Pediatric HIV care and treatment services in Tanzania: implications for survival

Long-term effect of antiretroviral therapy on mortality among HIV-positive children and adolescents in China

Introduction

Highly active antiretroviral therapy (HAART) was piloted in 2002 and was scaled up in 2003 in mainland China. The aim of this study was to evaluate the mortality and its possible predictors based on the long-term initial antiretroviral therapy (ART) cohort among HIV positive children and adolescents.

Methods

This prospective open-labeled multicenter cohort study was conducted from January 2008 to July 2021. The participants were recruited from six representative sites in mainland China. A total of 609 participants with an HIV-positive serostatus and <18 years old were recruited and each participant was informed consent at the time of enrollment. Mortality and annual hazard were calculated, and predictors for death were analyzed using Cox regression models generating hazard ratios (HR).

Results

The results showed that the mortality was 0.721 per hundred person-years, and the annual hazard was less than 0.10 over time. Both CD4+T cell count and CD4+T cell percentage declined in the death group during the follow-up. The Cox regression model showed that the baseline low CD4+T cell count level (Low vs. High: aHR = 8.309, 95% CI: (1.093, 63.135)) and age >5 years old at HIV diagnosis (6-12 vs. 0-5: aHR = 3.140, 95%CI: (1.331, 27.411)); 13-18 vs. 0-5: aHR = 5.451, 95%CI: (1.434, 20.724)) were possible risk factors for death.

Conclusion

The longitudinal cohort study demonstrated the efficacy of China's ART program among HIV-positive children and adolescents which could be beneficial to other countries with limited resources.

A scoping review on HIV early infant diagnosis among HIV exposed infants, ART use and adherence in Tanzania

BACKGROUND

HIV Early Infant Diagnosis (HEID) is critical for the timely initiation of HIV treatments and improved health outcomes among HIV-infected infants. However, the uptake of HEID remains largely low in Tanzania. This descriptive scoping review of evidence on HEID among HIV-exposed infants in Tanzania seeks to understand the dynamics of HEID, ART use and adherence to inform targeted interventions and promote its uptake.

METHODS

The Arksey and O'Malley's methodological framework guided this scoping review. We searched for peer-published articles on HEID in Tanzania through PubMed and Google Scholar with full-text retrieval from HINAR. We included only English language articles published between 2013 and 2022. Further searches for the materials on the reference lists of the publications yielded additional relevant articles. We carried out an inductive thematic analysis to analyze and synthesize the data.

RESULTS

In all, nine articles met the inclusion criteria and, hence, qualified for the review. The variations in the uptake of HEID in the empirical literature reviewed indicate an upward trend. HEID increased from 77.2% in 2009 to 97.8% in 2011 in Kilimanjaro, Mbeya and Tanga and from 53.2% in 2014 to 69.2% in 2016 in Dar es Salaam. The median age at the initial test ranged from 5.6 weeks in Kilimanjaro to 8.6 weeks in Mbeya. The uptake of HEID was necessitated by individual, household and health facility factors. Unknown HIV status at conception, low level of education of the household head, and large household size negatively affected uptake of HEID. The health facility factors such as unavailability of the test kits, long distances to the facility and transport costs negatively influenced HEID uptake. The percentage of HIV-positive infants on ART ranged from 52.7 to 61%, and loss to follow ranged from 31 to 61%.

CONCLUSION

The uptake of HEID varied among regions depending on individual, household and health facility factors. Multifaced efforts are needed to address these factors for accelerated uptake of HEID and improved health outcomes and survival among this strategic population group.

HIV burden and the global fast-track targets progress among pregnant women in Tanzania calls for intensified case finding: Analysis of 2020 antenatal clinics HIV sentinel site surveillance

BACKGROUND

For successful HIV response, updated information on the burden and progress toward HIV elimination targets are required to guide programmatic interventions. We used data from the 2020 HIV sentinel surveillance to update on the burden and factors associated with HIV infection, HIV status awareness, and ART coverage among pregnant women in Tanzania mainland.

METHODOLOGY

We conducted the surveillance in 159 antenatal clinics (ANC) from all 26 regions of Tanzania's mainland from September to December 2020. This cross-sectional study included all pregnant women (≥15 years) on their first ANC visit in the current pregnancy during the survey period. Routine HIV counselling and testing were done at the facility. A multivariable logistic regression model accounting for the survey design was used to examine factors associated with HIV infections.

RESULTS

38,783 pregnant women were enrolled (median age (IQR) = 25 (21-30) years). HIV prevalence was 5.9% (95%CI: 5.3% - 6.6%), ranging from 1.9% in the Manyara region to 16.4% in the Njombe region. Older age, lower and no education, not being in a marital union, and living in urban or semi-urban areas were associated with higher odds of HIV infection. HIV status awareness among women who tested positive was 70.9% (95% CI: 67.5%- 74.0%). ART coverage among those aware of their status was 91.6% (86.5%- 94.9%). Overall, 66.6% (95% CI: 62.4%- 70.6%) of all pregnant women who tested positive for HIV knew their HIV status and were on ART.

CONCLUSION

HIV is increasingly prevalent among pregnant women in Tanzania mainland especially among older, those with lower or no formal education, those outside marital union, and pregnant women living in urban and semi-urban areas. Behind the global fast-target to end HIV/ AIDS, about a third of pregnant women living with HIV initiating ANC were not on ART. Interventions to increase HIV testing and linkage to care among women of reproductive age should be intensified.

Predictors of the observed high prevalence of loss to follow-up in ART-experienced adult PLHIV: a retrospective longitudinal cohort study in the Tanga Region, Tanzania

BACKGROUND

Antiretroviral therapy (ART) programs have expanded rapidly, and they are now accessible free of charge, yet "loss to follow-up, LTFU" is still a national public health issue. LTFU may result in treatment failure, hospitalization, increased risk of opportunistic infections and drug-resistant strains, and shortening the quality of life. This study described the rates and predictors of LTFU among adults living with human immunodeficiency virus (PLHIV) on ART in the Tanga region, Tanzania.

METHODS

A retrospective longitudinal cohort study was conducted between October 2018 and December 2020 in Tanga's care and treatment health services facilities. The participants were HIV adult PLHIV aged 15 years and above on ART and attended the clinic at least once after ART initiation. LTFU was defined as not taking ART refills for 3 months or beyond from the last attendance of a refill and not yet classified as dead or transferred out. Cox proportional hazard regression models were employed to identify risk factors for LTFU. P values were two-sided, and we considered a p < 0.05 statistically significant.

RESULTS

57,173 adult PLHIV were on ART of them, 15,111 (26.43%) were LTFU, of whom 10,394 (68.78%) were females, and 4717 (31.22%) were males. Factors independently associated with LTFU involved age between 15 and 19 years (HR: 1.85, 95% CI 1.66-2.07), male sex (HR: 2.00 95% CI 1.51-2.62), divorce (HR: 1.35, 95% CI 1.24-1.48), second-line drug type (HR: 1.13, 95% CI 1.09-1.18), poor drug adherence (HR: 1.50, 95% CI 1.23-1.75), unsuppressed viral load (HR: 2.15, 95% CI 2.02-2.29), not on DTG-related drug (HR: 7.51, 95% CI 5.88-10.79), advanced HIV disease WHO stage III and IV (HR: 2.51, 95% CI 2.32-2.72). In contrast to cohabiting, ART duration < 1 year, and being pregnant showed a reduced likelihood of LTFU.

CONCLUSION

A high prevalence of LTFU was observed in this study. Young age, not using DTG-based regimen, WHO clinical stage IV, poor drug adherence, male sex, unsuppressed viral load, divorcee, and second-line regime were independently associated with LTFU. To reduce LTFU, evidence-based interventions targeting the identified risk factors should be employed.

Rates and Determinants of Retention on ART Among Orphans and Vulnerable Children Living With HIV in Tanzania

Despite the global progress in response to HIV and AIDS, notable challenges remain for children, especially identification, linkage, and retention in HIV care and treatment services. To succeed in pediatric HIV programming requires the linkage and retention of the children in those services over time. This study assessed the level of retention to antiretroviral therapy (ART) and its associated factors among orphans and vulnerable children living with HIV (OVCLHIV) in Tanzania. Data were obtained from the USAID Kizazi Kipya project that collected pediatric ART data from October 2017 to October 2019 in 81 district councils of Tanzania. Community-based volunteers supported the linkage and retention of the OVCLHIV on ART. Analysis of on-ART status was conducted in a cohort of OVCLHIV aged 0–20 years enrolled in the project and monitored for 24 months. OVCLHIV who remained on ART until the end of the follow-up period were referred to as “retained,” otherwise, “not retained”. Multivariable analysis was conducted using logistic regression, adjusting for baseline characteristics. Of the 5,304 OVCLHIV analyzed, the mean age was 13.1 years, 51.5% were female, and 72.2% were living with female caregivers. Their overall rate of retention on ART over the 24 months was 86.7%. Multivariable analysis showed that as the higher frequency of home visit by the project staff increased, the likelihood of retention increased by 8% [adjusted odds ratio (aOR) = 1.08, 95% CI 1.06–1.11, p < 0.001]. Membership in people living with HIV (PLHIV) support groups was associated with a higher likelihood of retention compared to nonmembership (aOR = 3.31, 95% CI 2.60–4.21, p < 0.001). Children in larger family size were 22% less likely to sustain ART (aOR = 0.78, 95% CI 0.72–0.84, p < 0.001). Urban OVCLHIV were 18% less likely to remain on ART than their rural counterparts (aOR = 0.82, 95% CI 0.69–0.98, p = 0.030). Remaining on ART was 49% more likely for OVC in economically better-off households than those in destitute households (aOR = 1.49, 95% CI 1.22–1.81, p < 0.001). Male OVC were 17% less likely to be retained on ART than their female counterparts (aOR = 0.83, 95% CI 0.71–0.99, p = 0.033). Community-based OVC support resulted in a high pediatric retention rate over the 24 months of follow-up. While key enablers of retention were higher frequency of home visits by the project volunteer, participation in PLHIV support groups, and better economic status, large family sizes, urban place of residence, and male gender of the OVC were barriers. This study brings useful evidence to inform strategies for advancing retention of OVCLHIV on ART for their better health outcomes and overall wellbeing.

Predictors of mortality among adolescents and young adults living with HIV on antiretroviral therapy in Dar es Salaam, Tanzania: a retrospective cohort study

INTRODUCTION

Global AIDS-related deaths have declined by only 10% among adolescents since its peak in 2003. This is disproportionately low compared to a decline of 74% among children aged 0-9 years old. We determined the magnitude of, and predictors of mortality among adolescents and young adults living with HIV on antiretroviral therapy (ART) in Dar-es-Salaam, Tanzania.

METHODS

A retrospective cohort study was conducted among adolescents (aged 10-19) and young adults (aged 20-24) living with HIV and enrolled in care and treatment centres in Dar es Salaam, Tanzania between January 2015 and December 2019. Data were analysed using STATA version 16. Cumulative hazard curves were used to estimate and illustrate 1-year mortality. Predictors for mortality were assessed by the Fine and Gray competing risk regression model. Sub-hazard ratios (SHR) and 95% confidence intervals (95% CI) were then reported.

RESULTS

A total of 15,874 young people living with HIV were included: 4916 (31.3%) were adolescents and 10,913 (68.7%) were young adults. A total of 3843 (77.5%) adolescents and 9517 (87.2%) young adults were female. Deaths occurred in 2.3% (114/4961) of adolescents and 1.2% (135/10,913) of young adults (p < 0.001). Over a follow-up of 9292 person-years, the mortality rate was 3.8 per 100 person years [95% CI 3.2-4.6/100 person-years] among adolescents and 2.1 per 100 person-years among young adults [95% CI 1.8-2.5/100 person-years]. Independent predictors of mortality among adolescents were male sex (adjusted (SHR) aSHR = 1.90, 95% CI: 1.3-2.8), CD4 count < 200 cells/mm³ (aSHR = 2.7, 95% CI: 1.4-5.0) and attending a private health facility (aSHR = 1.7, 95% CI: 1.1-2.5). Predictors of mortality among young adults were CD4 count < 200 cells/mm³ (aSHR = 2.8, 95% CI 1.7-4.5), being underweight (aSHR = 2.1, 95% CI: 1.4-3.3) and using nevirapine-based therapy (aHR = 8.3, 95% CI: 3.5-19.5).

CONCLUSIONS

The mortality rate for persons living with HIV and on ART in Tanzania was significantly higher in adolescents than young adults. Age- and sex-specific risk factors identify targets for intervention to reduce mortality among affected adolescents and young adults.

Treatment outcomes among children younger than five years living with HIV in rural Zambia, 2008-2018: a cohort study

Background

HIV testing and treatment guidelines for children in sub-Saharan Africa have evolved over time, such that children are now treated at younger ages. The objective of this study was to describe the treatment experience for immunologic, virologic, and growth outcomes among HIV-infected Zambian children younger than 5 years of age from 2008 to 2018.

Methods

Participants enrolled in a clinical cohort study in Macha, Zambia and initiating antiretroviral treatment before 5 years of age between 2008 and 2015 were included in the analysis and followed up to the end of 2018. Outcomes, including growth, CD4+ T-cell percentage, viral suppression, and mortality, were evaluated among all children using longitudinal and survival analyses. Comparisons by age at treatment initiation (< 1, 1 to < 2, and 2 to < 5 years) were also evaluated.

Results

Three hundred eighty-one children initiating treatment before 5 years of age between 2008 and 2015 were included in the analysis. Growth metrics and CD4+ T-cell percentage improved over time after treatment initiation. However, 20% of children remained underweight and 40% of children remained stunted after the first 36 months of treatment. 85% of children had a viral load < 400 copies/mL after 12 months of treatment. However, children < 1 year at treatment initiation were more likely to have a detectable viral load in the first 12 months of treatment and less likely to achieve viral suppression compared to older children. Mortality was highest in the first 12 months of treatment, among underweight children, and among children initiating treatment in 2008–2010 compared to 2011–2015.

Conclusions

Most children initiating antiretroviral treatment from 2008 to 2015 in rural Zambia responded well to treatment. However, many children remained underweight and stunted, and experienced high mortality rates during the first few months of treatment. This supports continued efforts to improve early infant diagnosis, nutritional support, and pediatric drug formulations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02793-y.

Prevalence and incidence rate of tuberculosis among HIV-infected patients enrolled in HIV care, treatment, and support program in mainland Tanzania

BACKGROUND

Despite improvements in access to antiretroviral therapy (ART), mortality in people living with human immunodeficiency virus (PLHIV) is still high and primarily attributed to tuberculosis (TB) infection. In Sub-Saharan Africa, approximately 80% of HIV-related mortality cases are associated with TB. Relatively little is known about the incidence of TB among PLHIV in Tanzania and the determinant factors. We report the prevalence and incidence rate of confirmed TB and determine association with selected demographic and program-related factors based on data in the national HIV care and treatment program from 2011 to 2014.

METHODS

We used the Tanzania National AIDS Control Programme database to obtain information on all HIV clients enrolled in the HIV care and treatment program between January 2011 and December 2014. We analyzed retrospective cohort data to assess the prevalence and TB incidence rate per 1000 person-years. A multivariable Cox proportional hazards regression model was used to estimate hazard ratios and 95% confidence intervals for putatively associated factors.

RESULTS

Over 4 years, there were 22,071 confirmed cases of pulmonary TB in 1,323,600 person-years. The overall TB incidence was around 16.7 (95% CI 16.4-16.9) cases per 1000 person-years. The annual incidence rate decreased by 12.4 % from 17.0 (95% CI 16.5-17.4) in 2011 to 14.9 (95% CI 14.5-15.4) in 2014. The TB incidence rate was higher in persons not using ART and in males than in females. The incidence of TB was higher in patients with advanced HIV disease and decreased with increasing age. The overall prevalence of TB was 2.2%, with a peak prevalence of 2.5% in 2013 and was higher among children < 15 years (3.2%) in the same year.

CONCLUSION

The study found an overall decrease in the incidence of TB in PLHIV. Our results emphasize the need for early initiation of ART and the provision of TB preventive therapy for those PLHIV without active TB after intensified TB case-finding.

The Standardized Pediatric Expedited Encounters for ART Drugs Initiative (SPEEDI): description and evaluation of an innovative pediatric, adolescent, and young adult antiretroviral service delivery model in Tanzania

BACKGROUND

As countries scale up antiretroviral therapy (ART) for children, innovative strategies to deliver quality services to children are needed. Differentiated ART delivery models have been successful in adults, but no such program has been described in children. We describe the Standardized Pediatric Expedited Encounters for ART Drugs Initiative (SPEEDI).

METHODS

Descriptive analysis of patients eligible for SPEEDI was done via retrospective review of children, adolescents, and young adults on ART at the Baylor Centre of Excellence (COE) in Mbeya, Tanzania between January 2013 and December 2015. Eligibility for SPEEDI visits included the following: stable children, adolescents, and young adults on ART for approximately 3 months or longer, no medical or social complications, good adherence to ART, and presence of reliable caregiver. During a SPEEDI visit, patients were fast tracked in triage to collect medications directly without physically seeing a clinician. SPEEDI patients came to clinic every two months, and alternated SPEEDI visits with standard visits. Baseline characteristics, mortality, and lost-to-follow up rates of SPEEDI patients were analyzed.

RESULTS

One thousand one hundred sixty-four patients utilized SPEEDI, totaling 3493 SPEEDI visits. SPEEDI reached 51.3% (1164/2269) of pediatric ART patients, accounting for 7.7% (3493/44489) of total patient encounters. SPEEDI patients were 52% (605/1164) female, median age of 11.7 years (range 1.2-25.5 yr), median time on ART of 21 months (range 4-130 months) and 83.5% (964/1155) categorized as no or mild HIV-associated immunodeficiency. SPEEDI patients had good outcomes (98.8%), low LTFU (0.1%) and low mortality rates (0.61 deaths per 100 patient-years).

CONCLUSION

SPEEDI was an effective model for delivering ART to children, adolescents, and young adults in our setting, leading to good clinical outcomes, low mortality, and low LTFU. The SPEEDI program safely and effectively expedited and spaced out ART visits for children, adolescents, and young adults, and can serve as an adaptable ART delivery model for other resource limited settings.