Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
Empilweni Service and Research Centre, Rahima Moosa Mother and Child Hospital, University of Witwatersrand, Johannesburg, South Africa.
Lancet HIV. 2021 Jun;8(6):e353-e362. doi: 10.1016/S2352-3018(21)00004-7. Epub 2021 Apr 28.
The proportion of children living with HIV and receiving antiretroviral therapy (ART) in sub-Saharan Africa has increased greatly since 2006, yet the changes in their demographic characteristics and treatment outcomes have not been well described. We examine the trends in characteristics and outcomes of children living with HIV who were younger than 5 years at ART initiation, and compare outcomes over time and across country income groups.
We conducted a retrospective cohort analysis of data from children living with HIV who were younger than 5 years at ART initiation from 45 paediatric sites in 16 low-income, lower-middle-income, and upper-middle-income countries in sub-Saharan Africa (Benin, Burundi, Côte d'Ivoire, Democratic Republic of the Congo, Ghana, Kenya, Lesotho, Malawi, Mali, Mozambique, Rwanda, South Africa, Togo, Uganda, Zambia, and Zimbabwe). Outcomes were trends in patient characteristics at ART initiation (age, weight, height, and CD4%), and comparisons of mortality and loss to follow-up during ART over time and in various economic settings. We identified risk factors for mortality using Cox proportional hazards models. Each participating region had relevant institutional ethics review board approvals to contribute data to the analysis.
We included 32 221 children living with HIV and initiating ART younger than 5 years between Jan 1, 2006, and Dec 31, 2017. Median age at ART initiation was 20·4 months (IQR 9·4-36·0) in 2006-10, 19·2 months (8·3-33·6) in 2011-13, and 19·2 months (8·8-33·7) in 2014-17. Median age at ART initiation was 13·2 months (IQR 4·7-26·8) in upper-middle-income countries, 22·6 months (13·2-37·5) in lower-middle-income countries and 24·2 months (13·5-39·1) in low-income countries. The proportion of children initiating ART younger than 3 months increased from 770 (5·1%) of 14 943 children in 2006-10 to 728 (10·0%) of 7290 children in 2014-17. The proportion of children initiating ART with severe immunosuppression decreased from 5469 (74·7%) of 7314 children for whom CD4% data were available in 2006-10 to 2353 (55·2%) of 4269 children in 2014-17. Mortality at 24 months on ART decreased from 970 (6·5%) of 14 943 children in 2006-10 to 214 (2·9%) of 7290 children in 2014-17. Loss to follow-up was 20·5% (95% CI 20·1-21·0) overall, and was similar across time periods. In multivariable analysis, lower mortality was observed for more recent ART initiation cohorts (adjusted hazard ratio 0·70, 95% CI 0·63-0·79 for 2011-13; 0·53, 0·45-0·72 for 2014-17 vs 2006-10) and for those residing in an upper-middle-income country (0·42, 0·35-0·49 vs low-income countries).
Mortality declined significantly after universal ART recommendations for children younger than 2 years in 2010 and children younger than 5 years in 2013. However, substantial variations persisted across country income groups, and one in five children continue to be lost to follow-up. Targeted interventions are required to improve outcomes of children living with HIV, especially in the poorest countries.
National Institute of Allergy and Infectious Disease.
自 2006 年以来，撒哈拉以南非洲地区接受抗逆转录病毒治疗（ART）的儿童中 HIV 感染者的比例大幅增加，但他们的人口统计学特征和治疗结果的变化尚未得到很好的描述。我们研究了在开始接受 ART 时年龄小于 5 岁的 HIV 儿童的特征和治疗结果的变化趋势，并比较了不同时间段和国家收入组之间的结果。
我们对来自撒哈拉以南非洲 16 个低收入、中低收入和中高收入国家的 45 个儿科地点的开始接受 ART 时年龄小于 5 岁的 HIV 儿童进行了回顾性队列分析。（贝宁、布隆迪、科特迪瓦、刚果民主共和国、加纳、肯尼亚、莱索托、马拉维、马里、莫桑比克、卢旺达、南非、多哥、乌干达、赞比亚和津巴布韦）。结果是在开始接受 ART 时患者特征的趋势（年龄、体重、身高和 CD4%），以及不同经济环境下 ART 期间的死亡率和失访率的比较。我们使用 Cox 比例风险模型确定了死亡率的危险因素。每个参与地区都有相关的机构伦理审查委员会批准向分析提供数据。
我们纳入了 2006 年 1 月 1 日至 2017 年 12 月 31 日期间开始接受 ART 时年龄小于 5 岁的 32221 名 HIV 儿童。2006-10 年期间开始接受 ART 的中位数年龄为 20.4 个月（9.4-36.0），2011-13 年为 19.2 个月（8.3-33.6），2014-17 年为 19.2 个月（8.8-33.7）。中高收入国家的中位数年龄为 13.2 个月（4.7-26.8），中低收入国家为 22.6 个月（13.2-37.5），低收入国家为 24.2 个月（13.5-39.1）。从 2006-10 年的 14943 名儿童中 770 名（5.1%）开始接受 ART 的儿童中，到 2014-17 年的 7290 名儿童中 728 名（10.0%）开始接受 ART 的比例有所增加。严重免疫抑制开始接受 ART 的儿童比例从 2006-10 年有 CD4%数据的 7314 名儿童中的 5469 名（74.7%）下降到 2014-17 年的 4269 名儿童中的 2353 名（55.2%）。24 个月时 ART 死亡率从 2006-10 年的 14943 名儿童中的 970 名（6.5%）下降到 2014-17 年的 7290 名儿童中的 214 名（2.9%）。失访率为 20.5%（95%CI 20.1-21.0），在不同时间段内相似。多变量分析显示，最近开始接受 ART 的队列死亡率较低（2011-13 年的调整危险比为 0.70，95%CI 为 0.63-0.79；2014-17 年的 0.53，0.45-0.72 vs 2006-10 年），居住在中高收入国家的死亡率也较低（0.42，0.35-0.49 vs 低收入国家）。
2010 年普遍建议 2 岁以下儿童和 2013 年 5 岁以下儿童开始接受抗逆转录病毒治疗后，死亡率显著下降。然而，各国之间仍存在很大差异，五分之一的儿童继续失访。需要有针对性的干预措施来改善 HIV 儿童的治疗结果，特别是在最贫穷的国家。
国家过敏和传染病研究所。
