Introduction: Globally, increasing numbers of HIV-infected children are reaching adolescence due to antiretroviral therapy (ART). We investigated rates of loss-to-follow-up (LTFU) from HIV care services among children as they transition from childhood through adolescence.Methods: Individuals aged 5–19 years initiated on ART in a public-sector HIV clinic in Bulawayo, Zimbabwe, between 2005 and 2009 were included in a retrospective cohort study. Participants were categorized into narrow age-bands namely: 5–9 (children), 10–14 (young adolescents) and 15–19 (older adolescents). The effect of age at ART initiation, current age (using a time-updated Lexis expansion) and transitioning from one age group to the next on LTFU was estimated using Poisson regression.Results: Of 2273 participants, 1013, 875 and 385 initiated ART aged 5–9, 10–14 and 15–19 years, respectively. Unlike those starting ART as children, individuals starting ART as young adolescents had higher LTFU rates after moving to the older adolescent age-band (Adjusted rate ratio (ARR) 1.54; 95% CI: 0.94–2.55) and similarly, older adolescents had higher LTFU rates after transitioning to being young adults (ARR 1.79; 95% CI: 1.05–3.07). In older adolescents, the LTFU rate among those who started ART in that age-band was higher compared to the rate among those starting ART at a younger age (ARR = 1.70; 95% CI: 1.05, 2.77). This however did not hold true for other age-groups.Conclusions: Adolescents had higher rates of LTFU compared to other age-groups, with older adolescents at particularly high risk in all analyses. Age-updated analyses that examine movement across narrow age-bands are paramount in understanding how developmental heterogeneity in children affects HIV outcomes.

ProblemIn Zimbabwe, many health facilities are not able to manage serious obstetric complications. Staff most commonly identified inadequate training as the greatest barrier to preventing avoidable maternal deaths.ApproachWe established an onsite obstetric emergencies training programme for maternity staff in the Mpilo Central Hospital. We trained 12 local staff to become trainers and provided them with the equipment and resources needed for the course. The trainers held one-day courses for 299 staff at the hospital.Local settingMaternal mortality in Zimbabwe has increased from 555 to 960 per 100 000 pregnant women from 2006 to 2011 and 47% of the deaths are believed to be avoidable. Most obstetric emergencies trainings are held off-site, away from the clinical area, for a limited number of staff.Relevant changesFollowing an in-hospital train-the-trainers course, 90% (138/153) of maternity staff were trained locally within the first year, with 299 hospital staff trained to date. Local system changes included: the introduction of a labour ward board, emergency boxes, colour-coded early warning observation charts and a maternity dashboard. In this hospital, these changes have been associated with a 34% reduction in hospital maternal mortality from 67 maternal deaths per 9078 births (0.74%) in 2011 compared with 48 maternal deaths per 9884 births (0.49%) in 2014.Lessons learntIntroducing obstetric emergencies training and tools was feasible onsite, improved clinical practice, was sustained by local staff and associated with improved clinical outcomes. Further work to study the implementation and effect of this intervention at scale is required.

Objectives:In this study we examine whether adolescents treated for HIV/AIDS in southern Africa can achieve similar treatment outcomes to adults.Design:We have used a retrospective cohort study design to compare outcomes for adolescents and adults commencing antiretroviral therapy (ART) between 2004 and 2010 in a public sector hospital clinic in Bulawayo, Zimbabwe.Methods:Cox proportional hazards modelling was used to investigate risk factors for death and loss to follow-up (LTFU) (defined as missing a scheduled appointment by ≥3months).Results:One thousand, seven hundred and seventy-six adolescents commenced ART, 94% having had no previous history of ART. The median age at ART initiation was 13.3 years. HIV diagnosis in 97% of adolescents occurred after presentation with clinical disease and a higher proportion had advanced HIV disease at presentation compared with adults [WHO Stage 3/4 disease (79.3 versus 65.2%, P < 0.001)]. Despite this, adolescents had no worse mortality than adults, assuming 50% mortality among those LTFU (6.4 versus 7.3 per 100 person-years, P = 0.75) with rates of loss to follow-up significantly lower than in adults (4.8 versus 9.2 per 100 person-years, P < 0.001). Among those who were followed for 5 years or more, 5.8% of adolescents switched to a second-line regimen as a result of treatment failure, compared with 2.1% of adults (P < 0.001).Conclusion:With adolescent-focused services, it is feasible to achieve good outcomes for adolescents in large-scale ART programs in sub-Saharan Africa. However, adolescents are at high risk of treatment failure, which compromises future drug options. Interventions to address poor adherence in adolescence should be prioritized.

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