Factors Determining Survival and Retention among HIV-Infected Children and Adolescents in a Community Home-Based Care and a Facility-Based Family-Centred Approach in Kampala, Uganda: A Cohort Study
We describe factors determining retention and survival among HIV-infected children and adolescents engaged in two health care delivery models in Kampala, Uganda: one is a community home-based care (CHBC) and the other is a facility-based family-centred approach (FBFCA). This retrospective cohort study reviewed records from children aged from 0 to 18 years engaged in the two models from 2003 to 2010 focussing on retention/loss to follow-up, mortality, use of antiretroviral therapy (ART), and clinical characteristics. Kaplan Meier survival curves with log rank tests were used to describe and compare retention and survival. Overall, 1,623 children were included, 90.0% (1460/1623) from the CHBC. Children completed an average of 4.2 years of follow-up (maximum 7.7 years). Median age was 53 (IQR: 11–109) months at enrolment. In the CHBC, retention differed significantly between patients on ART and those not (log-rank test, adjusted, ). Comparing ART patients in both models, there was no significant difference in long-term survival (log-rank test, , adjusted, ), while retention was higher in the CHBC: 94.8% versus 84.7% in the FBFCA (log-rank test, , adjusted ). Irrespective of model of care, children receiving ART had better retention in care and survival. 1. Background Sub-Saharan Africa (SSA) is home to the vast majority of infants, children, and adolescents living with HIV and morbidity and mortality remain high [1–3]. For example, mortality among HIV-infected children has been measured at 4.3% per year in East Africa and 8.3% in West Africa [4, 5]. A recent meta-analysis conducted in SSA reported a higher risk of early death among perinatally infected children [6]. Studies have also shown that substantial proportions of children and adolescents initiate treatment in SSA with advanced disease (46.3%–72.0%) and comorbidities such as tuberculosis (TB) (5.7%–34.0%) and malnutrition (33%–54%) that tend to be associated with early mortality and poor clinical outcomes [7–10]. Significant child mortality can be averted if antiretroviral therapy (ART) is started early [11–14]. However, despite overwhelming evidence demonstrating the benefits of ART, in practice high mortality and poor retention persist among HIV-infected children and adolescents in care in the resource-limited settings of SSA. In addition to scarce resources for programmes for children, the situation is compounded by a combination of factors including late HIV diagnosis, missed opportunities to initiate ART, health care programmes not tailored to the needs of the infected child and their family,
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