TUPE373 - Poster Exhibition
Trends in pediatric characteristics at antiretroviral therapy (ART) initiation, and retention on ART in Swaziland, 2004-2010
C. Azih1, H. Nuwagaba-Biribonwoha2, H. Kamiru3, A.F. Auld4, D. Baughman4, L. Gonzalez3, S. Agolory4, G. Bicego4, P. Ehrenkranz5, V. Okello1
1Swaziland National AIDS Program, Ministry of Health, Government of the Kingdom of Swaziland, Mbabane, Swaziland, 2ICAP, Columbia University, New York, United States, 3ICAP, Columbia University, Mailman School of Public Health, New York, United States, 4United States Centers for Disease Control, Atlanta, United States, 5United States Centers for Disease Control, Mbabane, Swaziland
Background: Swaziland''s national antiretroviral therapy
(ART) program was initiated in 2004. Adults and children initiated ART
according to World Health Organization (WHO) guidelines, and, when stable (ART adherent
and clinically well), were down-referred to lower-level health facilities for
Methods: A retrospective cohort
study to assess attrition (documented death, stopping ART, loss-to-follow-up, LTFU
defined as no clinic visit in >90 days) was conducted among a nationally
representative sample of children initiating ART during 2004-2010. 12/28 clinics initiating children
< 15 years(y) on ART were selected using probability-proportional-to-size
sampling; medical records were randomly selected for abstraction. Changes in characteristics at ART initiation
were assessed using trend tests. Adjusted
hazard ratios, AHRs (95% Confidence Intervals) for attrition were estimated
using Cox proportional hazards regression models adjusted for multistage
sampling and study design.
Results: Among 2,008 pediatric ART
enrollees, 30% were < 2y, 20% 2-4y, 32% 5-9y and 18% 10-14y. During 2004-2010,
the proportion of ART enrollees < 2y increased from 8% to 34%; the proportion
with WHO stage III/IV declined from 90% to 61%; and among children >5y at ART
initiation, median CD4+ count increased from 199(IQR
56-273) to 267(IQR 148-369) cells/ µL. Ten percent of the children who initiated ART were down-referred.
At 24 months after ART
initiation, 78% remained on ART, 5% had died, and 16% were LTFU, trends over
time were not statistically significant.
In a complete-case multivariable
analysis, attrition did not change with year of ART initiation.
Compared with children 0-2y, children 10-14y had lower attrition: AHR 0.34(0.22-0.53).
Compared with children starting ART at WHO stage I/II, children with WHO stage
IV had higher attrition: AHR 1.66(1.13-2.45).
For every one-unit increase in weight-for-age z-score, risk of attrition
decreased 13%: AHR 0.87(0.82-0.92).
Down-referral after ART initiation was protective against attrition in
univariate analysis: AHR 0.43(0.23-0.82), but not in multivariable analysis: AHR
Conclusions: Over the evaluation period, more
children initiated ART at a younger age and with less advanced HIV disease. The
lower attrition observed among down-referred children is probably due to selection
of children with fewer risk factors for attrition, but could be a viable
strategy for optimizing retention.
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