Victoria Iyun1, Karl-Gunter Technau2, Brian Eley3, Helena Rabie4, Andrew Boulle1,5, Geoffrey Fatti6,7, Matthias Egger1,8, Frank Tanser9,10, Robin Wood11, Lee Fairlie12, Mark F Cotton5,13, Mary-Ann Davies1. 1. From the Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town Medicine, Cape Town, South Africa. 2. Empilweni Services and Research Centre, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa. 3. Red Cross War Memorial Children's Hospital, Paediatric Infectious Diseases Unit, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa. 4. Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa. 5. Khayelitsha ART Programme and Health Impact Assessment, Western Cape Department of Health, Cape Town, South Africa. 6. Kheth'Impilo, South Africa. 7. Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa. 8. Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland. 9. Africa Health Research Institute, KwaZulu-Natal, South Africa. 10. College of Social Science, University of Lincoln, Lincoln, UK. 11. Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa. 12. Wits Reproductive Health and HIV Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. 13. Aid for AIDS, Division of Medscheme Holdings Pty Ltd, Cape Town.
Abstract
BACKGROUND: Early infant diagnosis of HIV and antiretroviral therapy (ART) has been rapidly scaled-up. We aimed to examine the effect of expanded access to early ART on the characteristics and outcomes of infants initiating ART. METHODS: From 9 cohorts within the International epidemiologic Databases to Evaluate AIDS-Southern Africa collaboration, we included infants with HIV initiating ART ≤3 months of age between 2006 and 2017. We described ART initiation characteristics and the probability of mortality, loss to follow-up (LTFU) and transfer out after 6 months on ART and assessed factors associated with mortality and LTFU. RESULTS: A total of 1847 infants started ART at a median age of 60 days [interquartile range: 29-77] and CD4 percentage (%) of 27% (18%-38%). Across ART initiation calendar periods 2006-2009 to 2013-2017, ART initiation age decreased from 68 (53-81) to 45 days (7-71) (P < 0.001), median CD4% improved from 22% (15%-34%) to 32% (22-43) (P < 0.001) and the proportion with World Health Organization clinical disease stage 3 or 4 declined from 81.6% to 32.7% (P < 0.001). Overall, the 6-month mortality probability was 5.0% and LTFU was 20.4%. Mortality was 10.6% (95% confidence interval: 7.8%-14.4%) in 2006-2009 and 4.6% (3.1%-6.7%) in 2013-2017 (P < 0.001), with similar LTFU across calendar periods (P = 0.274). Pretreatment weight-for-age Z score <-2 was associated with higher mortality. CONCLUSIONS: Infants with HIV are starting ART younger and healthier with associated declines in mortality. However, the risk of mortality remained undesirably high in recent years. Focused interventions are needed to optimize the benefits of earlier diagnosis and treatment.
BACKGROUND: Early infant diagnosis of HIV and antiretroviral therapy (ART) has been rapidly scaled-up. We aimed to examine the effect of expanded access to early ART on the characteristics and outcomes of infants initiating ART. METHODS: From 9 cohorts within the International epidemiologic Databases to Evaluate AIDS-Southern Africa collaboration, we included infants with HIV initiating ART ≤3 months of age between 2006 and 2017. We described ART initiation characteristics and the probability of mortality, loss to follow-up (LTFU) and transfer out after 6 months on ART and assessed factors associated with mortality and LTFU. RESULTS: A total of 1847 infants started ART at a median age of 60 days [interquartile range: 29-77] and CD4 percentage (%) of 27% (18%-38%). Across ART initiation calendar periods 2006-2009 to 2013-2017, ART initiation age decreased from 68 (53-81) to 45 days (7-71) (P < 0.001), median CD4% improved from 22% (15%-34%) to 32% (22-43) (P < 0.001) and the proportion with World Health Organization clinical disease stage 3 or 4 declined from 81.6% to 32.7% (P < 0.001). Overall, the 6-month mortality probability was 5.0% and LTFU was 20.4%. Mortality was 10.6% (95% confidence interval: 7.8%-14.4%) in 2006-2009 and 4.6% (3.1%-6.7%) in 2013-2017 (P < 0.001), with similar LTFU across calendar periods (P = 0.274). Pretreatment weight-for-age Z score <-2 was associated with higher mortality. CONCLUSIONS: Infants with HIV are starting ART younger and healthier with associated declines in mortality. However, the risk of mortality remained undesirably high in recent years. Focused interventions are needed to optimize the benefits of earlier diagnosis and treatment.
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