Predictors of loss to follow-up in children receiving antiretroviral treatment in Johannesburg, South Africa
Date
2012-01-17
Authors
Sengayi, Mazvita Molleen
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Abstract
Introduction
Ninety percent of the world’s 2.1 million HIV-infected children live in sub-Saharan Africa and 2.5% of South African children are living with HIV. As HIV care programmes scale-up, loss to follow-up is on the rise.
The aim of the study was to determine the rate of loss to follow-up (LTFU) in children receiving antiretroviral treatment and to identify baseline characteristics associated with LTFU and temporary interruption of follow-up (TIFU) in these children. The reasons given by caregivers for clinic non-attendance were also explored.
Materials and Methods
The study is a retrospective analysis of data that was prospectively collected as part of routine clinical care of HIV-infected children at the Harriet Shezi Children’s Clinic in Soweto, Johannesburg. Children aged 12 years or less that had initiated highly active antiretroviral therapy (HAART) at the clinic between 1 April 2004 and 31 December 2008 and had been on treatment for at least 3 months, were included in the study. Follow-up was censored on 30 September 2009. Kaplan-Meier methods were used to estimate time to LTFU or TIFU. Cox proportional hazards models were fitted to investigate associations between baseline characteristics and LTFU as well as TIFU. Pie charts and frequency tables were used to describe reasons for clinic non-attendance.
Results
Of the 2536 children included in the study, 174 (6.86%) were LTFU at the end the study period. The cumulative probabilities of LTFU at 6 months, 12 months and 2 years were found to be 0.9% (95% CI 0.67 – 1.47), 2.85% (95% CI 2.26 – 3.59) and 5.22% (95% CI 4.36 – 6.25) respectively. Independent predictors of LTFU were WHO clinical stage 3 or 4 [HR 2.14 (95% CI 1.22 – 3.73) p=0.026] and younger age [HR 0.91 (95% CI 0.84 – 0.99) p=0.008] the hazard of LTFU decreasing by 9% for every 1 year increase in age. A total of 338(13.32%) children interrupted follow-up for at least 6months before returning to care. Factors independently associated with TIFU were taking a protease inhibitor based regimen [HR 1.67 (95% CI 1.18 – 2.35) p=0.004] and being moderately underweight [HR 0.66 (95% CI 0.45 – 0.99) p=0.043] was protective. Social reasons (46.43%) and financial reasons (10.05%) together accounted for the majority of reasons given for clinic non-attendance. Caregiver-related problems (53.22%) were the commonest social reasons given for missing a clinic visit.
Conclusions
These LTFU rates are much lower than those found in studies where children on HAART duration of less than 3 months were included and may reflect on true LTFU with minimal effect of unreported early mortality. WHO clinical stage 3 or 4 and younger age independently predicted LTFU. Independent predictors of TIFU were moderate underweight and being on a PI-based regimen. LTFU is not necessarily permanent with most of those who interrupt follow-up returning to care. The main reasons why children miss clinic appointments are social. Caregiver-related problems are important reasons for clinic non-attendance in children on HAART.
Recommendations
Initiating children on HAART in earlier disease stages may reduce LTFU. Strategies to improve LTFU need to target younger children and there is need for further research to investigate why young children are especially vulnerable to LTFU. Caregivers of children who temporarily interrupt follow-up can potentially provide a unique opportunity for health workers to learn the true reasons why children get LTFU. Such caregivers may also be targeted for more intensive adherence counselling. Further studies on the implications of TIFU on the development of resistance to antiretroviral drugs are needed. Primary caregivers of children need to be encouraged to identify secondary caregivers who can bring the child to the clinic in the event that the primary caregiver is unable to bring the child.