: BACKGROUND
  Paediatric antiretroviral therapy (ART) guidelines have been updated several times in recent years. We assessed implementation of ART guidelines among under-five children to inform the transition to universal paediatric ART in Tanzania.
  
  
  METHODS
  We conducted a retrospective cohort analysis of infants (0 to 11 months) and children (12 to 59 months) enrolled between 2010 and 2012 using routinely collected data. Infants and children were initiated on ART according to the 2008 World Health Organization (WHO) recommendations/2009 Tanzania guidelines (universal ART for infants). Cumulative ART initiation incidence and correlates of ART initiation were examined using competing risk methods accounting for attrition (death or loss to follow-up). Kaplan-Meier methods and Cox regression models were used to examine attrition on ART and its correlates.
  
  
  RESULTS
  A total of 1679 children were enrolled at 69 clinics: 469 (28%) infants and 1210 (74%) children. Infant cumulative ART initiation incidence was 59.6, 71.3 and 78.0% at one, three and six months of follow-up. Infants were more likely to start ART if enrolled in 2012 [adjusted sub-hazard ratio (AsHR)=2.2, 95% confidence interval (CI): 1.7 to 2.8] or 2011 (AsHR=1.8, 95% CI: 1.4 to 2.3) compared to 2010; they were more likely to start ART from prevention of mother-to-child HIV transmission (AsHR=1.6, 95% CI: 1.3 to 2.1) and inpatient wards (AsHR=1.5, 95% CI: 1.2 to 2.0) versus being enrolled from voluntary counselling and testing centres. Attrition at 12 months on ART was 33.9% and was more likely among infants with WHO Stage 4 [adjusted hazard ratio (AHR)=3.1. 95% CI: 1.8 to 5.2] and severe malnutrition (AHR=1.4, 95% CI: 1.0 to 1.9).Among 599 children eligible for ART at enrollment, cumulative ART initiation incidence was 51.8, 68.6 and 76.1% at one, three, and six months. Children were more likely to start ART if enrolled in 2012 (AsHR=1.8, 95% CI: 1.4 to 2.3) or 2011 (AsHR=1.5, 95% CI: 1.2 to 1.8) compared to 2010; they were more likely to start ART at primary health facilities (AsHR=1.5, 95% CI: 1.1 to 2.0) and less likely at urban facilities (AsHR=0.6, 95% CI: 0.5 to 0.9) and facilities without CD4 testing on site (AsHR=0.7, 95% CI: 0.5 to 0.9). Attrition at 12 months on ART was 23.1% and was more likely with severe malnutrition (AHR=1.8, 95% CI: 1.1 to 3.0), WHO Stage 4 (AHR=3.0, 95% CI: 1.0 to 8.5) and outpatient enrolees (AHR=1.7, 95% CI: 1.1 to 2.7).
  
  
  CONCLUSIONS
  Our findings suggest the gradual adoption of guidelines over calendar time. Interventions to expedite ART initiation and support retention on ART are needed.
authors.affiliation: ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA.|Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; hn2158@cumc.columbia.edu.
authors.forename: Harriet
authors.initials: H
authors.lastname: Nuwagaba-Biribonwoha
authors.affiliation: ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA.
authors.forename: Chunhui
authors.initials: C
authors.lastname: Wang
authors.affiliation: National AIDS Control Program, Dar Es Salaam, Tanzania.
authors.forename: Bonita
authors.initials: B
authors.lastname: Kilama
authors.affiliation: Zanzibar AIDS Control Program, Zanzibar, Tanzania.
authors.forename: Farhat K
authors.initials: FK
authors.lastname: Jowhar
authors.affiliation: ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA.
authors.forename: Gretchen
authors.initials: G
authors.lastname: Antelman
authors.affiliation: ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA.
authors.forename: Milembe F
authors.initials: MF
authors.lastname: Panya
authors.affiliation: ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA.|Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
authors.forename: Elaine J
authors.initials: EJ
authors.lastname: Abrams
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D007223:Infant; D008297:Male; D012189:Retrospective Studies
chemical_list: D019380:Anti-HIV Agents
keywords: ART cascade; HIV-infected children; Tanzania; antiretroviral therapy; infants