Objective: Clinical outcomes of HIV-infected children on antiretroviral treatment (ART) in a decentralized, nurse/counsellor-led programme.
Design: Clinical cohort.
Setting: KwaZulu-Natal, South Africa.
Patients: HIV-infected children aged ≤15 years on ART, June 2004-2008
Main outcome measures: Survival according to baseline characteristics including age, WHO clinical stage, haemoglobin, and CD4% was assessed in Kaplan-Meier analyses; hazard ratios for mortality estimated using Cox proportional hazards regression. Changes in laboratory parameters and weight-for-age z-scores (WAZ) after 6-12 months on treatment.
Results: 477 HIV-infected children initiated ART: at a median age of 74 months (range 4-180); median CD4 count (CD4%) 433 cells/mm3 (17%); and median HIV viral load log 4.2 copies/ml; 105 (22%) were on treatment for tuberculosis; and 317 (76.6%) were WHO Stage 3/4. There were significant increases after ART initiation in CD4% (17% vs. 22%; p<0.001), haemoglobin (9.9 vs. 11.7 g/L; p≤0.001), and albumin (30 vs. 36 g/L; p≤0.001). 32 (6.7%) children died over 732 child-years of follow-up (43.7 deaths per 1000 child-years; 95% CI, 32.7 - 58.2), 17 (53.1%) within 90 days of treatment initiation; median age of death 84 (IQR 10-181) months. Children with baseline haemoglobin ≤8g/L were more likely to die (adjusted HR 4.5; 95% CI 1.6 - 12.3), as were those aged <18 months compared to >60 months (adjusted HR 3.2; 95% CI 1.2 - 9.1).
Conclusions: Good clinical outcomes in HIV-infected children on ART are possible in a rural, decentralized service. Few young children are on ART, highlighting the urgent need to identify HIV-exposed infants.