22 research outputs found

    The \u27Child\u27 Remembers

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    Matthew 18:1-6

    Retention in care of HIV-infected children from HIV test to start of antiretroviral therapy: systematic review

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    BACKGROUND: In adults it is well documented that there are substantial losses to the programme between HIV testing and start of antiretroviral therapy (ART). The magnitude and reasons for loss to follow-up and death between HIV diagnosis and start of ART in children are not well defined. METHODS: We searched the PubMed and EMBASE databases for studies on children followed between HIV diagnosis and start of ART in low-income settings. We examined the proportion of children with a CD4 cell count/percentage after after being diagnosed with HIV infection, the number of treatment-eligible children starting ART and predictors of loss to programme. Data were extracted in duplicate. RESULTS: Eight studies from sub-Saharan Africa and two studies from Asia with a total of 10,741 children were included. Median age ranged from 2.2 to 6.5 years. Between 78.0 and 97.0% of HIV-infected children subsequently had a CD4 cell count/percentage measured, 63.2 to 90.7% of children with an eligibility assessment met the eligibility criteria for the particular setting and time and 39.5 to 99.4% of the eligible children started ART. Three studies reported an association between low CD4 count/percentage and ART initiation while no association was reported for gender. Only two studies reported on pre-ART mortality and found rates of 13 and 6 per 100 person-years. CONCLUSION: Most children who presented for HIV care met eligibility criteria for ART. There is an urgent need for strategies to improve the access to and retention to care of HIV-infected children in resource-limited settings

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    Do Increasing Rates of Loss to Follow-up in Antiretroviral Treatment Programs Imply Deteriorating Patient Retention?

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    In several studies of antiretroviral treatment (ART) programs for persons with human immunodeficiency virus infection, investigators have reported that there has been a higher rate of loss to follow-up (LTFU) among patients initiating ART in recent years than among patients who initiated ART during earlier time periods. This finding is frequently interpreted as reflecting deterioration of patient retention in the face of increasing patient loads. However, in this paper we demonstrate by simulation that transient gaps in follow-up could lead to bias when standard survival analysis techniques are applied. We created a simulated cohort of patients with different dates of ART initiation. Rates of ART interruption, ART resumption, and mortality were assumed to remain constant over time, but when we applied a standard definition of LTFU, the simulated probability of being classified LTFU at a particular ART duration was substantially higher in recently enrolled cohorts. This suggests that much of the apparent trend towards increased LTFU may be attributed to bias caused by transient interruptions in care. Alternative statistical techniques need to be used when analyzing predictors of LTFU-for example, using "prospective" definitions of LTFU in place of "retrospective" definitions. Similar considerations may apply when analyzing predictors of LTFU from treatment programs for other chronic diseases

    Timing of combination antiretroviral therapy (cART) initiation is not associated with stillbirth among HIV-infected pregnant women in Malawi

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    OBJECTIVE: To assess the association between timing of maternal combination ART (cART) initiation and stillbirth among HIV-infected pregnant women in Malawi's Option B+ programme. METHODS: Cohort study of HIV-infected pregnant women delivering singleton live or stillborn babies at ≥28 weeks of gestation using routine data from maternity registers between 1 January 2012 and 30 June 2015. We defined stillbirth as death of a foetus at ≥28 weeks of gestation. We report proportions of stillbirth according to timing of maternal cART initiation (before pregnancy, 1st or 2nd trimester, or 3rd trimester or labour). We used logistic regression, with robust standard errors to account for clustering of women within health facilities, to investigate the association between timing of cART initiation and stillbirth. RESULTS: Of 10 558 mother-infant pairs abstracted from registers, 8380 (79.4%) met inclusion criteria. The overall rate of stillbirth was 25 per 1000 deliveries (95% confidence interval 22-29). We found no significant association between timing of maternal cART initiation and stillbirth. In multivariable models, older maternal age, male sex of the infant, breech vaginal delivery, delivery at < 34 weeks of gestation and experience of any maternal obstetric complication were associated with higher odds of stillbirth. Deliveries managed by a mission hospital or health centre were associated with lower odds of stillbirth. CONCLUSION: Pregnant women's exposure to cART, regardless of time of its initiation, was not associated with increased odds of stillbirth

    Forest plots – time from HIV diagnosis to start of antiretroviral therapy (ART).

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    <p>A): Percentage of HIV positive children with a CD4 cell count/percentage. B): Percentage of children with an eligibility assessement who meet eligibility criteria for ART. C): Percentage of ART eligible children starting ART.</p

    Characteristics of studies included in review, first CD4 cell count measurement after HIV diagnosis and mortality rates prior to initiation of antiretroviral therapy (ART).

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    <p>n.r. not reported.</p>*<p>Immunological and clinical eligibility criteria for ART initiation were the following:</p><p></p><p></p><p>WHO 2003 guidelines <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0056446#pone.0056446-World4" target="_blank">[33]</a>: all children if WHO paediatric stage III.</p><p>WHO paediatric stage I (only when CD4 count available) or paediatric stage II:</p><p><18 months: CD4 percentage <20%.</p><p>≥18 months: CD4 percentage <15%.</p><p></p><p></p><p>WHO 2006 guidelines <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0056446#pone.0056446-World2" target="_blank">[20]</a>: all children if WHO stage 3 or 4 (there are specific rules for WHO stage 3 in case of co-infections).</p><p>WHO stage 1 or 2 (total lymphocyte counts are used in sites where CD4 values cannot be determined):</p><p><1 year: CD4 percentage <25% or absolute CD4 cell count <1500 cells/µl.</p><p>1 to <3 years: CD4 percentage <20% or absolute CD4 cell count <750 cells/µl.</p><p>3 to <5 years: CD4 percentage <15% or absolute CD4 cell count <350 cells/µl.</p><p>≥5 years: CD4 percentage <15% or absolute CD4 cell count <200 cells/µl.</p><p></p><p></p><p>• WHO 2010 guidelines <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0056446#pone.0056446-World3" target="_blank">[21]</a>: all children if <2 years or in WHO stage 3 or 4.</p><p>WHO stage 1 or 2:</p><p>2 to <5 years: CD4 percentage ≤25% or absolute CD4 cell count ≤750 cells/µl.</p><p>≥5 years: ≤350 cells/µl.</p><p></p><p></p><p></p><p>WHO 2003 guidelines <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0056446#pone.0056446-World4" target="_blank">[33]</a>: all children if WHO paediatric stage III.</p><p>WHO paediatric stage I (only when CD4 count available) or paediatric stage II:</p><p><18 months: CD4 percentage <20%.</p><p>≥18 months: CD4 percentage <15%.</p><p>WHO 2006 guidelines <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0056446#pone.0056446-World2" target="_blank">[20]</a>: all children if WHO stage 3 or 4 (there are specific rules for WHO stage 3 in case of co-infections).</p><p>WHO stage 1 or 2 (total lymphocyte counts are used in sites where CD4 values cannot be determined):</p><p><1 year: CD4 percentage <25% or absolute CD4 cell count <1500 cells/µl.</p><p>1 to <3 years: CD4 percentage <20% or absolute CD4 cell count <750 cells/µl.</p><p>3 to <5 years: CD4 percentage <15% or absolute CD4 cell count <350 cells/µl.</p><p>≥5 years: CD4 percentage <15% or absolute CD4 cell count <200 cells/µl.</p><p>• WHO 2010 guidelines <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0056446#pone.0056446-World3" target="_blank">[21]</a>: all children if <2 years or in WHO stage 3 or 4.</p><p>WHO stage 1 or 2:</p><p>2 to <5 years: CD4 percentage ≤25% or absolute CD4 cell count ≤750 cells/µl.</p><p>≥5 years: ≤350 cells/µl.</p>**<p>Absolute CD4 count A, percentage CD4 P.</p>***<p>Of 162 HIV exposed children, all 24 children who were diagnosed HIV positive were included.</p

    Identification and selection of studies.

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    <p>ART: Antiretroviral therapy; RCT: Randomized controlled trial; PMTCT: Prevention of mother to child transmission.</p

    Comparison of different systematic reviews about linkage to care in adults and children.

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    *<p>Percentages with 95% confidence intervals are shown if not stated otherwise</p><p># Rosen: staged and referred for ART or pre-ART care</p><p>Mugglin: Provided CD4 sample irrespective or referral to ART or pre-ART care</p
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