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

London School of Hygiene and Tropical Medicine, United Kingdom
PLoS ONE (Impact Factor: 3.23). 02/2013; 8(2):e56446. DOI: 10.1371/journal.pone.0056446
Source: PubMed


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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    • "In 2012, only 34% of children under the age of 15 and in need of treatment received antiretroviral therapy compared to 64% of adults (UNICEF, 2013). These disparities can partly be explained by children's reliance on their caregivers to access HIV services (Skovdal, Campbell, Madanhire, Nyamukapa, & Gregson, 2011) and the inadequacy of HIV services to address the clinical and social needs of children living with HIV (Mugglin et al., 2013). Even when children are initiated on ART, barriers such as poverty, the distance to the local clinic, side effects, stigma and discrimination, and lack of disclosure affect the ability of children and youth to adhere to their treatment regimen and result in 'loss to follow-up' (Braitstein et al., 2011; Campbell et al., 2012; Wachira, Middlestadt, Vreeman, & Braitstein, 2012). "
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    ABSTRACT: There are concerns that current models of HIV service delivery pay insufficient attention to the struggles of children, their families and health services in managing the social factors that govern the health, development and psychosocial well-being of children and youth growing up with HIV in sub-Saharan Africa. The papers in this Special Issue offer some direction for how we can offer more holistic and integrated responses that accommodate a broader vision of children’s needs and provide a strong rationale for developing a framework of Social Determinants of Health as they relate to children and youth living with HIV in sub-Saharan Africa. We argue that such a perspective has the potential to improve HIV treatment outcomes by cementing the need to i) understand, measure and respond to drivers of health, health inequities as well as barriers to development; ii) foster partnerships and inter-sectoral cooperation; iii) adopt child-, family- and community-centered approaches that are linked to broader care and support systems; and iv) develop a focused research agenda on Social Determinants of Health as they relate to children and youth living with HIV. Given that HIV is experienced, lived and managed within interpersonal relationships, overlapping and complex social structures and economic systems, we conclude that efforts to achieve an AIDS-free generation must recognize and engage with the Social Determinants of Health as they relate to children and youth living with HIV.
    Full-text · Article · Oct 2014 · Children and Youth Services Review
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    • "A systematic review investigating patient and programme level factors associated with retention in care during the pre-ART period and linkage to ART care in sub-Saharan Africa found that the commonly cited barriers included psychosocial (stigma and fear of disclosure), economic (inability to afford transport costs, distance to healthcare facility) and health system (long waiting times, shortage of health care workers) factors [11]. Moreover, poor linkage to care has been reported among groups such as pregnant women [12] and children [13]. Among ART-eligible pregnant women in low- and middle-income countries, 38–88% failed to initiate ART, though point of attrition assessed by the different studies differ, with financial constraints and fear of stigma identified as the main obstacles to ART care [12]. "
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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.
    Full-text · Article · Aug 2014 · Journal of the International AIDS Society
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    • "Studies from low and middle-income countries have shown that 25% of adults in need of HIV treatment die or are lost to follow up (LTFU) before starting ART.5,6 However, data on the attrition of ART-eligible children, especially outside sub-Saharan Africa, is scarce.7 "
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    ABSTRACT: Data on attrition due to mortality or loss to follow-up (LTFU) from antiretroviral therapy (ART) eligibility to ART initiation of HIV-infected children are scarce. The aim of this study is to describe attrition before ART initiation of 247 children who were eligible for ART in a cohort study in India. Multivariable analysis was performed using competing risk regression. The cumulative incidence of attrition was 12.6% (95% confidence interval, 8.7-17.3) after five years of follow-up, and the attrition rate was higher during the first months after ART eligibility. Older children (>9 years) had a lower mortality risk before ART initiation than those aged <2 years. Female children had a lower risk of LTFU before ART initiation than males. Children who belonged to scheduled tribes had a higher risk of delayed ART initiation and LTFU. Orphan children had a higher risk of delayed ART initiation and mortality. Children who were >3 months in care before ART eligibility were less likely to be LTFU. The 12-month risk of AIDS, which was calculated using the absolute CD4 cell count and age, was strongly associated with mortality. A substantial proportion of ART-eligible children died or were LTFU before the initiation of ART. These findings can be used in HIV programmes to design actions aimed at reducing the attrition of ART-eligible children in India.
    Full-text · Article · May 2014 · Infectious disease reports
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