Browsing by Author "Technau KG"

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Cervical cancer prevention and care in HIV clinics across sub-Saharan Africa: results of a facility-based survey.
(2024-Jul) Asangbeh-Kerman SL; Davidović M; Taghavi K; Dhokotera T; Manasyan A; Sharma A; Jaquet A; Musick B; Twizere C; Chimbetete C; Murenzi G; Tweya H; Muhairwe J; Wools-Kaloustian K; Technau KG; Anastos K; Yotebieng M; Jousse M; Ezechi O; Orang'o O; Bosomprah S; Pierre Boni S; Basu P; Bohlius J; Graduate School for Health Sciences, University of Bern, Bern, Switzerland.; Department of Medicine and Epidemiology, Albert Einstein College of Medicine, Bronx, New York, USA.; Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana.; Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.; Newlands Clinic, Harare, Zimbabwe.; Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France.; Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA.; Institute of Global Health, University of Geneva, Geneva, Switzerland.; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.; Programme PAC-CI, Site ANRS Treichville, Abidjan, Côte d'Ivoire.; Moi University, Eldoret, Kenya.; Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Johannesburg-Braamfontein, South Africa.; SolidarMed, Partnership for Health, Chiure, Mozambique.; Programme National de Lutte contre le Cancer (PNLCa), Abidjan, Côte d'Ivoire.; Centre National de Reference en Matière de VIH/SIDA, Bujumbura, Burundi.; University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France.; Swiss Tropical and Public Health Institute, Allschwil, Switzerland.; Department of Clinical Sciences, Nigerian Institute of Medical Research, Lagos, Nigeria.; Einstein-Rwanda Research and Capacity Building Programme, Research for Development and Rwanda Military Hospital, Kigali, Rwanda.; SolidarMed, Partnerships for Health, Maseru, Lesotho.; Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, Indiana, USA.; Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.; University of Basel, Basel, Switzerland.; Graduate School of Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland.; International Training and Education Centre for Health (I-TECH), Lilongwe, Malawi.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: To eliminate cervical cancer (CC), access to and quality of prevention and care services must be monitored, particularly for women living with HIV (WLHIV). We assessed implementation practices in HIV clinics across sub-Saharan Africa (SSA) to identify gaps in the care cascade and used aggregated patient data to populate cascades for WLHIV attending HIV clinics. METHODS: Our facility-based survey was administered between November 2020 and July 2021 in 30 HIV clinics across SSA that participate in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We performed a qualitative site-level assessment of CC prevention and care services and analysed data from routine care of WLHIV in SSA. RESULTS: Human papillomavirus (HPV) vaccination was offered in 33% of sites. Referral for CC diagnosis (42%) and treatment (70%) was common, but not free at about 50% of sites. Most sites had electronic health information systems (90%), but data to inform indicators to monitor global targets for CC elimination in WLHIV were not routinely collected in these sites. Data were collected routinely in only 36% of sites that offered HPV vaccination, 33% of sites that offered cervical screening and 20% of sites that offered pre-cancer and CC treatment. CONCLUSIONS: Though CC prevention and care services have long been available in some HIV clinics across SSA, patient and programme monitoring need to be improved. Countries should consider leveraging their existing health information systems and use monitoring tools provided by the World Health Organization to improve CC prevention programmes and access, and to track their progress towards the goal of eliminating CC.
Characterizing the double-sided cascade of care for adolescents living with HIV transitioning to adulthood across Southern Africa.
(2020-Jan) Tsondai PR; Sohn AH; Phiri S; Sikombe K; Sawry S; Chimbetete C; Fatti G; Hobbins MA; Technau KG; Rabie H; Bernheimer J; Fox MP; Judd A; Collins IJ; Davies MA; TREAT Asia/amfAR - The Foundation for AIDS Research, Bangkok, Thailand.; Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.; MRC Clinical Trials Unit at UCL, University College London (UCL), London, United Kingdom.; SolidarMed, Luzern, Switzerland.; Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.; Department of Paediatrics and Child Health, Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch, South Africa.; Lighthouse Trust Clinic, Lilongwe, Malawi.; Newlands Clinic, Harare, Zimbabwe.; Empilweni Services and Research Unit, Department of Paediatrics & Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.; Médecins Sans Frontiers, Khayelitsha, South Africa.; Kheth'Impilo, Cape Town, South Africa.; Department of Global Health and Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.; Harriet Shezi Children's Clinic, Wits Reproductive Health and HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: As adolescents and young people living with HIV (AYLH) age, they face a "transition cascade," a series of steps associated with transitions in their care as they become responsible for their own healthcare. In high-income countries, this usually includes transfer from predominantly paediatric/adolescent to adult clinics. In sub-Saharan Africa, paediatric HIV care is mostly provided in decentralized, non-specialist primary care clinics, where "transition" may not necessarily include transfer of care but entails becoming more autonomous for one's HIV care. Using different age thresholds as proxies for when "transition" to autonomy might occur, we evaluated pre- and post-transition outcomes among AYLH. METHODS: We included AYLH aged <16 years at enrolment, receiving antiretroviral therapy (ART) within International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) sites (2004 to 2017) with no history of transferring care. Using the ages of 16, 18, 20 and 22 years as proxies for "transition to autonomy," we compared the outcomes: no gap in care (≥2 clinic visits) and viral suppression (HIV-RNA <400 copies/mL) in the 12 months before and after each age threshold. Using log-binomial regression, we examined factors associated with no gap in care (retention) in the 12 months post-transition. RESULTS: A total of 5516 AYLH from 16 sites were included at "transition" age 16 (transition-16y), 3864 at 18 (transition-18y), 1463 at 20 (transition-20y) and 440 at 22 years (transition-22y). At transition-18y, in the 12 months pre- and post-transition, 83% versus 74% of AYLH had no gap in care (difference 9.3 (95% confidence interval (CI) 7.8 to 10.9)); while 65% versus 62% were virally suppressed (difference 2.7 (-1.0 to 6.5%)). The strongest predictor of being retained post-transition was having no gap in the preceding year, across all transition age thresholds (transition-16y: adjusted risk ratio (aRR) 1.72; 95% CI (1.60 to 1.86); transition-18y: aRR 1.76 (1.61 to 1.92); transition-20y: aRR 1.75 (1.53 to 2.01); transition-22y: aRR 1.47; (1.21 to 1.78)). CONCLUSIONS: AYLH with gaps in care need targeted support to prevent non-retention as they take on greater responsibility for their healthcare. Interventions to increase virologic suppression rates are necessary for all AYLH ageing to adulthood.
Effect of antiretroviral therapy care interruptions on mortality in children living with HIV.
(2022-Apr-01) Davies C; Johnson L; Sawry S; Chimbetete C; Eley B; Vinikoor M; Technau KG; Ehmer J; Rabie H; Phiri S; Tanser F; Malisita K; Fatti G; Osler M; Wood R; Newton S; Haas A; Davies MA; Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University.; School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.; Queen Elizabeth Central Hospital, Blantyre, Malawi.; Red Cross War Memorial Children's Hospital and Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.; Lighthouse Trust Clinic, Kamuzu Central Hospital, Lilongwe, Malaysia.; Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.; Gugulethu HIV Programme and Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.; Department of Paediatrics and Child Health, Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch, South Africa.; Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town.; Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Harriet Shezi Children's Clinic, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa.; SolidarMed, Lucerne, Switzerland.; Kheth'Impilo AIDS Free Living.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Institute of Social and Preventive Medicine, University of Bern, Switzerland.; Newlands Clinic, Harare, Zimbabwe.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVE: To evaluate the characteristics and outcomes of HIV-infected children that have care interruptions, during which the child's health status and use of medication is unknown. DESIGN: We included data on children initiating ART between 2004 and 2016 at less than 16 years old at 16 International Epidemiologic Databases to Evaluate AIDS Southern Africa cohorts. Children were classified as loss to follow up (LTFU) if they had not attended clinic for more than 180 days. Children had a care interruption if they were classified as LTFU, and subsequently returned to care. Children who died within 180 days of ART start were excluded. METHODS: The main outcome was all cause mortality. Two exposed groups were considered: those with a first care interruption within the first 6 months on ART, and those with a first care interruption after 6 months on ART. Adjusted hazard ratios were determined using a Cox regression model. RESULTS: Among 53 674 children included, 23 437 (44%) had a care interruption, of which 10 629 (20%) had a first care interruption within 6 months on ART and 12 808 (24%) had a first care interruption after 6 months on ART. Increased mortality was associated with a care interruption within 6 months on ART [adjusted hazard ratio (AHR) = 1.52, 95% CI 1.12-2.04] but not with a care interruption after 6 months on ART (AHR = 1.05, 95% CI 0.77-1.44). CONCLUSION: The findings suggest that strengthening retention of children in care in the early period after ART initiation is critical to improving paediatric ART outcomes.
Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004-2012.
(2015-Aug-15) Porter M; Davies MA; Mapani MK; Rabie H; Phiri S; Nuttall J; Fairlie L; Technau KG; Stinson K; Wood R; Wellington M; Haas AD; Giddy J; Tanser F; Eley B; *School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; †MMed Paeds and Child Health (UNZA), Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; ‡Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa; §Lighthouse Trust Clinic, Lilongwe, Malawi; ‖Red Cross War Memorial Children's Hospital, Cape Town, South Africa; ¶School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa; #Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa; **Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital and University of the Witwatersrand, Johannesburg, South Africa; ††Médecins Sans Frontierès, Khayelitsha and School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; ‡‡Gugulethu Community Health Centre and Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa; §§Newlands Clinic, Harare, Zimbabwe; ‖‖Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland; ¶¶McCord Hospital, Durban, South Africa; and ##Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: There are limited published data on the outcomes of infants starting antiretroviral therapy (ART) in routine care in Southern Africa. This study aimed to examine the baseline characteristics and outcomes of infants initiating ART. METHODS: We analyzed prospectively collected cohort data from routine ART initiation in infants from 11 cohorts contributing to the International Epidemiologic Database to Evaluate AIDS in Southern Africa. We included ART-naive HIV-infected infants aged <12 months initiating ≥3 antiretroviral drugs between 2004 and 2012. Kaplan-Meier estimates were calculated for mortality, loss to follow-up (LTFU), transfer out, and virological suppression. We used Cox proportional hazard models stratified by cohort to determine baseline characteristics associated with outcomes mortality and virological suppression. RESULTS: The median (interquartile range) age at ART initiation of 4945 infants was 5.9 months (3.7-8.7) with follow-up of 11.2 months (2.8-20.0). At ART initiation, 77% had WHO clinical stage 3 or 4 disease and 87% were severely immunosuppressed. Three-year mortality probability was 16% and LTFU 29%. Severe immunosuppression, WHO stage 3 or 4, anemia, being severely underweight, and initiation of treatment before 2010 were associated with higher mortality. At 12 months after ART initiation, 17% of infants were severely immunosuppressed and the probability of attaining virological suppression was 56%. CONCLUSIONS: Most infants initiating ART in Southern Africa had severe disease with high probability of LTFU and mortality on ART. Although the majority of infants remaining in care showed immune recovery and virological suppression, these responses were suboptimal.
Prognosis of children with HIV-1 infection starting antiretroviral therapy in Southern Africa: a collaborative analysis of treatment programs.
(2014-Jun) Davies MA; May M; Bolton-Moore C; Chimbetete C; Eley B; Garone D; Giddy J; Moultrie H; Ndirangu J; Phiri S; Rabie H; Technau KG; Wood R; Boulle A; Egger M; Keiser O; From the *School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; †School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom; ‡Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; §University of North Carolina, Chapel Hill, NC; ¶Newlands clinic, Harare, Zimbabwe; ‖Red Cross Children's Hospital and School of Child and Adolescent Health, University of Cape Town; **Médecins Sans Frontières (MSF) South Africa and Khayelitsha ART Programme, Cape Town; ††Sinikithemba Clinic, McCord Hospital, Durban; ‡‡Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg; §§Harriet Shezi Children's Clinic, Chris Hani Baragwanath Hospital, Soweto; ¶¶Africa Centre for Health and Population Studies, University of Kwazulu-Natal, Somkhele, South Africa; ‖‖Lighthouse Trust Clinic, Kamuzu Central Hospital, Lilongwe, Malawi and Liverpool School of Tropical Medicine, Liverpool, United Kingdom; ***Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch; †††Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, and University of the Witwatersrand, Johannesburg; ‡‡‡Gugulethu ART Programme and Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa; and §§§Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Prognostic models for children starting antiretroviral therapy (ART) in Africa are lacking. We developed models to estimate the probability of death during the first year receiving ART in Southern Africa. METHODS: We analyzed data from children ≤10 years of age who started ART in Malawi, South Africa, Zambia or Zimbabwe from 2004 to 2010. Children lost to follow up or transferred were excluded. The primary outcome was all-cause mortality in the first year of ART. We used Weibull survival models to construct 2 prognostic models: 1 with CD4%, age, World Health Organization clinical stage, weight-for-age z-score (WAZ) and anemia and the other without CD4%, because it is not routinely measured in many programs. We used multiple imputation to account for missing data. RESULTS: Among 12,655 children, 877 (6.9%) died in the first year of ART. We excluded 1780 children who were lost to follow up/transferred from main analyses; 10,875 children were therefore included. With the CD4% model probability of death at 1 year ranged from 1.8% [95% confidence interval (CI): 1.5-2.3] in children 5-10 years with CD4% ≥10%, World Health Organization stage I/II, WAZ ≥ -2 and without severe anemia to 46.3% (95% CI: 38.2-55.2) in children <1 year with CD4% < 5%, stage III/IV, WAZ< -3 and severe anemia. The corresponding range for the model without CD4% was 2.2% (95% CI: 1.8-2.7) to 33.4% (95% CI: 28.2-39.3). Agreement between predicted and observed mortality was good (C-statistics = 0.753 and 0.745 for models with and without CD4%, respectively). CONCLUSIONS: These models may be useful to counsel children/caregivers, for program planning and to assess program outcomes after allowing for differences in patient disease severity characteristics.
Tuberculosis diagnosis, treatment, and prevention services for children living with HIV in low- and middle-income countries: a multiregional site survey.
(2025-May-28) Laycock K; Technau KG; Lelo P; Jantarabenjakul W; Yonaba C; Pinto J; Menser M; Maruri F; Odhiambo F; Rambiki E; Babakazo P; Van Lam N; Folquet M; Machado DM; Kalema N; Muula G; Brazier E; Dinh Qui N; Dame J; Luque MT; Semeere A; Eley B; Yotebieng M; Kariminia A; Rouzier V; Byakwaga H; Marcy O; Enane LA; Lighthouse Clinic Trust, Lilongwe, Malawi.; The Kirby Institute, UNSW Sydney, Australia.; Kalembelembe Pediatric Hospital, Unit of Infectious Diseases, Kinshasa, Democratic Republic of Congo.; CHU Cocody, Service Pédiatrie, Abidjan, Côte d'Ivoire.; Center of Excellence for Pediatric Infectious Diseases and Vaccines, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.; Red Cross War Memorial Children's Hospital and the Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.; Pediatric Department, Centre Hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso.; Infectious Diseases Department, Children's Hospital 2, Ho Chi Minh City, Vietnam.; Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.; Kinshasa School of Public Health, Democratic Republic of Congo.; Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa.; University of Ghana Medical School and Korle Bu Teaching Hospital, Accra Ghana.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia.; Instituto Hondureño de Seguridad Social, Tegucigalpa, Honduras.; Indiana University Department of Biostatistics and Health Data Science, Indianapolis, United States.; Indiana University Center for Global Health Equity, Indianapolis, United States.; The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, United States.; Center for Tropical Diseases, Vietnam National Children's Hospital, Hanoi, Vietnam.; Federal University of Minas Gerais, Belo Horizonte, Brazil.; City University of New York, Institute for Implementation Science in Population Health, New York, United States.; Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, The Bronx, New York, United States.; Mbarara University of Science and Technology, Mbarara, Uganda.; Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya.; University of Bordeaux, Inserm U1219 Bordeaux Population Health, IRD EMR271 GHiGS, Bordeaux, France.; Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, United States.; Les Centres GHESKIO, Port-au-Prince, Haiti.; Escola Paulista de Medicina - Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Tuberculosis (TB) remains a leading cause of morbidity and mortality for children living with HIV (CLHIV), with gaps in TB screening, diagnostics, management, and TB preventive therapy (TPT). We investigated reported practices in these domains at sites caring for CLHIV in low- and middle-income countries (LMICs) within the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. METHODS: We implemented a site survey during September 2020-February 2021, querying pre-pandemic practices. This analysis included sites in LMICs providing care for CLHIV that diagnosed TB in 2019. We analyzed responses using descriptive statistics and assessed regional differences using Fisher's exact or chi-square tests. RESULTS: Of 238 IeDEA sites, 227 (95%) responded and 135 met inclusion criteria. Most (90%) reported screening for TB at HIV care enrollment. Access to diagnostics varied significantly by region, including for nucleic acid amplification testing (NAAT, range 67-100%), mycobacterial culture (range 43-83%), and drug susceptibility testing (range 30-82%) (p<0.001). On-site TB treatment was high (90%). Reported stock-outs occurred for isoniazid (23/116, 20%) and other TB medications (11/114, 9.6%, range 0-33%, p=0.008). TPT provision ranged 50-100% (p<0.001). Six months of isoniazid was the most common TPT regimen for children (88%). Shorter TPT regimens were uncommon (0.9-2.8%), as were regimens for multidrug-resistant TB exposure (4.6%). CONCLUSIONS: Overall reported availability of NAAT and integrated TB/HIV treatment for CLHIV cared for at these IeDEA sites in LMICs is encouraging but varies by context. Heterogeneous implementation gaps remain-particularly for drug susceptibility testing, TPT delivery and TPT regimens-which successful outcomes for CLHIV, warranting continued close attention over time and as global TB care guidelines and services evolve.
Variations in the characteristics and outcomes of children living with HIV following universal ART in sub-Saharan Africa (2006-17): a retrospective cohort study.
(2021-Jun) Iyun V; Technau KG; Vinikoor M; Yotebieng M; Vreeman R; Abuogi L; Desmonde S; Edmonds A; Amorissani-Folquet M; Davies MA; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. Electronic address: toyiniyun@gmail.com.; Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.; University Hospital of Cocody, Abidjan, Côte d'Ivoire.; Inserm U1027, Université Paul Sabatier Toulouse 3, Toulouse, France.; Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Health Impact Assessment, Western Cape Department of Health, Cape Town, South Africa.; Department of Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.; Empilweni Service and Research Centre, Rahima Moosa Mother and Child Hospital, University of Witwatersrand, Johannesburg, South Africa.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: The proportion of children living with HIV and receiving antiretroviral therapy (ART) in sub-Saharan Africa has increased greatly since 2006, yet the changes in their demographic characteristics and treatment outcomes have not been well described. We examine the trends in characteristics and outcomes of children living with HIV who were younger than 5 years at ART initiation, and compare outcomes over time and across country income groups. METHODS: We conducted a retrospective cohort analysis of data from children living with HIV who were younger than 5 years at ART initiation from 45 paediatric sites in 16 low-income, lower-middle-income, and upper-middle-income countries in sub-Saharan Africa (Benin, Burundi, Côte d'Ivoire, Democratic Republic of the Congo, Ghana, Kenya, Lesotho, Malawi, Mali, Mozambique, Rwanda, South Africa, Togo, Uganda, Zambia, and Zimbabwe). Outcomes were trends in patient characteristics at ART initiation (age, weight, height, and CD4%), and comparisons of mortality and loss to follow-up during ART over time and in various economic settings. We identified risk factors for mortality using Cox proportional hazards models. Each participating region had relevant institutional ethics review board approvals to contribute data to the analysis. FINDINGS: We included 32 221 children living with HIV and initiating ART younger than 5 years between Jan 1, 2006, and Dec 31, 2017. Median age at ART initiation was 20·4 months (IQR 9·4-36·0) in 2006-10, 19·2 months (8·3-33·6) in 2011-13, and 19·2 months (8·8-33·7) in 2014-17. Median age at ART initiation was 13·2 months (IQR 4·7-26·8) in upper-middle-income countries, 22·6 months (13·2-37·5) in lower-middle-income countries and 24·2 months (13·5-39·1) in low-income countries. The proportion of children initiating ART younger than 3 months increased from 770 (5·1%) of 14 943 children in 2006-10 to 728 (10·0%) of 7290 children in 2014-17. The proportion of children initiating ART with severe immunosuppression decreased from 5469 (74·7%) of 7314 children for whom CD4% data were available in 2006-10 to 2353 (55·2%) of 4269 children in 2014-17. Mortality at 24 months on ART decreased from 970 (6·5%) of 14 943 children in 2006-10 to 214 (2·9%) of 7290 children in 2014-17. Loss to follow-up was 20·5% (95% CI 20·1-21·0) overall, and was similar across time periods. In multivariable analysis, lower mortality was observed for more recent ART initiation cohorts (adjusted hazard ratio 0·70, 95% CI 0·63-0·79 for 2011-13; 0·53, 0·45-0·72 for 2014-17 vs 2006-10) and for those residing in an upper-middle-income country (0·42, 0·35-0·49 vs low-income countries). INTERPRETATION: Mortality declined significantly after universal ART recommendations for children younger than 2 years in 2010 and children younger than 5 years in 2013. However, substantial variations persisted across country income groups, and one in five children continue to be lost to follow-up. Targeted interventions are required to improve outcomes of children living with HIV, especially in the poorest countries. FUNDING: National Institute of Allergy and Infectious Disease.