Mortality in Children with Human Immunodeficiency Virus Initiating Treatment: A Six-Cohort Study in Latin America

Abstract

Objectives: To assess the risks of and factors associated with mortality, loss to follow-up, and changing regimens after children with HIV infected perinatally initiate combination antiretroviral therapy (cART) in Latin America and the Caribbean.

Study design: This 1997-2013 retrospective cohort study included 1174 antiretroviral therapy-naïve, perinatally infected children who started cART age when they were younger than 18 years of age (median 4.7 years; IQR 1.7-8.8) at 1 of 6 cohorts from Argentina, Brazil, Haiti, and Honduras, within the Caribbean, Central and South America Network for HIV Epidemiology. Median follow-up was 5.6 years (IQR 2.3-9.3). Study outcomes were all-cause mortality, loss to follow-up, and major changes in cART. We used Cox proportional hazards models stratified by site to examine the association between predictors and times to death or changing regimens.

Results: Only 52% started cART at younger than 5 years of age; 19% began a protease inhibitor. At cART initiation, median CD4 count was 472 cells/mm³ (IQR 201-902); median CD4% was 16% (IQR 10-23). Probability of death was high in the first year of cART: 0.06 (95% CI 0.04-0.07). Five years after cART initiation, the cumulative mortality incidence was 0.12 (95% CI 0.10-0.14). Cumulative incidences for loss to follow-up and regimen change after 5 years were 0.16 (95% 0.14-0.18) and 0.30 (95% 0.26-0.34), respectively. Younger children had the greatest risk of mortality, whereas older children had the greatest risk of being lost to follow-up or changing regimens.

Conclusions: Innovative clinical and community approaches are needed for quality improvement in the pediatric care of HIV in the Americas.

Keywords: HIV/AIDS; infectious diseases.

Figure 1

Estimated cumulative incidence (and 95% confidence intervals) for mortality, loss to follow-up, and regimen change after cART initiation.

Figure 2

Predicted probability of mortality, loss to follow-up, and regimen change 5 years after cART initiation based on age at cART initiation. For these predictions, all other covariates are set at their medians/modes (i.e., female sex, CD4 of 472 cells/mm³, year of cART 2005, first regimen class not PI-based, not having clinical AIDS at baseline, and study site as GHESKIO-Haiti). Pointwise 95% confidence intervals are illustrated with dashed curves.

Figure 3

(online). Median age at cART initiation by year of cART initiation overall and by site. Dot size is proportional to the number of patient starting cART in a given year.