Retention in Care of HIV-Infected Children from HIV Test to Start of Antiretroviral Therapy: Systematic Review.

Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland.
PLoS ONE (Impact Factor: 3.53). 02/2013; 8(2):e56446. DOI: 10.1371/journal.pone.0056446
Source: PubMed

ABSTRACT In adults it is well documented that there are substantial losses to the programme between HIV testing and start of antiretroviral therapy (ART). The magnitude and reasons for loss to follow-up and death between HIV diagnosis and start of ART in children are not well defined.
We searched the PubMed and EMBASE databases for studies on children followed between HIV diagnosis and start of ART in low-income settings. We examined the proportion of children with a CD4 cell count/percentage after after being diagnosed with HIV infection, the number of treatment-eligible children starting ART and predictors of loss to programme. Data were extracted in duplicate.
Eight studies from sub-Saharan Africa and two studies from Asia with a total of 10,741 children were included. Median age ranged from 2.2 to 6.5 years. Between 78.0 and 97.0% of HIV-infected children subsequently had a CD4 cell count/percentage measured, 63.2 to 90.7% of children with an eligibility assessment met the eligibility criteria for the particular setting and time and 39.5 to 99.4% of the eligible children started ART. Three studies reported an association between low CD4 count/percentage and ART initiation while no association was reported for gender. Only two studies reported on pre-ART mortality and found rates of 13 and 6 per 100 person-years.
Most children who presented for HIV care met eligibility criteria for ART. There is an urgent need for strategies to improve the access to and retention to care of HIV-infected children in resource-limited settings.

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    ABSTRACT: We describe factors determining retention and survival among HIV-infected children and adolescents engaged in two health care delivery models in Kampala, Uganda: one is a community home-based care (CHBC) and the other is a facility-based family-centred approach (FBFCA). This retrospective cohort study reviewed records from children aged from 0 to 18 years engaged in the two models from 2003 to 2010 focussing on retention/loss to follow-up, mortality, use of antiretroviral therapy (ART), and clinical characteristics. Kaplan Meier survival curves with log rank tests were used to describe and compare retention and survival. Overall, 1,623 children were included, 90.0% (1460/1623) from the CHBC. Children completed an average of 4.2 years of follow-up (maximum 7.7 years). Median age was 53 (IQR: 11-109) months at enrolment. In the CHBC, retention differed significantly between patients on ART and those not (log-rank test, adjusted, P < 0.001). Comparing ART patients in both models, there was no significant difference in long-term survival (log-rank test, P = 0.308, adjusted, P = 0.489), while retention was higher in the CHBC: 94.8% versus 84.7% in the FBFCA (log-rank test, P < 0.001, adjusted P = 0.006). Irrespective of model of care, children receiving ART had better retention in care and survival.
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    ABSTRACT: IntroductionSeveral approaches have been taken to reduce pre-antiretroviral therapy (ART) losses between HIV testing and ART initiation in low- and middle-income countries, but a systematic assessment of the evidence has not yet been undertaken. The aim of this systematic review is to assess the potential for interventions to improve or facilitate linkage to or retention in pre-ART care and initiation of ART in low- and middle-income settings.MethodsAn electronic search was conducted on Medline, Embase, Global Health, Web of Science and conference databases to identify studies describing interventions aimed at improving linkage to or retention in pre-ART care or initiation of ART. Additional searches were conducted to identify on-going trials on this topic, and experts in the field were contacted. An assessment of the risk of bias was conducted. Interventions were categorized according to key domains in the existing literature. ResultsA total of 11,129 potentially relevant citations were identified, of which 24 were eligible for inclusion, with the majority (n=21) from sub-Saharan Africa. In addition, 15 on-going trials were identified. The most common interventions described under key domains included: health system interventions (i.e. integration in the setting of antenatal care); patient convenience and accessibility (i.e. point-of-care CD4 count (POC) testing with immediate results, home-based ART initiation); behaviour interventions and peer support (i.e. improved communication, patient referral and education) and incentives (i.e. food support). Several interventions showed favourable outcomes: integration of care and peer supporters increased enrolment into HIV care, medical incentives increased pre-ART retention, POC CD4 testing and food incentives increased completion of ART eligibility screening and ART initiation. Most studies focused on the general adult patient population or pregnant women. The majority of published studies were observational cohort studies, subject to an unclear risk of bias.ConclusionsFindings suggest that streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives may decrease attrition, but the quality of the current evidence base is low. Few studies have investigated combined interventions, or assessed the impact of interventions across the HIV cascade. Results from on-going trials investigating POC CD4 count testing, patient navigation, rapid ART initiation and mobile phone technology may fill the quality of evidence gap. Further high-quality studies on key population groups are required, with interventions informed by previously reported barriers to care.
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    ABSTRACT: Background: We examine attrition and loss to follow-up (LTFU) and their baseline predictors among HIV-infected children and adolescents in a Community Home-Based Care (CHBC) model in Kampala (Uganda). Methods: We conducted a retrospective cohort analysis of attrition and LTFU and their predictors among children and adolescents aged 0-20 years in the Tukula Fenna project. The project operates at the Home Care Department of Nsambya Hospital and four outreach clinics, located in Kampala and three surrounding districts in Uganda. The project uses community home-based care to provide free Antiretroviral Therapy (ART), other medical treatment as necessary, nutritional support, psychosocial support, and home visits. Kaplan-Meier curves were used to assess attrition and LTFU, and multivariate Cox proportional hazard regression models were used to identify their predictors. Results: 1162 children and adolescents with confirmed positive HIV status were enrolled in the Tukula Fenna project between October 2003 and August 2012. Over this period, 5.34% (62) of patients died 37.61% were LTFU (437), and overall attrition was 42.94% (499). This resulted in overall incidence of death of 18 per 1000 person-years, of LTFU of 126 per 1000 person-years, and of attrition of 144 per 1000 person-years. The single factor significantly associated with overall attrition among the 1162 patients was absence of ART (HR: 0.11, 95% CI: 0.09,0.14). Both baseline BMI z-score (HR: 0.96, 95% CI: 0.91, 1.00) and receipt of ART (HR: 0.12, 95% CI: 0.10, 0.15) were significantly negatively associated with LTFU among all 1162 patients in this cohort. Conclusion: Not receiving ART was the single factor significantly associated with overall attrition. Both baseline BMI z-scores and receipt of ART were protective against LTFU among HIV positive children and adolescents enrolled in the Tukula Fenna project. Orphans need more nutritional support and improved access to early ART initiation.
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