Retention of HIV-infected and HIV-exposed children in a comprehensive HIV clinical care programme in Western Kenya.

Paediatric treatment

Retention of HIV-infected and HIV-exposed children in a comprehensive HIV clinical care programme in Western Kenya.

The aim of the study is to describe incidence rates and risk factors for loss-to-follow-up among HIV-infected and HIV-exposed children in a large HIV treatment programme in Western Kenya. The USAID-AMPATH Partnership has enrolled >100 000 patients (20% children) at 23 clinic sites throughout western Kenya. Loss-to-follow-up is defined as being absent from the clinic for >3 months if on combination antiretroviral treatment and >6 months if not. Included in this analysis were children aged <14>3106 children who at enrolment were HIV infected and 10 404 children who were HIV exposed. The overall incidence rate of loss-to-follow-up was 18.4 (17.8-18.9) per 100 child-years. Among HIV-infected children, 15.2 (13.8-16.7) and 14.1 (13.1-15.8) per 100 CY became lost-to-follow-up, pre- and post- antiretroviral therapy initiation, respectively. The only independent risk factor for becoming lost-to-follow-up among the HIV-infected children was severe immune suppression (AHR: 2.17, 95% CI: 1.51-3.12). Among the HIV-exposed children, 20.1 per 100 (19.4-20.7) became lost-to-follow-up. Independent risk factors for loss-to-follow-up among them were being severely low weight for height (AHR: 1.69, 95% CI: 1.25-2.28), being orphaned at enrolment (AHR: 1.57, 95% CI: 1.23-1.64), being CDC Class B or C (AHR: 1.41, 95% CI: 1.14-1.74), and having received combination antiretroviral therapy (AHR: 1.56, 95% CI: 1.23-1.99). Protective against becoming lost-to-follow-up among the HIV exposed were testing HIV positive (AHR: 0.26, 95% CI: 0.21-0.32), older age (AHR: 0.90, 95% CI: 0.85-0.96), enrolling in later time periods, and receiving food supplementation (AHR: 0.58, 95% CI: 0.32-1.04). There is a high rate of loss-to-follow-up among these highly vulnerable children, particularly among the HIV exposed. These data suggest that HIV-infected and HIV-exposed children are at especially high risk for loss-to-follow-up if they are sick or malnourished.

The findings from this study of a large, geographically and ethnically diverse population observed over years likely have application for other populations of HIV-affected children in East Africa. About 50% of adults lost-to-follow-up are deceased and the associations seen here for loss-to-follow-up of HIV–exposed children (severely low weight for height, advanced clinical disease, and severe immunosuppression) suggest that mortality is an important cause of disappearance from the clinic. With priority being given to retention of children with HIV infection who are on antiretroviral treatment (to prevent disease progression and drug resistance) followed by children with HIV infection not yet eligible for treatment (to provide prophylaxis and timely initiation of antiretroviral treatment), it is perhaps not surprising that HIV-exposed children have the highest rates of loss-to-follow-up. The findings suggest that food supplementation for HIV-exposed children could reduce loss-to-follow-up, both by improving nutritional status and by acting as an incentive to continue in care pending an HIV diagnosis. In the end, those taking care of children ultimately decide whether to take a child to the clinic. Qualitative studies to determine the factors influencing their decisions would inform changes in clinical services aimed at reducing loss-to-follow-up