High retention among HIV-infected children in Rwanda during scale-up and decentralization of HIV care and treatment programs, 2004 to 2010.
High retention among HIV-infected children in Rwanda during scale-up and decentralization of HIV care and treatment programs, 2004 to 2010.
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DOI：
10.1097/inf.0b013e31828c2744
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发表时间：
2013-08
期刊：
影响因子：
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通讯作者：
Abrams EJ
中科院分区：
文献类型：
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作者：
Tene G;Lahuerta M;Teasdale C;Mugisha V;Kayonde L;Muhayimpundu R;Nyemazi JP;Vandebriel G;Nsanzimana S;Sahabo R;Twyman P;Abrams EJ
在高负担国家扩大艾滋病毒治疗的努力，扩大了获得护理的机会，提高了受艾滋病毒感染儿童的存活率，降低了发病率。卢旺达在扩大儿科艾滋病毒服务覆盖面方面取得了重大成就。我们描述了2004年至2010年卢旺达各地39家ICAP支持的机构中接受艾滋病毒护理的儿童（<15岁）的死亡率和失访（LTF）的程度和相关因素，按抗逆转录病毒治疗（ART）状态分类。我们估计了所有参加治疗的儿童（ART前）和接受ART的儿童的1年累积死亡率和LTF发生率。生存分析用于评估两组中与死亡和LTF相关的因素。2004年1月至2010年6月期间，有3 244名中位年龄为5.7岁（四分位数间距2.8-9.6）的儿童参加了艾滋病毒护理。ART前儿童的死亡和LTF的一年累积发生率分别为4%（95%置信区间[CI]：3-5%）和5%（95% CI：4-6%）。总体而言，2035例（63%）儿童开始ART治疗，中位年龄6.3岁（四分位数范围3.3-10.4）：1年Kaplan-Meier估计的死亡率和LTF分别为3%（95% CI：3-4%）和1%（95% CI：1-2%）。与ART前儿童死亡风险增加相关的因素包括年龄<18个月与≥5岁（调整的亚风险比[aSHR] = 4.4，95% CI：2.9-6.8）和世界卫生组织IV期与I期（aSHR = 4.1，95% CI：2.0-8.4），而通过预防母婴传播进入护理的儿童比自愿咨询和检测的儿童的风险低（aSHR = 0.50，95% CI：0.25-1.0）。晚期疾病的标志物，包括严重的免疫抑制（aSHR = 0.25，95% CI：0.12-0.54），以及在农村与城市诊所的护理登记（aSHR = 0.71，95% CI：0.53-0.97）对LTF具有保护作用。对于接受抗逆转录病毒治疗的儿童，与死亡风险相关的因素包括年龄较小（校正后风险比[aHR] <18个月vs ≥5年= 2.1，95% CI：1.3-3.6），重度营养不良vs非营养不良（aHR = 3.2，95% CI：1.3-8.1），世界卫生组织晚期（aHR IV vs I = 9.8，95% CI：3.5-27.4）和重度免疫缺陷vs无证据（aHR = 2.3，95% CI：1.7-3.3）。在接受抗逆转录病毒治疗的儿童中，没有观察到与长期信托基金相关的情况。结果表明，卢旺达接受艾滋病毒护理的儿童中，长期信托基金的保留率非常高。年龄较小的儿童仍然特别容易受到伤害，这突出表明迫切需要及早发现、迅速开始治疗和长期接受照料。
Efforts to scale-up HIV treatment in high burden countries have resulted in wider access to care, improved survival and decreased morbidity for HIV-infected children. The country of Rwanda has made significant achievements in expanding coverage of pediatric HIV services. We describe the extent of and factors associated with mortality and lost to follow-up (LTF) in children (<15 years) enrolled in HIV care at 39 ICAP-supported facilities across Rwanda from 2004 to 2010 by antiretroviral treatment (ART) status. We estimated the 1-year cumulative incidence of death and LTF among all children enrolled in care (pre-ART) and children on ART. Survival analysis was used to evaluate factors associated with death and LTF in both groups. Between January 2004 and June 2010, 3244 children with a median age of 5.7 years (interquartile range 2.8–9.6) enrolled in HIV care. One-year cumulative incidence for death and LTF among pre-ART children was 4% (95% confidence interval [CI]: 3–5%) and 5% (95% CI: 4–6%), respectively. Overall, 2035 (63%) children initiated ART, median age 6.3 years (interquartile range 3.3–10.4): 1-year Kaplan–Meier estimates of death and LTF were 3% (95% CI: 3–4%) and 1% (95% CI: 1–2%), respectively. Factors associated with an increased hazard for death among pre-ART children included being <18 months old versus ≥5 years (adjusted sub hazard ratio [aSHR] = 4.4, 95% CI: 2.9–6.8) and World Health Organization stage IV versus I (aSHR = 4.1, 95% CI: 2.0–8.4), whereas children entering care through prevention of mother-to-child transmission had lower hazard than those from voluntary counseling and testing (aSHR = 0.50, 95% CI: 0.25–1.0). Markers of advanced disease, including severe immunosuppression (aSHR = 0.25, 95% CI: 0.12–0.54), and enrollment in care in rural versus urban clinics (aSHR = 0.71, 95% CI: 0.53–0.97) were protective against LTF. For children on ART, factors associated with hazard of death included younger age (adjusted hazard ratio [aHR] <18 months versus ≥5 years = 2.1, 95% CI: 1.3–3.6), severe malnutrition versus not malnourished (aHR = 3.2, 95% CI: 1.3–8.1), advanced World Health Organization stage (aHR IV versus I = 9.8, 95% CI: 3.5–27.4) and severe immunodeficiency versus no evidence (aHR = 2.3, 95% CI: 1.7–3.3). No associations were observed with LTF among children on ART. The results demonstrate very high retention among children enrolled in HIV care in Rwanda. Younger children continue to be particularly vulnerable, underscoring the urgent need for early identification, rapid treatment initiation and long-term retention in care.