Transcript Poster THPE0101 XVII International AIDS Conference Early mortality (pre and post antiretroviral treatment) amongst children with HIV/AIDS enrolled in two programs in Cambodia Raguenaud.

Poster THPE0101 XVII International AIDS Conference
Early mortality (pre and post antiretroviral treatment)
amongst children with HIV/AIDS enrolled in two
programs in Cambodia
Raguenaud ME.¹, Isaakidis P.¹, Vantha T.², Seithaboth S.³, Kazumi A.³, Zachariah
R4
¹ Médecins Sans Frontières (MSF), Cambodia, ² Donkeo Referral Hospital, Ministry of Health, Takeo,
Cambodia, ³ Angkor Hospital for Children, Siem Reap, Cambodia, 4 Médecins Sans Frontières,
Operational Centre Brussels
Death rates
BACKGROUND
There is very limited documented information on the
importance of early mortality (death within first 6 months)
among children enrolled within HIV/AIDS programs in
resource-limited settings.
Table. Cumulative death rates by 3 and 6 months of HIVpositive children in the Donkeo hospital and AHC.
Time
period
OBJECTIVES
We a) determined the incidence of early mortality prior to and
after initiating ART and b) assessed risk factors associated with
early mortality.
SETTING
Person-time not on ART (from screening)
Deaths (%
of total
deaths)
Personyears
Rate per 100
PY
2
(1.8%)
12
(11%)
39
(36%)
37
(34%)
50
(46%)
70
(64%)
657
5.6
657
7.6
657
10.6
1443
0.1
1443
0.8
1443
2.7
Early mortality rate was 9.5 times higher in
patients not treated than in patients on ART
Risk factors for early mortality
• In the univariate analysis, among children not on
treatment, early death was associated with male
sex, CDC stage C, baseline CD4 <200,
CD4%<15%, admission during the early years of
the program (before 2006), and W/H <-2 z-score.
METHODS
• Retrospective cohort study using patient data entered in
HIV-specific software
• All children admitted from 2002 until end 2007 included.
Observation period ended in April 2008
• Cox-regression analysis done to assess for risk factors of
early death
• Likely cause of death assessed from patient chart review
RESULTS
Enrolment and follow up
• Total of 1246 children enrolled in HIV program (48%
girls)
• 146 (12%) were <18 months, 564 (45%) 18-60months,
and 536 (43%)>60months
• Median CD4% 17.9 (10.0-24.2) in 18-60 months age
• Median CD4 218cells/mm³(39-562) in >=5yrs age
•714 (57%) started ARV treatment
• Median ART initiation time: 4.8 months (IQR:2.8-9.1)
• Median time from ART eligibility until ART start: 3.6
months (IQR:2.2-7.1)
Children on ART
601 (84%)
13 (2%)
39 (5%)
61 (9%)
Person-time on ART (from start of
treatment)
Deaths (% of
Person Rate per
total deaths)
-years 100 PY
50 of 62 (82%) children who died within 6 months
of enrolment in the HIV programs were not yet
receiving ART
•National HIV prevalence
rate 0.9% (2006)
• 2 programs: pediatric
HIV clinic of Takeo public
hospital and the HIV clinic
of the charity-run ‘Angkor
Hospital for Children’ in
Siem Reap
• Care and ART
(3TC/D4T/NVP or EFV)
delivered free of charge
Status at end of study
In active cohort
Loss to follow-up
Dead
Transferred out
Up to 90
days
Up to 180
days
Until end
of
observatio
n period
Among all patients (from
screening)
Deaths
PersonRate
(% of
years
per
total
100
deaths)
PY
39
2537
1.5
(36%)
62
2537
2.4
(57%)
109
2537
4.3
(100%)
Children not on ART
293 (55%)
129 (24%)
70 (13%)
40 (8%)
• In the multivariate analysis only blood CD4 was
associated with early death:
- Mortality rate ratio comparing those with CD4 cell counts
<200 and ≥200 cells/mm³ was 8.10 (95%CI, 1.1-61.4)
- Mortality rate ratio comparing those with CD4 % <15% and
≥15% was 11.1 (95%CI, 1.0-119.0)
• 41 out of 50 (82%) children with early death
before treatment met the ART eligibility criteria.
• Median delay between ART eligibility date and
date of death: 50 days (IQR: 24-74)
Cause of early death
Cause of death
All patients (n=62)
Tuberculosis
Lower respiratory
tract infection
Wasting syndrome
Other
Unknown
28 (45.2)
16 (25.8)
7 (11.3)
7 (11.3)
4 (6.4)
Patients receiving
ART (n=12)
6 (50.0)
3 (25.0)
Patients not receiving
ART (n=50)
22 (44.0)
13 (26.0)
2 (16.7)
1 (8.3)
5 (10.0)
6 (12.0)
4 (8.0)
Conclusions
Most deaths among children enrolled in two
program settings in Cambodia occur within the
first 6 months after enrolment. Early mortality
rates were more than nine-fold higher among
children not yet initiated on ART compared to
those placed on treatment.
Urgent measures to promptly initiate ART in
eligible children should be taken such as a fasttrack procedure, earlier preparatory counselling
sessions, improved access to laboratory tests and
results, systematic HIV screening in children
diagnosed with TB and considering early ART
initiation among children treated for TB.