Attrition of HIV-exposed infants from early infant diagnosis services in low- and middle-income countries: a systematic review and meta-analysis

Abstract

Introduction: Identification and retention of HIV-exposed infants in early infant diagnosis (EID) services helps to ensure optimal health outcomes. This systematic review and meta-analysis examines the magnitude of attrition from EID services in low- and middle-income countries (LMICs).

Methods: We performed a comprehensive database search through April 2016. We included original studies reporting retention/attrition data for HIV-exposed infants in LMICs. Outcomes included loss to follow-up (LTFU), death and overall attrition (LTFU + death) at time points along the continuum of EID services. At least two authors determined study eligibility, performed data extraction and made quality assessments. We used random-effects meta-analytic methods to aggregate effect sizes and perform meta-regression analyses. This study adhered to PRISMA reporting guidelines.

Results: We identified 3040 unique studies, of which 92 met eligibility criteria and were included in the quantitative synthesis. The included studies represent data from 110,805 HIV-exposed infants, the majority of whom were from Africa (77%). LTFU definitions varied widely, and there was significant variability in outcomes across studies. The bulk of attrition occurred in the first six months of follow-up, with additional losses over time. Overall, 39% of HIV-exposed infants were no longer in care at 18 months. When restricted to non-intervention studies, 43% were not retained at 18 months.

Conclusions: These findings underscore the high attrition of HIV-exposed infants from EID services in LMICs and the urgent need for implementation research and resources to improve retention among this vulnerable population.

Keywords: HIV; attrition; infants; loss to follow-up; low- and middle-income countries; retention.

Figure 1

Flow diagram for study selection. A complete list of references included and excluded from the meta‐analysis can be found at: https://rocket.app.vumc.org/index.php?doc_id=20779.

Figure 2

Meta‐analysis results of attrition (loss to follow‐up (LTFU) or death) from HIV early infant diagnosis (EID) services in low‐ and middle‐income countries. CI, confidence interval; EZ, effect size (pooled proportion); K, number of individual cohorts (may include separate effect sizes for independent samples in a single study) in the meta‐analysis; LTFU, lost to follow up. ^†Original forest plots and meta‐analysis results are displayed in the Figures S1 to S12. ^‡K(Death only)+K(LTFU)≤K(Overall), because cohorts included in the overall may or may not specifically indicate source of attrition (see Methods). ^§I² denotes assessment of heterogeneity of the included studies/findings, using random‐effect models to aggregate effect sizes I² >25%. ^¶Chi‐square test for trend using the pooled proportion calculated based on meta‐analysis results. ^δChi‐ square test for trend using the original study‐level individual data.