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

Abstract

BackgroundReducing 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.MethodsThis 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.ResultsThe 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).ConclusionA 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.

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

“… 14 , 16 In contrast, the findings of this study are higher than those of studies conducted in low and middle-income countries, 8 22%; Myanmar Asia, 6 14%; Mingalardon in Myanmar, 11 9.7%); and Southwest China, 25 (18.1%). It is also higher than that reported in studies conducted in Eritrea 28 (24.2%), the Oromia region, and Addis Ababa 15 (7.9%). This discrepancy may be due to differences in the study population; the study done in Myanmar excluded children aged <18 months 6 and dissimilarity in the measurement of attrition, defined as discontinuation of ART or loss to follow-up, as defined by a study in China.…”

“…The findings of this study are supported by evidence from a study conducted in Eritrea. 28 This may be because the majority of old ART regimens have side effects that enhance the progression of the disease and result in subsequent complications. A zidovudine-based ART regimen is associated with anemia, which has an additional effect on the immune system.…”

Predicting Lost to Follow-Up Status Using an Adolescent HIV Psychosocial Attrition Risk Assessment Tool: Results From a Mixed Methods Prospective Cohort Study in Uganda

“…Other studies have been performed to determine factors that lead to attrition and that are adolescentspecific; however, they also do not address psychosocial factors. 13,[29][30][31] Although we did not develop a tool that is able to predict LTFU among adolescents within 5 months, our tool does assess a range of psychosocial issues that affect adolescents in HIV care, including stigma, mental health, and HIV disclosure among others, and highlighted concerns about issues such as food security, stigma, and distance to care that were shared across the board by participants. 32,33 Despite the APARA tool not being able to predict LTFU after 5 months, the tool was useful for identifying psychosocial issues experienced by study participants and highlighting the challenges faced by participants.…”

Population-Specific Predictors of Immunologic Reconstitution Following Initiation of Combined Antiretroviral Therapy in Children: A Retrospective Observational Study from a 15-year Cohort of HIV-Positive Children and Adolescents in Eritrea

“…However, various psycho-social and behavioral factors could confound the practices of children, parents and caregivers. The non-linear trajectory of absolute CD4 percentages increment throughout the cohort year categories might have contributed to the confounding community variables such as HIV-related stigma, discrimination, profound fear of stigmatization, and isolation from social circles 42 . Moreover, the data shows that the advanced WHO clinical stage was signi cantly associated with IR following 6 months of cART initiation.…”