Retention across the continuum of care in a cohort of HIV infected children in rural India

G. Alvarez-Uria

RDT Hospital, Department of Infectious Diseases, Bathalapalli, India

Disclosures

• None

HIV diagnosis

• Linkage

Entry into care

• Retention

ART initiation

• Retention

Virological suppressio

n• Adherence

Background

• Although the cascade of care have been described in adults in different parts of the world, data about the retention across the continuum of care in children is not well know

• It is estimated that only one third of children who need ART are receiving it (UNAIDS 2012).

Methods

• Cohort study of children diagnosed with HIV between 2007 and 2012 in Bathalapalli RDT hospital, in Anantapur, a rural district in Andhra Pradesh

• We describe the attrition (loss to follow up [LTFU] or mortality) at each stage of care

• Children LTFU were actively searched for by phone calls and home visits

Statistical analysis

• Time to event methods• Mortality, LTFU and the event of interest (entry

into care, ART initiation) were considered competing events

• Competing risk analysis was used to estimate cumulative incidence and to perform univariate and multivariable analysis (Coviello 2004, Stata Journal 4:103)

Baseline characteristics N (%)Age

<18 months 65 (12.43)18-59 months 197 (37.67)5-9 years 179 (34.23)10-15 years 82 (15.68)

GenderFemale 267 (51.05)Male 256 (48.95)

HIV transmissionVertical 512 (97.9)Other 11 (2.1)

Time to the clinic<=30 min 139 (26.58)31-90 min 212 (40.54)>90 min 172 (32.89)

Status of parentsAlive 287 (54.84)Father died 119 (22.75)Mother died 51 (9.75)Both died 66 (12.62)

Entered into care

Died before entry into careDid not enter into care (LTFU)

0

.2

.4

.6

.8

1

Pro

porti

on o

f chi

ldre

n

0 6 12 18 24 30 36 42 48 54 60 66 72 78Months since HIV diagnosis

Status from HIV diagnosis to entry into care

Started ART

Died or lost to follow up

Retained in care0

.2

.4

.6

.8

1

Pro

porti

on o

f chi

ldre

n

0 6 12 18 24 30 36 42 48 54 60Months since engagement in care

Status from enrolment to ART initiation

DiedLost to follow up

Retained in care

0

.2

.4

.6

.8

1

Pro

porti

on o

f chi

ldre

n

0 6 12 18 24 30 36 42 48 54 60Months since ART initiation

Status after starting ART

Results (cont’d)

• Viral load was available in 82% of children who started ART

• 72.6% had viral load <400 copies/ml after a median of 31 months on ART (IQR 18–63)

HIV diagnosis Entered into care

Initiated ART Retained on ART

Virological suppression

0

10

20

30

40

50

60

70

80

90

10091.9%

80.2%

60.2%

45.1%

MortalityLoss to follow up

Factors associated with delayed or no entry into care

• Age < 18 months• Living >90 min from the hospital• When HIV diagnosis of the child was made

after the HIV diagnosis of the mother

Factors associated with attrition

• LTFU– Poor socio-economic conditions– Living >90 min from the hospital

• Mortality– Poor socio-economic conditions– Age >10 years– Low CD4 count (for age)

Limitations

• The proportion of children who did not enter into care is likely to be an underestimation, because we do not have data about all children diagnosed with HIV in the district

• Children LTFU might have enrolled in other HIV clinics / ART centres

Conclusions

• Fewer than half of children diagnosed with HIV followed all stages of care up to the achievement of virological suppression

• Half of the attrition occurred before starting ART. – Most research and funding have focused on the reduction of

morbidity and mortality of children on ART. – We should place more emphasis on promoting research on

interventions to reduce the attrition in the pre-ART period• The cascade of care can be used as a tool for service

providers and policy makers to examine gaps in the quality of care given to children living with HIV

Thank you