Retention in care of HIV-infected children from HIV test to start of antiretroviral therapy: systematic review

Abstract

Background: In adults it is well documented that there are substantial losses to the programme between HIV testing and start of antiretroviral therapy (ART). The magnitude and reasons for loss to follow-up and death between HIV diagnosis and start of ART in children are not well defined.

Methods: We searched the PubMed and EMBASE databases for studies on children followed between HIV diagnosis and start of ART in low-income settings. We examined the proportion of children with a CD4 cell count/percentage after after being diagnosed with HIV infection, the number of treatment-eligible children starting ART and predictors of loss to programme. Data were extracted in duplicate.

Results: Eight studies from sub-Saharan Africa and two studies from Asia with a total of 10,741 children were included. Median age ranged from 2.2 to 6.5 years. Between 78.0 and 97.0% of HIV-infected children subsequently had a CD4 cell count/percentage measured, 63.2 to 90.7% of children with an eligibility assessment met the eligibility criteria for the particular setting and time and 39.5 to 99.4% of the eligible children started ART. Three studies reported an association between low CD4 count/percentage and ART initiation while no association was reported for gender. Only two studies reported on pre-ART mortality and found rates of 13 and 6 per 100 person-years.

Conclusion: Most children who presented for HIV care met eligibility criteria for ART. There is an urgent need for strategies to improve the access to and retention to care of HIV-infected children in resource-limited settings.

Figure 1. Identification and selection of studies.

ART: Antiretroviral therapy; RCT: Randomized controlled trial; PMTCT: Prevention of mother to child transmission.

Figure 2. Forest plots – time from HIV diagnosis to start of antiretroviral therapy (ART).

A): Percentage of HIV positive children with a CD4 cell count/percentage. B): Percentage of children with an eligibility assessement who meet eligibility criteria for ART. C): Percentage of ART eligible children starting ART.