Attrition among HIV positive children enrolled under integrated HIV care programme in Myanmar: 12 years cohort analysis

Incidence and predictors of attrition among human immunodeficiency virus infected children on antiretroviral therapy in Amhara comprehensive specialized hospitals, Northwest Ethiopia, 2022: a retrospective cohort study

Attrition rate is higher in developing nations and it leftovers a major obstacle to enhance the benefits of therapy and achieve the 90-90-90 plan targets. Despite this fact, data on the incidence and its predictors of attrition among human immune deficiency virus infected children on antiretroviral therapy are limited in developing countries including Ethiopia especially after the test and treat strategy implemented. This study aimed to assess the incidence and predictors of attrition among human immune deficiency virus infected children on antiretroviral therapy in Amhara Comprehensive Specialized Hospitals, Northwest Ethiopia. A retrospective follow-up study was conducted among 359 children on ART from June 14, 2014, to June 14, 2022. Study participants were selected using simple random sampling method and the data were collected using Kobo Toolbox software and analysis was done by STATA version 14. Both bi-variable and multivariable Cox regression models were fitted to ascertain predictors. Lastly, an AHR with a 95% CI was computed and variables with a p-value of < 0.05 were took an account statistically key predictors of attrition. The overall incidence of attrition rate was 9.8 (95% CI 7.9, 11.9) per 100 PYO. Children having baseline hemoglobin < 10 mg/dl (AHR 3.94; 95% CI 2.32, 6.7), suboptimal adherence (AHR 1.96; 95% CI 1.23, 3.13), baseline opportunistic infection (AHR 1.8; 95% CI 1.17, 2.96), and children who had experienced drug side effects (AHR 8.3; 95% CI 4.93, 13.84) were established to be a significant predictors of attrition. The attrition rate was relatively high. Decreased hemoglobin, suboptimal adherence, presence of drug side effects and baseline opportunistic infection were predictors of attrition. Therefore, it is crucial to detect and give special emphasis to those identified predictors promptly.

Predictors of Suboptimal Adherence Among Children on Antiretroviral Therapy in Southern Ethiopia: A Multicenter Retrospective Follow-Up Study

Objectives: Despite increased access to and availability of antiretroviral therapy, the program's effectiveness is primarily affected by treatment adherence. Therefore, this study aimed to determine the magnitude and predictors of suboptimal adherence among children on ART in Southern Ethiopia. Methods: A multicenter retrospective study was conducted among human immunodeficiency virus (HIV) infected children in Gamo and South Omo zone public health facilities. To identify factors associated with suboptimal adherence, a binary logistic regression model was fitted. Variables with a p-value ≤0.25 in bivariable logistic regression analysis were included in multivariable logistic regression analysis. p-value <0.05 was used to declare statistical significance. Results: The suboptimal adherence was determined to be 30.3% (95% CI: 25.5%, 35.6%). Advanced clinical stage, hemoglobin level <10 mg/dL, unchanged initial regimen, and non-disclosure of HIV sero-status were significant predictors of suboptimal adherence. Conclusion: Suboptimal adherence is a significant public health problem in the study setting. Therefore, designing interventions towards improving adherence is needed especially for children with poor clinical characteristics.

Proportion of Attrition and Associated Factors Among Children Receiving Antiretroviral Therapy in Public Health Facilities, Southern Ethiopia

Purpose

Acquired immunodeficiency syndrome (AIDS) is a major global public health concern. Despite the improved access and utilization of antiretroviral therapy (ART), attrition from care among children continues to be a major obstacle to the effectiveness of ART programs. Hence, this study aimed to assess the proportion of attrition and associated factors among children receiving ART in public health facilities of Gamo and South Omo Zones, Southern Ethiopia.

Patients and Methods

A retrospective follow-up study was conducted in public health facilities of Gamo and South Omo Zones in Southern Ethiopia from April 12, 2022, to May 10, 2022. The proportion of attrition was determined by dividing the number of attrition by the total number of participants. Descriptive statistics were calculated. A binary logistic regression model was used to identify factors associated with attrition. Statistical significance was set at p-value <0.05.

Results

The median age of the participants was 5.5 (IQR: 2-9) years. The proportion of attrition from ART care was 32.4% (95% confidence interval (CI): 27.57% to 37.69%). Death of either of the parents (adjusted odds ratio (AOR) = 2.19; 95% CI:1.14, 4.18), or both parents (AOR = 3.19; 95% CI: 1.20, 8.52), hemoglobin level <10mg/dL (AOR = 2.39, 95% CI: 1.21, 4.70), a cluster of differentiation (CD)4 count ≤200 cells/mm3 (AOR = 6.78, 95% CI: 3.16, 14.53), CD4 count 200-350 cells/mm3 (AOR = 2.65, 95% CI: 1.16, 6.03), suboptimal adherence (AOR = 6.38; 95% CI: 3.36, 12.19), and unchanged initial regimen (AOR = 6.88; 95% CI: 3.58, 13.19) were factors associated with attrition.

Conclusion

Attrition from care is identified to be a substantial public health problem. Therefore, designing interventions to improve the timely tracing of missed follow-up schedules and adherence support is needed, especially for children with either/both parents died, unchanged initial regimen, low CD4, and/or low hemoglobin level.

Attrition and associated factors among children living with HIV at a tertiary hospital in Eritrea: a retrospective cohort analysis

BACKGROUND

Reducing attrition in paediatric HIV-positive patients using combined antiretroviral therapy (cART) programmes in sub-Saharan Africa is a challenge. This study explored the rates and predictors of attrition in children started on cART in Asmara, Eritrea.

METHODS

This was a retrospective cohort study using data from all paediatric patients on cART between 2005 and 2020, conducted at the Orotta National Referral and Teaching Hospital. Kaplan-Meier estimates of the likelihood of attrition and multivariate Cox proportional hazards models were used to assess the factors associated with attrition. All p values were two sided and p<0.05 was considered statistically significant.

RESULTS

The study enrolled 710 participants with 374 boys (52.7%) and 336 girls (47.3%). After 5364 person-years' (PY) follow-up, attrition occurred in 172 (24.2%) patients: 65 (9.2%) died and 107 (15.1%) were lost to follow-up (LTFU). The crude incidence rate of attrition was 3.2 events/100 PY, mortality rate was 2.7/100 PY and LTFU was 1.2/100 PY. The independent predictors of attrition included male sex (adjusted HR (AHR)=1.6, 95% CI: 1 to 2.4), residence outside Zoba Maekel (AHR=1.5, 95% CI: 1 to 2.3), later enrolment years (2010-2015: AHR=3.2, 95% CI: 1.9 to 5.3; >2015: AHR=6.1, 95% CI: 3 to 12.2), WHO body mass index-for-age z-score <-2 (AHR=1.4, 95% CI: 0.9 to 2.1), advanced HIV disease (WHO III or IV) at enrolment (AHR=2.2, 95% CI: 1.2 to 3.9), and initiation of zidovudine+lamivudine or other cART backbones (unadjusted HR (UHR)=2, 95% CI: 1.2 to 3.2). In contrast, a reduced likelihood of attrition was observed in children with a record of cART changes (UHR=0.2, 95% CI: 0.15 to 0.4).

CONCLUSION

A low incidence of attrition was observed in this study. However, the high mortality rate in the first 24 months of treatment and late presentation are concerning. Therefore, data-driven interventions for improving programme quality and outcomes should be prioritised.

Incidence and predictors of attrition among children on antiretroviral therapy at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2019: Retrospective follow-up study

Objectives:

Retaining on antiretroviral therapy is essential for reducing HIV-related morbidity and mortality. However, attrition in HIV-positive children remains a critical challenge in resource-limited settings, including Ethiopia. This study aims to determine the incidence and predictors of attrition among children on antiretroviral therapy at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

Methods:

An institution-based retrospective follow-up study was conducted among 357 HIV-positive children at the University of Gondar Comprehensive Specialized Hospital from 1 January 2005 to 30 December 2018 (G.C.). Data were collected by chart review using a structured and pre-tested data abstraction checklist. SPSS 22 and STATA 14.0 were used for data entry and analysis, respectively. In the Cox proportional hazard model, bivariables had a 0.25 computed to multivariable, and variables with a p-value of 0.05 at a 95% confidence interval were considered statistically significant predictors of attrition incidence.

Results:

A total of 344 child records with a completeness rate of 96.4% were reviewed and included in the analysis. The median follow-up period was 4.3 (interquartile range = 4.3 ± 4.7) years, and the median survival time was 132 months. The incidence rate of attrition was 6.6 per 100 person year observation (PYO) (95% confidence interval = 5.5, 8.0). In all, 105 (30.5%) children were recorded as attrition in the follow-up period. Baseline WHO clinical staging 3 and 4 (adjusted hazard ratio = 2.3 (95% confidence interval = 1.3, 4.0)), baseline weight-for-age −2 Z-score (adjusted hazard ratio = 3.1 (95% confidence interval = 1.7, 5.3)), cotrimoxazole non-users (adjusted hazard ratio = 2.5 (95% confidence interval = 1.4, 4.3)), and baseline hemoglobin levels 10 mg/dL (adjusted hazard ratio = 2.7 (95% confidence interval = 1.5, 47)) were found to be a predictor of attrition.

Conclusion:

The overall incidence of the rate of attrition was high. Baseline WHO clinical staging 3/4, baseline hemoglobin 10 mg/dL, cotrimoxazole (cotrimoxazole preventive therapy) non-user, and underweight at baseline (weight-for-age 2 Z-score) were found to be the main predictors of attrition.

Predictors of attrition among adults in a rural HIV clinic in southern Mozambique: 18-year retrospective study

HIV remains a major cause of morbidity and mortality for people living in many low-income countries. With an HIV prevalence of 12.4% among people aged over 15 years, Mozambique was ranked in 2019 as one of eight countries with the highest HIV rates in the world. We analyzed routinely collected data from electronical medical records in HIV-infected patients aged 15 years or older and enrolled at Carmelo Hospital of Chokwe in Chokwe from 2002 to 2019. Attrition was defined as individuals who were either reported dead or lost to follow-up (LTFU) (≥ 90 days since the last clinic visit with missed medical pick-up after 3 days of failed calls). Kaplan–Meier survival curves and Cox regression analyses were used to model the incidence and predictors of time to attrition. From January 2002 to December 2019, 16,321 patients were enrolled on antiretroviral therapy (ART): 59.2% were women, and 37.9% were aged 25–34 years old. At the time of the analysis, 7279 (44.6%) were active and on ART. Overall, the 16,321 adults on ART contributed a total of 72,987 person-years of observation. The overall attrition rate was 9.46 per 100 person-years. Cox regression showed a higher risk of attrition in those following an inpatient regimen (hazard ratio [HR] 3.18, 95% confidence interval [CI] 2.89–3.50; p < 0.001), having CD4 counts under 50 cells/µL (HR 1.91, 95% CI 1.63–2.24, p < 0.001), receiving anti-TB treatment within 90 days of ART initiation (HR 6.53, 95% CI 5.72–7.45; p < 0.001), classified as WHO clinical stage III (HR 3.75, 95% CI 3.21–4.37; p < 0.001), and having Kaposi’s sarcoma (HR 1.99, 95% CI 1.65–2.39, p < 0.001). Kaplan–Meier analysis showed that patients with CD4 counts of less than 50 cells/µL on ART initiation had a 40% lower chance of survival at 18 years. Low CD4 cell counts, ART initiation as an inpatient, WHO clinical stage III, and anti-tuberculosis treatment within 90 days of ART initiation were strongly associated with attrition. Strengthening HIV testing and ART treatment, improving the diagnosis of tuberculosis before ART initiation, and guaranteed psychosocial support systems are the best tools to reduce patient attrition after starting ART.

A 17 year experience of attrition from care among HIV infected children in Nnewi South-East Nigeria

BACKGROUND

A large number of HIV-infected children continue to die despite reported scale-up of paediatric HIV services.

AIM

The trend in attrition among children enrolled in an anti-retroviral therapy (ART) programme was evaluated.

METHODS

This was a retrospective review of children enrolled into NAUTH ART programme between 2003 and 2019.

RESULTS

1114 children < 15 years at enrolment were studied. The male: female ratio was 1:1 while median age at enrolment was 4.3 years. About two-thirds had WHO stage 3 or 4 disease at enrolment. The rate of loss to follow-up (LTFU) and death were 41.0 and 8.4%, respectively, with overall attrition incidence of 108/1000PY. Despite the downward trend, spikes occurred among those enrolled in 2008 to 2011 and in 2017. The trend in 6-, 12-, 24- and 36-months attrition varied similarly with overall rates being 20.4, 27.7, 34.3 and 37.3%, respectively. Among those on ART, > 50% of attrition was recorded within 6 months of care. Advanced WHO stage, young age, non-initiation on ART or period of enrolment (P <  0.001), and caregiver (p = 0.026) were associated with attrition in bivariate analysis. Apart from caregiver category, these factors remained significant in multivariate analysis. Most LTFU could not be reached on phone. Among those contacted, common reasons for being lost to follow-up were financial constraints, caregiver loss, claim to divine healing, family disharmony/child custody issues and relocation of family/child.

CONCLUSION/RECOMMENDATION

Attrition rate was high and was mostly due to LTFU. Predictors of attrition were late presentation, young age, delay in ART initiation and financial constraints. Efforts should be intensified at early diagnosis, linkage to care and implementation of "test and treat" strategy. Innovative child centered approaches should be adopted to enable the HIV-infected children remain in care despite challenges which can truncate treatment.

Incidence and predictors of attrition among children attending antiretroviral follow-up in public hospitals, Southern Ethiopia, 2020: a retrospective study

BACKGROUND

It is a global challenge to enrol and retain paediatric patients in HIV/AIDS care. Attrition causes preventable transmission, stoppable morbidity and death, undesirable treatment outcomes, increased cost of care and drug resistance. Thus, this study intended to investigate the incidence and predictors of attrition among children receiving antiretroviral treatment (ART).

METHOD

A retrospective follow-up study was conducted among children <15 years who had ART follow-up in Gedeo public hospitals. After collection, data were entered into Epi-data V.4.6, then exported to and analysed using STATA V.14. Data were described using the Kaplan-Meier statistics, life table and general descriptive statistics. The analysis was computed using the Cox proportional hazard regression model. Covariates having <0.25 p values in the univariate analysis (such as developmental stage, nutritional status, haemoglobin level, adherence, etc) were fitted to multivariable analysis. Finally, statistical significance was declared at a p value of <0.05.

RESULTS

An overall 254 child charts were analysed. At the end of follow-up, attrition from ART care was 36.2% (92 of 254), of which 70 (76.1%) were lost to follow-up, and 22 (23.9%) children died. About 8145.33 child-months of observations were recorded with an incidence attrition rate of 11.3 per 1000 child-months (95% CI: 9.2 to 13.9), whereas the median survival time was 68.73 months. Decreased haemoglobin level (<10 g/dl) (adjusted HR (AHR)=3.1; 95% CI: 1.4 to 6.9), delayed developmental milestones (AHR=3.6; 95% CI: 1.2 to 10.7), underweight at baseline (AHR=5.9; 95% CI: 1.6 to 21.7), baseline CD4 count ≤200 (AHR=4.4; 95% CI: 1.6 to 12.2), and poor or fair ART adherence (AHR=3.5; 95% CI: 1.5 to 7.9) were significantly associated with attrition.

CONCLUSION AND RECOMMENDATION

Retention to ART care is challenging in the paediatrics population, with such a high attrition rate. Immune suppression, anaemia, underweight, delayed developmental milestones and ART non-adherence were independent predictors of attrition to ART care. Hence, it is crucial to detect and control the identified predictors promptly. Serious adherence support and strengthened nutritional provision with monitoring strategies are also essential.

Attrition during pre-ART and ART time periods among adolescents enrolled in Integrated HIV Care Programme in Myanmar, 2005-2017

Retaining adolescents (aged 10–19 years), living with HIV (ALHIV) on antiretroviral therapy (ART) is challenging. In Myanmar, 1269 ALHIV were under an Integrated HIV Care (IHC) Programme by June 2017 and their attrition (death and lost to follow-up) rates were not assessed before. We undertook a cohort study using routinely collected data of ALHIV enrolled into HIV care from July 2005 to June 2017 and assessed their attrition rates in June 2018 by time-to-event analysis. Of 1269 enrolled, 197(16%) and of 1054 initiated ART, 224 (21%) had an attrition defining event. The pre-ART and ART attrition rates were 21.8 (95% CI 19.0–25.1) and 6.4 (95% CI 5.6–7.3) per 100 person-years follow-up, respectively. The factors ‘at enrolment’ that were associated with higher hazards of attrition were: (1) WHO stage 3 or 4; (2) haemoglobin <10 gm/dl; (3) no documented CD4 cell counts, hepatitis B and C test results; and (4) injection drug use. Baseline hazards were high during the initial 1–2 years and after 5–6 years. The pre-ART and ART attrition rates in ALHIV were lower than those in Africa but higher than the children under IHC. This warrants designing and implementing additional care tailored to the needs of ALHIV under IHC.

Short-term outcomes of rapid initiation of antiretroviral therapy among HIV-positive patients: real-world experience from a single-centre retrospective cohort in Taiwan

OBJECTIVES

Rapid initiation of antiretroviral therapy (ART) engenders faster viral suppression but with suboptimal rates of durable viral suppression and engagement in care, as reported by clinical trials in resource-limited settings. Real-world experience with rapid ART initiation remains limited in resource-rich settings.

DESIGN

Retrospective cohort study.

SETTING

A tertiary hospital in metropolitan Taipei, Taiwan.

PARTICIPANTS

We included 631 patients newly diagnosed as having HIV infection between March 2014 and July 2018.

MAIN OUTCOME MEASURES

Rapid ART initiation was defined as starting ART within 7 days after HIV diagnosis confirmation. HIV diagnosis, ART initiation and viral suppression dates and clinical outcome data were collected by reviewing medical records. The rates of loss to follow-up (LTFU), engagement in care and virological rebound at 12 months were compared between patients with rapid ART initiation and those with standard initiation.

RESULTS

Rapid ART initiation increased from 33.8% in 2014 to 68.3% in 2017, and the median interval between HIV diagnosis and viral suppression (HIV RNA load <200 copies/mL) decreased from 138 to 47 days. Patients with rapid ART initiation had a significantly higher rate of engagement in care at 12 months than did those with standard initiation (88.3% vs 79.0%; p=0.002). Patients aged <30 years had a higher risk of LTFU (HR: 2.19; 95% CI 1.20 to 3.98); and rapid ART initiation was associated with a lower risk of LTFU (HR: 0.41; 95% CI 0.24 to 0.83). Patients aged <30 years were more likely to acquire incident sexually transmitted infections (STIs) before achieving viral suppression.

CONCLUSIONS

Rapid ART initiation was associated with a higher rate of engagement in care at 12 months and shortened interval from diagnosis to HIV suppression. Delayed ART initiation may increase onwards HIV transmission considering the high rates of STIs.

ETHICS APPROVAL

The study was approved by the Research Ethics Committee of National Taiwan University Hospital (Registration No. 201003112R).

Early Success With Retention in Care Among People Living With HIV at Decentralized ART Satellite Sites in Yangon, Myanmar, 2015-2016

Introduction: Myanmar is one of the countries in the Asia-Pacific region hit hardest by the HIV epidemic that is concentrated among urban areas and key populations. In 2014, the National AIDS Programme (NAP) launched a new model of decentralized service delivery with the establishment ART satellite sites with care delivered by HIV peer workers.

Methods: ART satellite sites are implemented by non-government organizations to service high burden HIV areas and populations that suffer stigma or find access to public sector services difficult. They provide continuity of HIV care from outreach testing, counseling, linkage to care, and retention in care. Anti-retroviral (ART) initiation occurs at health facilities by specialist physicians. We conducted a retrospective cohort study of people living with HIV (PLHIV) who were initiated on ART from 2015 to 2016 at five ART satellite sites in Yangon, Myanmar to assess outcomes and time from enrolment to ART initiation.

Results: Of 1,339 PLHIV on ART treatment in 2015–16, 1,157 (89%) were retained, and 5% were lost from care and 5% reported dead, at the end of March 2018. Attrition rates (death and lost-to-follow-up) were found to be significantly associated with a CD4 count ≤ 50 cells/mm³ and having baseline weight ≤ 50 kg. Median time taken from enrolment to ART initiation was 1.9 months (interquartile range: 1.4–2.5).

Conclusion: We report high rates of retention in care of PLHIV in a new model of ART satellite sties in Yangon, Myanmar after 3 years of follow-up. The delays identified in time taken from enrolment to ART initiation need to be explored further and addressed. This initial study supports continuation of plans to scale-up ART satellite sites in Myanmar. To optimize outcomes for patients and the program and accelerate progress to reduce HIV transmission and end the HIV epidemic, operational research needs to be embedded within the response.