Clinical outcomes in children and adolescents initiating antiretroviral therapy in decentralized healthcare settings in Zimbabwe

Abstract

Introduction: Decentralized HIV care for adults does not appear to compromise clinical outcomes. HIV care for children poses additional clinical and social complexities. We conducted a prospective cohort study to investigate clinical outcomes in children aged 6–15 years who registered for HIV care at seven primary healthcare clinics (PHCs) in Harare, Zimbabwe. Methods: Participants were recruited between January 2013 and December 2014 and followed for 18 months. Rates of and reasons for mortality, hospitalization and unscheduled PHC attendances were ascertained. Cox proportional modelling was used to determine the hazard of death, unscheduled attendances and hospitalization. Results: We recruited 385 participants, median age 11 years (IQR: 9–13) and 52% were female. The median CD4 count was 375 cells/mm3 (IQR: 215–599) and 77% commenced ART over the study period, with 64% of those who had viral load measured achieving an HIV viral load <400 copies/ml. At 18 months, 4% of those who started ART vs. 24% of those who remained ART‐naïve were lost‐to‐follow‐up (p < 0.001). Hospitalization and mortality rates were low (8.14/100 person‐years (pyrs) and 2.86/100 pyrs, respectively). There was a high rate of unscheduled PHC attendances (34.94/100 pyrs), but only 7% resulted in hospitalization. Respiratory disease was the major cause of hospitalization, unscheduled attendances and death. CD4 count <350cells/mm3 was a risk factor for hospitalization (aHR 3.6 (95%CI 1.6–8.2)). Conclusions: Despite only 64% of participants achieving virological suppression, clinical outcomes were good and high rates of retention in care were observed. This demonstrates that in an era moving towards differentiated care in addition to implementation of universal treatment, decentralized HIV care for children is achievable. Interventions to improve adherence in this age‐group are urgently needed.

Multilevel modelling and multiple group analysis of disparities in continuity of care and viral suppression among adolescents and youths living with HIV in Nigeria

“…Also, while the odds for viral suppression reduced with lower levels of retention in older adolescents and young adults, there was no significant difference in odds for viral suppression among young adolescents retained in care and those who were not. Although these findings seem counterintuitive since better retention in care is expected to lead to higher rates of viral suppression, it corroborates findings from other studies [30][31][32][33][34][35][36] showing high rates of viral non-suppression among young adolescents despite perfect adherence, most notably among young adolescents initiated on AZT+3 TC+NVP/EFV. In our study, young adolescents were also initiated predominantly on ART regimen AZT+3 TC+NVP/EFV(63.2%), in contrast to older adolescents and young adults who were initiated predominantly on TDF/3TC/EFV or NVP (83.90% and 90.1%, respectively).…”

Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme

“…The adolescent’s group is known to be associated with additional intricacy in their HIV management due to different types of chronic comorbidities, and this whole complexity may impact on their ART outcomes including LTFU. 38 39 The high risk of becoming LTFU among adolescents can be attributed to structural deprivation due to medical and psychological reasons that contribute to poor adherence in this subpopulation group as a result of becoming LTFU. 40 The most common medical barrier that has been found to affect ART adherence include treatment side effects, multiple doses and health system dissatisfaction.…”

“…The mechanism should be a comprehensive package addressing inherent adolescents’ health issues like cognitive health, ART adherence, stigma, disclosure and socioeconomic issues. 38 44 Besides, a simple regimen, directly observed therapy and technological interventions like cellphone reminders have been found to increase ART adherence in adolescents.…”

High loss to follow-up of children on antiretroviral treatment in a primary care HIV clinic in Johannesburg, South Africa

“…In a prospective cohort study from Zimbabwe, only 4% of children aged 6 to 15 years were LTFU 18 months post ART initiation, although only 64% of children were virally suppressed. [ 34 ] Attention is needed to ensure that, in the long run, the care provided by decentralized services is not hampered by inadequate clinical and psychosocial support for patients in these often under resourced, high volume, primary care settings. [ 35 , 36 ] Innovative linking and tracing programmes need to be developed and scaled up to optimize retention throughout the treatment cascade.…”