title: Early Antiretroviral Therapy Initiation and Mortality Among Infants Diagnosed With HIV in the First 12 Weeks of Life: Experiences From Kinshasa, DR Congo and Blantyre, Malawi.
abstract: Based on clinical trial results, the World Health Organization recommends infant HIV testing at age 4-6 weeks and immediate antiretroviral therapy (ART) initiation in all HIV-infected infants. Little is known about the outcomes of HIV-infected infants diagnosed with HIV in the first weeks of life in resource-limited settings. We assessed ART initiation and mortality in the first year of life among infants diagnosed with HIV by 12 weeks of age.
  
  
  
  Cohort of HIV-infected infants in Kinshasa and Blantyre diagnosed before 12 weeks to estimate 12-month cumulative incidences of ART initiation and mortality, accounting for competing risks. Multivariate models were used to estimate associations between infant characteristics and timing of ART initiation.
  
  
  
  One hundred and twenty-one infants were diagnosed at a median age of 7 weeks (interquartile range, 6-8). The cumulative incidence of ART initiation was 46% [95% confidence interval (CI), 36%, 55%] at 6 months and 70% (95% CI 60%, 78%) at 12 months. Only age at HIV diagnosis was associated with ART initiation by age 6 months, with a subdistribution hazard ratio of 0.70 (95% CI 0.52, 0.91) for each week increase in age at DNA polymerase chain reaction test. The 12-month cumulative incidence of mortality was 20% (95% CI 13%, 28%).
  
  
  
  Despite early diagnosis of HIV, ART initiation was slow and mortality remained high, underscoring the complexity in translating clinical trial findings and World Health Organization's guidance into real-life practice. Novel and creative health system interventions will be required to ensure that all HIV-infected infants achieve optimal treatment outcomes under routine care settings.
authors.affiliation: From the *Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; †Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital, Blantyre, Malawi; ‡Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; §Division of Infection and Immunity, University College London, London, United Kingdom; and ¶Department of Epidemiology and Social Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
authors.forename: Anna
authors.initials: A
authors.lastname: Sheahan
authors.forename: Lydia
authors.initials: L
authors.lastname: Feinstein
authors.forename: Queen
authors.initials: Q
authors.lastname: Dube
authors.forename: Andrew
authors.initials: A
authors.lastname: Edmonds
authors.forename: Chawanangwa Mahebere
authors.initials: CM
authors.lastname: Chirambo
authors.forename: Emily
authors.initials: E
authors.lastname: Smith
authors.forename: Frieda
authors.initials: F
authors.lastname: Behets
authors.forename: Robert
authors.initials: R
authors.lastname: Heyderman
authors.forename: Annelies
authors.initials: A
authors.lastname: Van Rie
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D015023:Democratic Republic of the Congo / Q000453:epidemiology; D042241:Early Diagnosis; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D007223:Infant; D008295:Malawi / Q000453:epidemiology; D008297:Male; D061665:Time-to-Treatment
chemical_list: D044966:Anti-Retroviral Agents