Predictors of loss to follow-up after engagement in care of HIV-infected children ineligible for antiretroviral therapy in an HIV cohort study in India

Abstract

Introduction: Previous studies performed in low- and middle-income countries have shown that nearly half of HIV-infected adults not eligible for antiretroviral therapy (ART) at the time of enrolment in care are lost to follow-up (LTFU). However, data about the attrition from enrolment in care to ART eligibility of HIV-infected children are scarce, especially outside sub-Saharan Africa.

Methods: This is a retrospective study about the attrition before ART eligibility of 282 children ineligible for ART at enrolment in care in a cohort study in India. Multivariate analysis was performed using competing risk regression.

Results: During 5695 child-months of follow-up, three children died, 36 were LTFU and 144 became ART eligible. The cumulative incidence of attrition (mortality and LTFU) was 15.6% (95% confidence interval [CI], 11.3-20.5) at five years, and the attrition rate was higher during the first year after enrolment in care. The cumulative incidence of LTFU and mortality was 14.4% (95% CI, 10.2-19.2) and 1.2% (95% CI, 0.3-3.3) at five years, respectively. Children with a 12-month AIDS risk <3% had a higher risk of LTFU (subdistribution hazard ratio [SHR] 10.77, 95% CI 1.93-60.07) than those with a risk >4%. Those children whose father had died had a lower risk of LTFU (SHR 0.26, 95% CI 0.09-0.75) than those whose parents were alive and were living in a rented house. Children aged 10-14 had a lower risk of LTFU (SHR 0.12, 95% CI 0.03-0.55) than those aged 5-9 years.

Conclusion: In our setting, a substantial proportion of children ineligible for ART are lost to follow-up before ART eligibility, especially those with younger age, less severe immunosuppression or living with parents in poor socio-economic conditions. These findings can be used by HIV programmes to design interventions aimed at reducing the attrition of pre-ART care of HIV-infected children in India.

Keywords: HIV; India; antiretroviral therapy; eligibility determination; lost to follow-up; mortality; pediatrics; rural.

Conflict of interest statement

Conflicts of interest: The authors have declared no conflicts of interests.

Figures

Figure 1.. Stacked graph describing the cumulative incidence of antiretroviral therapy (ART) eligibility and loss to follow-up (LTFU) in 282 ART ineligible children in Anantapur, India.