Advanced HIV disease among children and adolescents in HIV care in Uganda: prevalence, clinical outcomes, and rate of mortality
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Background
People diagnosed with advanced HIV disease (AHD) are at high risk of increased mortality even after starting antiretroviral therapy (ART). We assessed AHD prevalence, clinical outcomes, and risk of mortality among children and adolescents living with HIV (CALHIV) in western Uganda.
Methods
We abstracted routinely-collected data of CALHIV aged 0-19 years from HIV clinic electronic medical records in 48 high-volume health facilities in two regions of western Uganda (Fort Portal and Hoima). Data for clients who initiated ART during January 2016—July 2023 were analysed. AHD was defined as a CD4 cell count <200 cells/μL, or WHO stage 3 or 4, or any child younger than five years of age living with HIV who had been on ART for more than 12 months and virally non-suppressed (≥1,000 copies). We used descriptive statistics (i.e., frequencies and percentages) to summarise prevalence and treatment outcomes. Kaplan-Meier curves were used to estimate overall survival and median time to death; log-rank tests were used to compare survival functions. A gamma-shared frailty model was used to determine factors associated with the rate of mortality. Effect measures were summarized using adjusted hazard ratios (aHRs) and their 95% confidence intervals (95%CI).
Results
A total of 5,143 CALHIV, including 3,067 (59.6%) females, with a median (interquartile range [IQR]) age of 10 (9) years were assessed. The overall prevalence of AHD was 18.2% (932/5,143) and varied by age—68.4% (0-4 years), 12.6% (5-9 years), 13.2% (10-14 years), and 7.7% (15-19 years). Just over half of the CALHIV diagnosed with AHD were active in care (51.5% [480/932]), about a quarter (26.4% [264/932]) had transferred out, 13.8% (129/932) were lost to follow-up, and 8.3% (77/932) had died. Survival was significantly higher in CALHIV who were not malnourished compared to those with malnutrition (p=0.001). Overall mortality rate among CALHIV with AHD was 3.41 (95% CI: 2.72-4.28) per 1,000 person-years and pronounced among those who had been on ART for three months or less (22.5; 95%CI: 17.0-29.8) compared to those above six months (0.8.2; 95%CI: 0.49 - 1.37).
Conclusion
Prevalence of AHD in CALHIV in western Uganda was within range compared to published adult-based studies. Risk of death differed by nutrition status and was high among those on ART three months or less. Early screening and management of malnutrition, as well as early ART initiation and adherence initiatives, might improve outcomes and reduce AHD-related mortality among CALHIV.
