High risk of death among adolescents while awaiting ART

Risk of death among those awaiting treatment for HIV infection in Zimbabwe: adolescents are at particular risk.

Shroufi A, Ndebele W, Nyathi M, Gunguwo H, Dixon M, Saint-Sauveur JF, Taziwa F, Vinoles MC, Ferrand RA. J Int AIDS Soc. 2015 Feb 23;18(1):19247. doi: 10.7448/IAS.18.1.19247. eCollection 2015.

Introduction: Mortality among HIV-positive adults awaiting antiretroviral therapy (ART) has previously been found to be high. Here, we compare adolescent pre-ART mortality to that of adults in a public sector HIV care programme in Bulawayo, Zimbabwe.

Methods: In this retrospective cohort study, we compared adolescent pre-ART outcomes with those of adults enrolled for HIV care in the same clinic. Adolescents were defined as those aged 10-19 at the time of registration. Comparisons of means and proportions were carried out using two-tailed sample t-tests and chi-square tests respectively, for normally distributed data, and the Mann-Whitney U-tests for non-normally distributed data. Loss to follow-up (LTFU) was defined as missing a scheduled appointment by three or more months.

Results: Between 2004 and 2010, 1382 of 1628 adolescents and 7557 of 11 106 adults who registered for HIV care met the eligibility criteria for ART. Adolescents registered at a more advanced disease stage than did adults (83% vs. 73% WHO stage III/IV, respectively, p<0.001), and the median time to ART initiation was longer for adolescents than for adults [21 (10-55) days vs. 15 (7-42) days, p<0.001]. Among the 138 adolescents and 942 adults who never commenced ART, 39 (28%) of adolescents and 135 (14%) of adults died, the remainder being LTFU. Mortality among treatment-eligible adolescents awaiting ART was significantly higher than among adults (3% vs. 1.8%, respectively, p=0.004).

Conclusions: Adolescents present to ART services at a later clinical stage than adults and are at an increased risk of death prior to commencing ART. Improved and innovative HIV case-finding approaches and emphasis on prompt ART initiation in adolescents are urgently needed. Following registration, defaulter tracing should be used, whether or not ART has been commenced.

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Editor’s notes: In this article the pre-antiretroviral therapy (ART) outcomes of adolescents (persons between 10 and 19 years) registered in a well-established ART programme in Zimbabwe between 2004 and 2010 are compared to those of adults. The authors found that adolescents living with HIV experience a higher risk of death while awaiting ART initiation. This is most likely due to the more advanced stage of HIV infection at the time of registration. Most adolescents in this study had acquired HIV at birth and underwent HIV testing following an HIV-associated illness. Treatment-eligible adolescents also waited significantly longer than adults to initiate ART. Under-preparedness to start ART, and reduced access to transport among adolescents were cited as possible reasons for this delay. The authors suggest that adolescents may be at higher risk of mortality because of the longer duration of having lived with untreated infection. They are therefore less able to afford further delays before starting ART. The authors therefore suggest prompt ART initiation for treatment-eligible adolescents. They emphasize the need for innovative methods of HIV case-finding for adolescents. Adolescents are often suspicious of health care workers, resulting in reduced uptake of health services, including HIV testing. To provide more effective HIV counselling and testing for adolescents, WHO has recognised adolescents as an important population for HIV prevention, and developed specific HIV testing guidelines in 2013.

Interestingly the authors suggest using 12-month mortality among ART-eligible individuals, whether on ART or not, as a programme indicator. Incorporating pre-ART deaths, which are often unrecorded, and deaths among individuals newly started on ART, which may be partly attributed to pre-ART delays, indicates how well a programme manages people from the time they are registered in care. This could provide a more inclusive estimate of programme quality. 

Africa
Zimbabwe
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