Scaling up antiretroviral therapy for HIV-infected children in Cote d'Ivoire: determinants of survival and loss to programme

Objective To investigate deaths and losses to follow-up in a programme designed to scale up antiretroviral therapy (ART) for HIV-infected children in Cote d'Ivoire. Methods Between 2004 and 2007, HIV-exposed children at 19 centres were offered free HIV serum tests (polymerase chain reaction tests in those aged <18 months) and ART. Computerized monitoring was used to determine: (i) the number of confirmed HIV infections, (ii) losses to the programme (i.e. death or loss to follow-up) before ART, (iii) mortality and loss-to-programme rates during 12 months of ART, and (iv) determinants of mortality and losses to the programme. Findings The analysis included 3876 ART-nave children. Of the 1766 with HIV-1 infections (17% aged <18 months), 124 (7.0%) died, 52 (2.9%) left the programme, 354 (20%) were lost to follow-up before ART, 259 (15%) remained in care without ART, and 977 (55%) started ART (median age: 63 months). The overall mortality rate during ART was significantly higher in the first 3 months than in months 4-12: 32.8 and 6.9 per 100 child-years of follow-up, respectively. Loss-to-programme rates were roughly double mortality rates and followed the same trend with duration' of ART. Independent predictors of 12-month mortality on ART were pre-ART weightfor-age z-score <-2, percentage of CD4+ T lymphocytes <10, World Health Organization HIV/AIDS clinical stage 3 or 4, and blood haemoglobin <8 g/dl. Conclusion The large-scale programme to scale up paediatric ART in Cote d'Ivoire was effective. However, ART in/as often given too late, and early mortality and losses to programme before and just after ART initiation were major problems.