Nearly one in every six HIV-infected children lost from ART follow-up at Debre Markos Referral Hospital, Northwest Ethiopia: A 14-year retrospective follow-up study.

BACKGROUND: Although antiretroviral therapy (ART) significantly improves the survival status and quality of life among human immunodeficiency virus (HIV)-infected children, loss to follow-up (LTFU) from HIV-care profoundly affecting the treatment outcomes of this vulnerable population. For better interventions, up-to-date information concerning LTFU among HIV-infected children on ART is vital. However, only a few studies have been conducted in Ethiopia to address this concern. Thus, this study aims to identify the predictors of LTFU among HIV-infected children receiving ART at Debre Markos Referral Hospital.
METHODS: An institution-based retrospective follow-up study was done among 408 HIV-infected children receiving ART at Debre Markos Referral Hospital between 2005 and March 15, 2019. Data were abstracted from the medical records of HIV-infected children using a standardized data abstracted checklist. We used Epi-Data Version 3.1 for data entry and Stata Version 14 for statistical analysis. The Kaplan-Meier survival curve was used to estimate the survival time. A generalized log-rank test was used to compare the survival curves of different categorical variables. Finally, both bi-variable and multivariable Cox proportional hazard regression models were used to identify the predictors of LTFU.
RESULTS: Of 408 HIV-infected children included in the final analysis, 70 (17.1%) children were LTFU at the end of the study. The overall incidence rate of LTFU among HIV-infected children was found to be 4.5 (95%CI: 3.5-5.7) per 100-child years of observation. HIV-infected children living in rural areas (AHR: 3.2, 95%CI: 2.0-5.3), having fair or poor ART drug adherence (AHR: 2.3, 95%CI: 1.4-3.7), children started ART through test and treat approach (AHR: 2.7, 95%CI: 1.4-5.5), and children started protease inhibiter (PI)-based ART regimens (AHR: 2.2, 95%CI: 1.1-4.4) were at higher risk of LTFU.
CONCLUSION: This study found that one in every six HIV-infected children lost form ART follow-up. HIV-infected children living in rural areas, having fair or poor ART drug adherence, started ART based on test and treat approach, and taking PI-based ART regimens were at higher risk of LTFU.

Introduction

Though the concept of “child at risk” highly varies across the continents, in Africa, it commonly refers to socially disadvantaged children, including human immunodeficiency virus (HIV) exposed infants [1]. HIV is a global challenge for humankind's survival, as Sub-Saharan Africa (SSA) is profoundly affected. Globally, an estimated 1.7 million children (age<15 years) were living with HIV in 2018 [2]. In 2014, 87% of new HIV infections and 86% of AIDS-related deaths among children were from SSA [3, 4]. Ethiopia is one of the SSA countries with a high HIV prevalence; nearly 62,000 children were living with HIV in 2017 [5, 6]. Antiretroviral therapy (ART) improves the survival status and quality of life among HIV-infected children through viral load suppression and increasing CD4 counts [7]. ART dug must be taken continuously and on a daily base to be effective [8]. Otherwise, patients could develop treatment failure and end-up with death in the early ART phase [5].

A systematic review found that about 5–29% of the children living HIV under the age of 10 lost from ART or died within the first one year of ART initiation worldwide in 2011 [9]. Another study from Asia and Africa reported that loss to follow up (LTFU) among HIV-infected children was reported as low of 4.1% in Asia and as high of 21.8% in West Africa [10]. In SSA, the proportion of LTFU among HIV-infected children after two years of ART initiation ranged from 9% in Southern Africa to 21.8% in West Africa [10]. As per report of previous studies, LTFU among HIV-infected children in Ethiopia was ranged from 5.9% [11] to 15% [12].

The Sustainable Development Goals (SDGs) are targeted to end the epidemic of HIV/AIDS by 2030 [13, 14]. Retention in ART care is a key strategy to achieve this ambitious goal [15]. In this regard, different interventions have been implemented nationally and internationally. For example, a short message service (SMS) to remind HIV-patients who missed their appointments has been implemented in Malawi, Kenya, South Africa, Mozambique, Zimbabwe, Ruanda, and Zambia [16]. The World Health Organization (WHO) also recommends that age-appropriate disclosure and caregivers’ regular support are essential to improve retention in ART care [5]. The orphans and vulnerable children (OVC) program in Africa, in collaboration with health care workers, is working persistently to trace individuals lost from HIV-care [17]. The Ethiopian government has also implemented adherence support through phone calls to trace patients lost from ART care [18].

The most commonly reported contributing factors for LTFU among HIV-infected children are: lack of caregivers’ contact information, fear of stigma, forgetfulness, scheduling conflict, lack of access to transportation, privacy concerns, not disclosing HIV-status, weak follow-up at the ART clinic, advanced WHO clinical disease stage, malnutrition, and younger age [19, 20]. Similarly, the common risk factors increasing LTFU among HIV-infected Ethiopian children are far from health institutions, lack of access to transportation, fear of stigma, not disclosing HIV-status, bedridden status, and lack of understanding as ART is a lifelong medication [21, 22].

Though discontinuation from ART care among children in Ethiopia is a serious public health concern, to our knowledge, only a few studies have been conducted to explore this problem. Therefore, this study aims to assess LTFU among HIV-infected children receiving ART at Debre Markos Referral Hospital. The results of this study will help policymakers and program planners working in the area of HIV/AIDS to design appropriate interventions in reducing LTFU in this vulnerable population. This study will also serve as an input for further prospective observational or interventional studies.

Methods

Study design, period, and setting

An institution-based retrospective follow-up study was conducted at Debre Markos Referral Hospital between 2005 and March 15, 2019. Debre Markos town is found 300 km from Addis Ababa, the capital city of Ethiopia. The town has one referral hospital and three public health centers. The hospital serves for more than 3.5 million people in East Gojjam Zone and neighboring Zones. It has been providing ART care and follow-up services since 2005. Currently, the ART clinic has two medical doctors, six nurses, three data clerks, one porter, one cleaner, five case managers, four CDC contract employees, and six adherence supporters. The hospital uses standardized monitoring and follow-up forms, adopted from the Ethiopian ART guideline. A total of 466 HIV-infected children on ART have been recorded since 2005. Of these, 326 children have an active monthly ART follow-up.

Study participants

The records of all HIV-infected children, whoever started ART at Debre Markos Referral Hospital, were the source population. The records of all HIV-infected children receiving ART between 2005 to March 15, 2019, and whose charts were available during the data collection period were our study population. All HIV-infected children who had at least one month of ART follow-up between 2005 and March 15, 2019 were included. Whereas, children who had incomplete baseline records (i.e., CD4 count, WHO stages, CPT, IPT, and hemoglobin level), unknown outcomes, and transferred in from other health institutions without baseline information were excluded.

Sample size and sampling procedures

This study included all HIV-infected children’s records ever started ART between 2005 and March 15, 2019. First, the files of all HIV-infected children ever started ART between 2005 and March 15, 2019 were sorted by data collectors. Second, children who met the above-mentioned inclusion criteria were isolated. Third, after excluding all incomplete records, a total of 408 HIV infected children records were included in the final analysis. Lastly, data across 14 years were collected from the charts of each enrolled child.

Data collection procedure and quality control

The data extraction checklist was adapted from a standardized ART intake and follow-up forms currently used in the ART clinic of Debre Markos Referral Hospital. The most recent clinical and laboratory tests at ART initiation were considered as baseline information. However, if pre-treatment laboratory tests were not recorded at ART initiation, laboratory tests done within the first month of ART initiation were considered as baseline information. In the case of two laboratory tests done in the first month of ART, the most recent laboratory value was taken as baseline. Before data collection, the consistency between the data extraction checklist and the recording system was cheeked by taking some randomly selected charts, and necessary amendments were made. Three nurses currently working in the ART clinic of Debre Markos Referral Hospital were recruited as data collectors. Moreover, the data extraction checklist was carefully prepared from a standardized ART intake and follow-up forms to maintain data quality. Furthermore, training for data collectors and supervisor about the objectives, significances, and variables of the study was given. Lastly, the supervisor and principal investigators carefully monitored the completeness and consistency of the whole data collection process.

Variables of the study

The dependent variable was the time to LTFU among HIV infected children after ART initiation. The independent variables were socio-demographic variables, clinical characteristics and laboratory tests, ART and other medications-related variables, and nutritional variables. Socio-demographic variables were age of the child, sex of the child, caregivers’ age, caregivers’ residence, marital status of the caregiver, family size, educational status of the caregiver, caregivers’ relation for the child, and religion. Clinical characteristics and laboratory tests were WHO clinical staging, CD4 count/percentage, Hgb level, viral load, functional or developmental status, and baseline OIs. ART and other medications-related variables included baseline ART regimens, duration of ART, ART side effects, regimen change, treatment failure, taking IPT, taking CPT, and adherence to ART. Nutritional status included weight for age (W/age), height for age (H/age), and weight for height (W/height).

Definition of variables

LTFU was recorded when HIV infected children missed their appointments from one month to three months [5].

Censored was considered when HIV-infected children had died, formally transferred to other health institutions, or still alive and on ART at the end of the study.

ART Adherence was classified as good, fair, and poor. Good was recorded when the child took ≥ 95% or missed ≤ three pills of monthly dose. Fair was recoded when the child took 85–94% or missed four to eight pills of monthly dose. Finally, poor was recorded when the child took <85% or missed ≥ nine pills of monthly dose.

Children who had CD4 cell counts < 1500/mm3 or 25% for age < 12 months, CD4 cell counts < 750/mm3 or < 20% for age 12–35 months, CD4 cell counts < 350/mm3 or < 15% for age 36–59 months, and CD4 cell counts < 200/mm3 or < 15% for age ≥ 60 months were classified as CD4 counts or percentage (%) below the threshold [23].

Child developmental status was classified as appropriate (able to attain milestones for age), delayed (failure to attain milestones for age); and regressed (loss of what has been attained for age). According to the recent Ethiopian ART guideline, developmental status has the following components: language, psychosocial, fine and gross motor skills, and cognition [5].

Weight for Age (W/Age) Z-score < -2 SD, Height for Age (H/Age) Z-score < -2 SD and Weight for height (W/H) Z-score < -2 SD were considered to represent moderate underweight, stunting, and wasting respectively [24, 25].

W/Age Z-score < -3 SD, H/Age Z-score < -3 SD, and W/H Z-score < -3 SD were considered to represent severe underweight, stunting, and wasting respectively [24, 25].

Data processing and analysis

We used EPI-Data Version 3.1for data entry and Stata Version 14 for analysis. The children’s Z-scores (WAZ, HAZ, and WHZ/BAZ) were generated using WHO Anthro-Plus Version 1.04 and ENA smart software. Descriptive statistics for categorical variables were visualized using tables and graphs. Summary results of continuous variables were described using the measure of central tendency (mean or median) and dispersion (standard deviation or interquartile range). The Kaplan-Meier survival plot was used to estimate the survival time after ART initiation. A Generalized log-rank test was used to compare the survival curves between categorical variables. The necessary assumption of Cox-proportional hazard model was assessed using Schoenfeld residual test and log-log plot. We used the cox-Snell residuals test to check model fitness. Variables with p-values ≤ 0.25 in the bi-variable analysis were fitted into the multivariate analysis [26]. In the final model, variables with p-values < 0.05 were considered as statistically significant predictors. We used the adjusted hazard ratios (AHR) with their 95% confidence intervals and p-values to measure the strength of association and identify statistically significant predictors.

Ethics considerations

Ethical letter was obtained from the Ethical Review Committee of College of Health Science, Debre Markos University. A permission letter was also written from the hospital general manager to HIV-care clinic focal person. As this was a retrospective study, informed consent from research participants was not feasible. Since the research was done by reviewing medical records, the individual patients were not subjected to any harm as far as confidentiality is kept. All collected data were coded and locked in a separate room, and computer data were secured by a personal password to maintain privacy. Lastly, names and unique ART numbers were not included in the data collection format, and the data were not disclosed to anyone other than the principal investigators.

Results

Socio-demographic characteristics participants

Among 466 retrieved HIV-infected children records, 58 (12.4%) were excluded due to incompleteness. Then, 408 HIV-infected children’s records were considered for the final analysis. More than half (54.7%) were males, and nearly two-thirds (67.7%) were from urban areas. The mean age of participants at ART initiation was 6.9 years (SD: ±3.7 years), and the mean age of caregivers was 33.5 years (SD: ±9.5 years). Moreover, more than half (53.7%) of the parents were alive. Furthermore, about 66.6% of the children disclosed their HIV status, and the majority (85.5%) of children were from the family of orthodox religious followers ().

Clinical, immunological, and nutritional characteristics of the children

More than half (52.7%) of the children had opportunistic infections (OIs) at ART initiation. About 52% of the study participants were classified as mild disease stage (WHO stage I and II). Nearly two-thirds (67.6%) of the children had CD4 counts or percentage above the threshold, and only 11.5% of the study children were anemic (Hgb< 10mg/dl). The majority (90.7%) of study participants started on NVP or EFV based ART drugs. More than half (60.8%) of the participants had ever taken past OI prophylaxis. Moreover, more than three-quarters (78.8%) of the children had good ART drug adherence in the last three months of ART follow-up. Furthermore, about 49.3%, 51.7%, and 75.5% of the children were underweight, stunted, and wasted, respectively ().

Incidence of loss to follow-up

In this study, the participants were followed for a minimum of two months and a maximum of 136 months. At the end of follow-up, 17.1% (95% CI: 13.7, 21.1%) of the children were LTFU from ART care. The total follow-up time of the entire cohort was 18,755 child-months of observation. The incidence density of LTFU among HIV-infected children in this study was 4.5 (95% CI: 3.5, 5.7) per 100 child-years of observation. The incidence rate of LTFU within the first year of ART initiation was 8.2 (95% CI: 5.7, 11.7) per 100 child-years of observation, whereas the incidence rate of LTFU after one year of ART initiation was 3.3 (95% CI: 2.6, 4.6) months per 100 child-years of observation. The mean survival time of the entire follow-up was 108.8 months (95% CI: 103.1, 114.5 months) ().

Kaplan-Meier survival curves for different categorical predictors

The survival function of residence and ART drug adherence was compared using a generalized log rank test. Accordingly, the mean survival time of HIV-infected children receiving ART from urban areas was 119 months (95% CI: 113.1, 124.9 months); however, the mean survival time of HIV-infected children receiving ART from rural areas was 84.4 months (95% CI: 74.0–94.8 months). This difference was statistically significant (p-value < 0.001) ().

The mean survival time of HIV infected children receiving ART who had good ART drug adherence was 115.1 months (95% CI: 109.0, 121.2 months); however, the mean survival time of HIV infected children receiving ART who had fair or poor ART drug adherence was 87.7 months (95% CI: 75.3, 99.9 months). This difference was statistically significant (p-value < 0.001) ().

Predictors of loss to follow-up

Ten variables (p-value < 0.25) were selected for the multivariable cox-regression analysis. In the multivariable analysis, only four variables were found to be statistically significant predictors of LTFU. Accordingly, the hazard of LTFU among HIV-infected children from rural areas was 3.2 times (95% CI: 2.0, 5.3) higher than those who were from urban areas. Additionally, the hazard of LTFU among HIV-children who had fair/poor ART drug adherence was 2.3 times (95% CI: 1.4, 3.8) higher as compared to those who had good ART drug adherence prior to three months of last observation. Furthermore, the hazard of LTFU among HIV-infected children started ART with test and treat criteria was 2.7 times (95% CI: 1.4, 5.5) higher than those who started by immunologic and clinical criteria. Finally, the hazard of LTFU among children who took PI-based ART regimens was 2.2 fold (95% CI: 1.1, 4.4) higher as compared to those who took NNRTI based ART regimens (EFV and NVP based) (). The goodness of fit for the cox-proportional hazard model was assessed using a Cox-Snell residual test. The graph suggested that the final model fits the data very well ().

Discussion

Nowadays, LTFU among HIV-infected children receiving ART has become a significant public health problem, negatively affecting the treatment outcomes. Therefore, we conducted this retrospective follow-up study to determine the incidence and predictors of LTFU among HIV-infected children receiving ART at Debre Markos Referral Hospital. At the end of follow-up, about 17.1% (95% CI: 13.7, 21.1%) of HIV-infected children lost from ART care. The incidence density of LTFU in this study was estimated to be 4.5 (95% CI: 3.5, 5.7) per 100 child-years of observation. Our finding is in line with studies done in South Africa (5.0 per 100 child-years) [27], Myanmar (4.7 per 100 child-years) [28], and Asia and Africa (4.1 per 100 child-years) [29]. Conversely, our finding is much lower than studies conducted in India (14.4 per 100-child years) [30], South Africa (10.8 per 100 child-years) [31], Tanzania (18.2 per 100-child years) [32], multicountry study (14.2 per 100-child years) [33], Malawi (12.6 per-100 child-years) [19], and Ethiopia (6.22 per 100 child-years) [11].

The above variations could be explained by differences in sample size, study setting, and measurement variability in LTFU. The lower incidence rate of LTFU in this study might be due to the different interventions implemented by the Ethiopian government, including adherence support through phone calls, case tracing through a home-to-home visit, and proactive use of community health workers. Another possible justification might be due to the difference in length of follow-up. Our study had relatively longer follow-up time (14 years) compared to previous studies conducted in SSA [19, 28, 31]. A further explanation for the variations could be due to differences in the characteristics of included participants. In this study, more than half (52%) of the study participants were classified as WHO stage I and II; however, about 73.2% of the study participants included in a study from South Africa were classified as WHO stage III and IV [27]. Evidence suggests that HIV-infected children classified as severe disease stage (WHO stage III and IV) at ART initiation were more prone to LTFU as compared to those children classified as WHO stage I and II [11, 31].

This study found that the incidence rate of LTFU within one year of ART initiation was 8.2 (95%, CI: 5.7, 11.7) per-100 child years of observation. However, the incidence of LTFU after one year of ART initiation was 3.3 (95% CI: 2.6, 4.6) per 100 child-years observation. A high rate of LTFU in the early ART phase was observed. This finding is comparable with studies conducted in South Africa, which showed that LTFU was higher in the first six months of ART follow-up [28, 31]. Supportive findings were also reported from studies done in multicountry based studies [9, 33], Tanzania [32], and Ethiopia [11].

HIV-infected children from rural areas were at higher risk of LTFU as compared to their urban counterparts. This finding is in agreement with other previous studies conducted in Asia and Africa [29], Ethiopia [11], and Malawi [19]. The possible justification could be due to the fact that children living in rural areas travel long distances to get access to ART. Studies suggested that patients living far from a health facility had a greater risk of LTFU [34, 35]. Moreover, children living in rural areas could have difficulties to access favorable transportation; as a result, they could miss their appointments. Additionally, caregivers maybe forget to bring their children to the ART clinic at each visit. Lastly, the caregiver’s level of education has a significant effect on LTFU because most rural mothers are uneducated. As a result, they commonly seek faith healing or traditional therapies [36].

This study also indicated that children who had fair or poor ART drug adherence were at higher risk of LTFU compared to those who had good adherence. It is well understood that the relationship between ART drug adherence and LTFU is bidirectional. The common reasons for poor ART adherence among people living with HIV are the use of traditional/herbal medicine, dissatisfaction with healthcare services, depression, discrimination and stigmatization, and poor social support [37]. These factors are also directly related to the risk of LTFU. The other common reason for LTFU is fear of ART side-effects. Lastly, if patens do not take their drug properly (have poor ART adherence), they don’t have good improvements in the early ART phase. This leads to early treatment failure and the rapid development of drug resistance.

This study also found that children who started ART based on the test and treat approach were at higher risk of LTFU as compared to those who started ART based on immunologic (CD4 counts) or clinical (WHO staging) criteria. Despite WHO recommends that HIV-positive patients can start ART within the seven days after HIV-confirmation, evidence from an observational study revealed that starting ART on the same day of HIV diagnosis increases the risk of LTFU [38]. According to the WHO recommendation, higher LTFU is documented as the main weakness of the test and treat approach [39]. Another possible explanation could be due since starting ART at the same day of HIV confirmation without intensive counselling and adequate preparation may lead to fear of stigma and discrimination and finally leads to LTFU in the early ART phase.

Finally, children who started PI-based ART regimens were at higher risk of LTFU as compared to those who started non-nucleoside reverse transcriptase inhibitors (Nevirapine or Efavirenz) based ART regimens. This finding contradicts a previous study done in Myanmar [28]. This variation could be due to the baseline differences between study participants at ART initiation, leading to the prescription of PI-based regimens. The actual effects of PI-based regimens on better treatment outcomes would need further follow-up studies.

Potential limitations of the study

This study has some constraints that must be considered before interpreting results. As the study used secondary data, some important variables such as viral load, micronutrient deficiency, and immunization status of the child were not included. This study was also unable to ascertain the reasons for and outcomes of LTFU due to incomplete documentation. Patients recorded as LTFU might be died or started ART in another health institutions. Therefore, the actual LTFU might be overestimated in this study. The study's main strength was conducted for a more extended period of follow-up time (14 years); this could increase observation time.

Conclusion

This study found that one in every six HIV-infected children lost form ART follow-up. Relatively a lower rate of LTFU was observed as compared to previous studies reported in Ethiopian and other SSA countries. Moreover, a higher rate of LTFU was seen within the first year of ART initiation. HIV-infected children from rural areas, having fair or poor ART drug adherence, started ART based on test and treat approach, and taking PI-based ART regimens were at higher risk of LTFU. Thus, particular emphasis and close follow-up must be given within the first year of ART initiation. Moreover, tracing mechanisms should be strengthened for children who are from rural areas. Furthermore, providing participatory advice and letting them decide rather than enforcing to start ART immediately after HIV confirmation is highly appreciated. Further prospective follow-up studies by considering viral load, child immunization, and micronutrient deficiencies are highly recommended. Lastly, qualitative studies to explore the reasons of LTFU are also recommended.

This S1 File is the date set used for this study.

(DTA)

Click here for additional data file.

13 Aug 2020

PONE-D-20-16100

Nearly one in every six children lost from ART follow-up at Debre Markos Referral Hospital, Northwest Ethiopia: A 14-year retrospective follow-up study

PLOS ONE

Dear Dr. Animut Alebel

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by 20 August. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Claudia Marotta

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We noticed you have some minor occurrence of overlapping text with the following previous publication, which needs to be addressed:

https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0195435

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

Additional Editor Comments (if provided):

Dear Authors,

I appreciate a lot your manuscript.

Following reviewes suggestions the paper can be publish after minor revisions

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Authors written a very interesting article on a vunerable population (childeren) in a fragile setting .

Only some suggestion:

1. Introduction: well wrote, introduce the concept of children at risk (cite this article. The At Risk Child Clinic (ARCC): 3 Years of Health Activities in Support of the Most Vulnerable Children in Beira, Mozambique. Int J Environ Res Public Health. 2018;15(7):1350. Published 2018) that explain the role also of the research on this issue. Als see this article e Schacht C, Lucas C, Mboa C, et al. Access to HIV prevention and care for HIV-exposed and HIV-infected children: a qualitative study in rural and urban Mozambique. BMC Public Health. 2014;14:1240. Published 2014 Dec 3.

2. Methods and Results: no comment.

3. Discussion: well. I f you can improve with a proposal. Why the children lost to follow up? discuss other experience as for example this in Mozambique (Pathways of care for HIV infected children in Beira, Mozambique: pre-post intervention study to assess impact of task shifting. BMC Public Health. 2018;18(1):703. Published 2018 Jun 7.)

I consider it as an excellent article.

Reviewer #2: This institution-based retrospective follow-up study conducted among 408 HIV-infected children on ART at Debre Markos Referral Hospital between 2005 and March 15, 2019, has provided very important information or indicators for lost to follow up among kids enrolled in HIV treatment programs that could be generalized or applied to other settings within Ethiopia and countries with similar status. Lost to follow up is current a serious problem in the management of HIV treatment among adults and kids, putting together data to identify potential reasons for this in this setting is highly rewarding as it will definitely lead t implementation of strategies to address gaps identified. It is interesting to identify in the study that starting ART immediately or sooner after diagnosis following WHO recommendation is also a factor that influence lost to follow. Addressing should also impact national policy on the country’s treatment program. This study is highly recommended. Potential limitations, including not being able to include that of VL which could provided information to virally suppression status of these kids is nothing; something that should be considered in future studies.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Francesco Di Gennaro

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

25 Aug 2020

1) Thank you for updating your data availability statement. You note that your data are available within the Supporting Information files, but no such files have been included with your submission. At this time we ask that you please upload your minimal data set as a Supporting Information file, or to a public repository such as Fig share or Dryad. Please also ensure that when you upload your file you include separate captions for your supplementary files at the end of your manuscript. As soon as you confirm the location of the data underlying your findings, we will be able to proceed with the review of your submission.

Response: Thank you for your concern. We have uploaded the Stata data set as S1 file.

2) Your ethics statement must appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please also ensure that your ethics statement is included in your manuscript, as the ethics section of your online submission will not be published alongside your manuscript.

Response: Thank you for your concern. We have moved the ethics statement to the method section. Please see line 184-193.

Reviewer #1:

Authors written a very interesting article on a vulnerable population (children) in a fragile setting.

Response: Thank you for your encouraging words.

Only some suggestion:

1. Introduction: well written, introduce the concept of children at risk (cite this article. The At Risk Child Clinic (ARCC): 3 Years of Health Activities in Support of the Most Vulnerable Children in Beira, Mozambique. Int J Environ Res Public Health. 2018;15(7):1350. Published 2018) that explain the role also of the research on this issue. Also see this article e Schacht C, Lucas C, Mboa C, et al. Access to HIV prevention and care for HIV-exposed and HIV-infected children: a qualitative study in rural and urban Mozambique. BMC Public Health. 2014;14:1240. Published 2014 Dec 3.

Response: Thank you for your suggestion. We have introduced the concept of “child at risk” in the first paragraph of our introduction. Please see line 52-54.

2. Methods and Results: no comment.

Response: Thank you for your precious time.

3. Discussion: well. I f you can improve with a proposal. Why the children lost to follow up? Discuss other experience as for example this in Mozambique (Pathways of care for HIV infected children in Beira, Mozambique: pre-post intervention study to assess impact of task shifting. BMC Public Health. 2018;18 (1):703. Published 2018 Jun

Response: Thank you very much for your suggestion. The suggested article is not related to our title. Therefore, we did not cite it. The question “Why the children lost to follow up?” needs further studies. As this is beyond our objective, we haven’t any data on this issue. This has been acknowledged as a limitation part of our research. And further qualitative studies are recommended to address this issue. Please see line 335-36 and 351-52.

I consider it as an excellent article.

Reviewer #2:

This institution-based retrospective follow-up study conducted among 408 HIV-infected children on ART at Debre Markos Referral Hospital between 2005 and March 15, 2019, has provided very important information or indicators for lost to follow up among kids enrolled in HIV treatment programs that could be generalized or applied to other settings within Ethiopia and countries with similar status. Lost to follow up is current a serious problem in the management of HIV treatment among adults and kids, putting together data to identify potential reasons for this in this setting is highly rewarding as it will definitely lead to implementation of strategies to address gaps identified. It is interesting to identify in the study that starting ART immediately or sooner after diagnosis following WHO recommendation is also a factor that influence lost to follow. Addressing should also impact national policy on the country’s treatment program. This study is highly recommended. Potential limitations, including not being able to include that of VL which could provide information to virally suppression status of these kids is nothing; something that should be considered in future studies.

Response: Thank you for your concern. Future studies by considering VL are strongly recommended. Please see line 349-351.

28 Aug 2020

Nearly one in every six children lost from ART follow-up at Debre Markos Referral Hospital, Northwest Ethiopia: A 14-year retrospective follow-up study

PONE-D-20-16100R1

Dear Dr. Alebel,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Claudia Marotta

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Authors,

two different reviewers suggest to accept your manuscript.

I appreciate a lot element of your article: the long period-time of study (14ys), the setting (Ethiopia) and the idea research (child, HIV, lost to follw up)

Congratulations for your great job!

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Congratulations I appreciate a lot your article. I appreciate the methods and the idea reasearch.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Di Gennaro Framcesco

3 Sep 2020

PONE-D-20-16100R1

Nearly one in every six HIV-infected children lost from ART follow-up at Debre Markos Referral Hospital, Northwest Ethiopia: A 14-year retrospective follow-up study

Dear Dr. Alebel:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Claudia Marotta

Academic Editor

PLOS ONE

Table 1

Sociodemographic characteristics of HIV-infected children receiving ART at Debre-Markos Referral Hospital, Northwest Ethiopia, 2019.

Variables	Frequency (N)	Percentage (%)
Sex
Male	223	54.2
Female	185	54.3
Age of the child (in months)
0–35 month	63	15.5
36–96 month	207	50.7
≥ 97 month	138	33.8
Residence
Urban	276	67.7
Rural	132	32.7
Parents status
Both mother and father alive	219	53.7
One or both died	189	46.3
Age of the caregiver
18–24 year	51	12.5
25–34 year	198	48.5
35–44 year	113	27.7
≥ 45 year	46	11.3
Marital status of the caregiver
Married	173	42.4
Widowed/divorced	136	33.3
Others	99	24.3
Educational status of the caregiver
Unable to read and write	148	36.3
Able to read and write	260	63.7
Occupation of the caregiver
Farmer	79	19.4
Governmental	86	21.1
Non-governmental	49	12.0
House wife	36	8.8
Daily laborer	89	21.8
Merchant	69	16.9
Child HIV status disclosure (180)
Yes	120	66.6
No	60	33.4
Religion of the caregiver
Orthodox	349	85.5
Others	59	14.5
Relation of caregiver for the child
Parent	348	85.3
Other guardians	60	14.7

Table 2

Clinical, immunological, and nutritional characteristics of HIV infected children receiving ART at Debre-Markos Referral Hospital, Northwest Ethiopia, 2019.

Variables	Frequency (N)	Percentage (%)
Baseline OIs
Yes	215	52.7
No	193	47.3
Functional status (age ≥ 5 years)(287)
Working	153	53.3
Ambulatory	113	39.4
Bedridden	21	7.3
Developmental status (age < 5 year) (121)
Appropriate	73	60.3
Delayed	41	33.9
Regressed	7	5.8
WHO clinical staging
Stage I and II	212	52.0
Stage III and IV	196	48.0
CD4 counts or CD4% at baseline
Below the threshold	132	32.4
Above the threshold	276	67.6
Level hemoglobin
Anemic (< 10 mg/dl)	47	11.5
Non-anemic (≥ 10 mg/dl)	361	88.5
OI prophylaxis given
Yes	248	60.8
No	160	39.2
Baseline ART regimens
EFV or NVP based	370	90.7
PI based	38	9.3
OIs during follow-up
Yes	120	29.4
No	288	70.6
ART eligibility criteria
Immunologic or Clinical	341	83.6
Test and treat	67	16.4
ART adherence in last three months
Good	321	78.7
Fair/poor	87	21.3
ART drug side-effects
Yes	20	4.9
No	388	95.1
Regimen change
Yes	85	20.8
No	323	79.2
Treatment failure
Yes	20	4.9
No	288	95.1
Underweight
Normal	207	50.7
Underweight	210	49.3
Stunting
Normal	197	48.3
Stunted	211	51.7
Wasting
Normal	308	75.5
Wasted	100	24.5

Table 3

Bi-variable and multivariable Cox regression analysis to identify the predictors of LTFU among HIV-infected children receiving ART at Debre-Markos Referral Hospital, Northwest Ethiopia, 2019.

Variables	Survival status		CHR (95%CI)	AHR (95%CI)
	Lost	Censured
Residence
Urban	28	248	1	1
Rural	42	90	3.6(2.3, 5.9)	3.2(2.0, 5.3)**
Religion of the caregiver
Orthodox	66	283	1	1
Others	4	55	0.31(0.1, 0.9)	0.5 (0.2, 1.5)
Relation of caregiver to the child
Parent	64	284	1	1
Other guardians	6	54	0.5(0.2, 1.1)	1.1(0.4, 2.8)
ART drug adherence
Good	40	281	1	1
Fair/poor	30	57	2.6(1.6, 4.1)	2.7(1.4, 5.5)**
ART eligibility criteria
Immunologic and clinical	55	286	1	1
Test and treat	15	52	2.6(1.4, 4.6)	2.7(1.4, 5.5) **
Baseline ART regimen
NVP and EFV based	59	311	1	1
PI based	11	27	3.8(1.9, 7.3)	2.2(1.1, 4.4)**
WHO clinical staging
Stage I and II	31	181	1	1
Stage III and IV	39	157	1.3 (0.8, 2.2)	1.2 (0.7, 2.1)
CD4 counts
Below the threshold	43	233	1	1
Above the threshold	27	103	1.5(0.9, 2.4)	1.5(0.8, 2.6)
Wasting
Wasted	47	261
Normal	23	77	1.5(0.9, 2.5)	1.3(0.8, 2.2)
OI prophylaxis given
Yes	28	200	1	1
No	22	138	0.7(0.4–1.2)	0.8(0.47, 1.4)

**significant variables in the multivariable analysis.