Earlier ART reduces infant mortality in South Africa but risk of death and loss to follow up still high

Infants are starting ART earlier, with less disease progression and declines in mortality according to findings from the IeDEA-SA collaboration. But mortality and loss to follow up among infants starting ART remains unacceptably high.

Over the past few years there has been a significant expansion of universal ART for HIV positive children less than five years old. WHO recommendations have expanded the eligibility to ‘treat all’ in this age group – from only those less than one year in 2008, to all children less than five years old in 2013.

There has also been a shift towards early infant diagnosis (EID) and early infant ART (EIART) but little is known about the outcomes of children starting ART in the context of changing paediatric HIV testing and treatment guidelines.

Investigators from the IeDEA-SA showed results from an evaluation conducted to describe temporal trends in characteristics of infants starting ART in South Africa and six month outcomes. These data were presented at IAS 2017.

The analysis included infants starting ART less at less than three months old and described characteristics and outcomes over three guideline periods: 2006–2009, 2010–2012 and 2013 and after.

The median age at ART initiation of 1380 eligible infants was 56 days (IQR: 27 to 73). Median log viral load at ART initiation declined from 5.9 (IQR 5.4–6.4) in 2006–2009 to 5.4 (IQR: 3.9 to 6.3) in 2013+. Median absolute CD4 count increased progressively from 888 cells/mm³ (IQR: 380 to 1703) in 2006–2009 to 1526 (IQR: 659 to 2231) in 2013+, (both p<0.001).

After six months on ART, 78 (5.7%) children died overall. Mortality declined from 9.7% in 2006–2009 to 4.8% in 2013+ (p<0.001). Loss to follow up was 225 (17.6%) overall, declining from 22.4% in 2006–2009 to 14.4% in 2013+ (p=0.004).

Among the children lost to follow up, 72% had no visit after starting ART and 28% after at least one subsequent visit on ART.

In multivariate analysis, neither age, CD4 count, weight for age z-score nor ART initiation period were predictors for mortality.

The investigators concluded that children are starting ART earlier, with less advanced disease and decline in mortality. But about 40% still start ART with advanced disease and mortality estimates remain unacceptably high. Loss to follow up also remains high overall.

“Innovative approaches are required to ensure HIV infected infants have optimal treatment outcomes”, the investigators wrote.

Iyun V et al. Earlier treatment and lower mortality in infants initiating antiretroviral therapy at < 12 weeks of age in South Africa: The International epidemiologic Databases to Evaluate AIDS Southern Africa (IeDEA-SA) Collaboration. 9th IAS Conference on HIV Science. 23–26 July 2017. Paris. Poster abstractTUPDB0206LB
http://programme.ias2017.org/Abstract/Abstract/5641 (abstract)