Mortality and clinical outcomes in children treated with antiretroviral therapy in four African vertical programs during the first decade of paediatric HIV care, 2001-2010

Objective: To assess mortality and clinical outcomes in children treated with antiretroviral therapy (ART) in four African vertical programmes between 2001 and 2010. Methods: Cohort analysis of data from HIV-infected children (<15 years old) initiating ART in 4 sub-Saharan HIV programs in Kenya, Uganda and Malawi, between December 2001 and December 2010. Rates of mortality, program attrition and first-line clinico-immunological failure were calculated by age group (<2, 2-4 and 5-14 years), 1 or 2 years after ART initiation and risk factors were examined. Results: A total of 3,949 children, 22.7% aged <2 years, 32.2% 2-4 years, 45.1% aged 5-14 years, were included. At ART initiation 60.8% had clinical stage 3 or 4, and 46.5% severe immune-suppression. Overall mortality, attrition and 1-year failure rates were 5.1, 10.8 and 9.0 per 100 person-years, respectively. Immunosuppression, stage 3 or 4 and underweight were associated with increased rates of mortality, attrition and treatment failure. Adjusted estimates showed lower mortality hazard ratios (HR) among children aged 2-4 years (HR=0.57, 95%CI 0.42-0.77 compared to 5-14 years). One-year treatment failure incidence rate ratios (IRR) were similar regardless of age (IRR=0.91, 95%CI 0.67-1.25 for <2 years; 1.01, 95%CI 0.83-1.23 for 2-4 years, compared to 5-14 years). Conclusions: Good treatment outcomes were achieved during the first decade of HIV pediatric care despite the late start of therapy. Encouraging early HIV infant diagnosis in and outside prevention of mother-to-child-transmission programs, and linkage to care services for early ART initiation are needed to reduce mortality and delay treatment failure.