Outcomes of late initiation of antiretroviral therapy in Ugandan-HIV -infected children treated at Mildmay Jajja home

Abstract

INTRODUCTION: Antiretroviral therapy (ART) has been proven to significantly improve the quality and quantity of lives of patients infected with HIV. However, several barriers exist that prevent children from being initiated on treatment on time. Studies in adults have shown that the timing of treatment influence outcomes of ART; but little is known about this in children. Hence, the need for this study. The purpose of this study was to characterize the outcomes of late initiation of ART in HIV- positive children seen at the Mildmay Jajja Home center. METHODOLOGY: The study was a cross-sectional survey involving all children who were initiated at the Mildmay Jajja Home in 2005 and had had been on ART for at least 18 months. Two sets of data were collected, for the children on ART: their age and sex were recorded. In addition, based on the Ugandan clinical guidelines for ART, children were grouped into two groups; those 6 six years and below; and those above 6 years. Clinical variables recorded were baseline and repeated measurements of bodyweights, and CD4 counts; weight and CD4 counts at the time of initiation of ART, at 12 months and at 18 months. For the care providers: their age, gender, education level, relationship to the child was recorded. Three outcomes of treatment were assessed, adherence level by the 12th month on treatment; hospitalisation by the 12th month (during the first 12 months of treatment); and survival or death at by the 12th and 18th month on treatment. RESULTS: In total, 114 children were included in the sample. Among them, 54.4% of children were initiated late. Based on age, children 6 years old and younger were more likely and significantly initiated late as compared to those over 6 years old as about 70% of them were actually initiated late. Based on sex, female children older than 6 years were significantly initiated late as compared to boys. The characteristics of care providers that were associated with children being initiated late were being male, less than 40 years old, with a primary school level of education, and not knowing their own HIV status. With regard to outcomes of the treatment, adherence, hospitalisation, and survival were assessed. Overall, 59.4% of children achieved an adherence level of 90% or more; 17.3% of children had been hospitalised at least once; and the mortality was 17.5% during the 2 year period covered by the study. Adherence was influenced slightly by the timing of the start of the treatment since less than half (46.34%) of those initiated late achieved an adherence level of 90% or more as compared to over 53% among those initiated timely. Though there was not statistically significant difference, adherence was slightly better in children whose care providers were biological parents, whose HIV status was known as positive, and female. With regard to hospitalisation, children less than 6 years were significantly more hospitalised than the older ones; their care providers were relatives, not educated, and of unknown HIV status. Those initiated late were significantly more hospitalised than those initiated timely (63.15% versus 36.84%, p=0.03). With regard to survival, the majority of children who died were over 6 years old, and female. The majority of their care providers were female, under 40 years old, and known HIV-positive. In children initiated late, the mortality was 50% (n=14) and 83.3% (n=6) respectively by the 12th and 18th month of treatment as compared to those initiated timely. In conclusion, 54.4% of children were initiated late. Late initiation was associated with negative outcomes such as low adherence to treatment as less than half of them achieved a adherence level of 90% or more; hospitalisation as those initiated late were significantly more hospitalised than those initiated timely; and high mortality since among those who died, 50% and 83.3% of deaths occurred respectively by the 12th and 18th month of treatment among those initiated late. In order to minimize the probability that the majority of children are initiated late, a general awareness campaign should be directed at the general public so that they can be sensitized to the need to bring children to medical attention as soon as possible