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Implementation of antiretroviral therapy guidelines for under-five children in Tanzania: translating recommendations
Harriet Nuwagaba-Biribonwoha1,2, Chunhui Wang1, Bonita Kilama3
1ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA.
Insights
Tanzanian children under five are gradually adopting antiretroviral therapy (ART) guidelines. Interventions are needed to speed up ART initiation and improve patient retention on treatment.
Area of Science:
- Public Health
- Pediatrics
- Infectious Diseases
Background:
- Paediatric antiretroviral therapy (ART) guidelines have undergone several updates.
- Assessing ART guideline implementation in Tanzanian children under five is crucial for the transition to universal ART.
- This study evaluates the real-world application of ART guidelines in a vulnerable population.
Purpose of the Study:
- To assess the implementation of updated paediatric antiretroviral therapy (ART) guidelines in Tanzania.
- To identify factors associated with ART initiation and retention among children under five.
- To inform strategies for improving universal paediatric ART access and adherence.
Main Methods:
- Retrospective cohort analysis of 1679 children (infants and children aged 0-59 months) enrolled between 2010-2012.
- Used routinely collected data, applying competing risk and Kaplan-Meier methods to analyze ART initiation and attrition.
- Examined correlates of ART initiation and retention, accounting for factors like enrollment year, clinical setting, and disease stage.
Main Results:
- Infant ART initiation incidence reached 78.0% by six months; later enrollment years and specific clinical settings (PMTCT, inpatient) were associated with higher initiation rates.
- Child ART initiation incidence reached 76.1% by six months; later enrollment years and primary health facilities were associated with higher initiation.
- 12-month attrition on ART was 33.9% for infants and 23.1% for children, with higher rates linked to advanced WHO stage, severe malnutrition, and specific enrollment types.
Conclusions:
- Findings indicate a gradual adoption of ART guidelines over time in Tanzania.
- There is a clear need for interventions to accelerate ART initiation and enhance long-term retention on ART for children.
- Optimizing ART delivery requires addressing factors influencing both initiation and adherence.
Introduction:
Paediatric antiretroviral therapy (ART) guidelines have been updated several times in recent years. We assessed implementation of ART guidelines among under-five children to inform the transition to universal paediatric ART in Tanzania.
Methods:
We conducted a retrospective cohort analysis of infants (0 to 11 months) and children (12 to 59 months) enrolled between 2010 and 2012 using routinely collected data. Infants and children were initiated on ART according to the 2008 World Health Organization (WHO) recommendations/2009 Tanzania guidelines (universal ART for infants). Cumulative ART initiation incidence and correlates of ART initiation were examined using competing risk methods accounting for attrition (death or loss to follow-up). Kaplan-Meier methods and Cox regression models were used to examine attrition on ART and its correlates.
Results:
A total of 1679 children were enrolled at 69 clinics: 469 (28%) infants and 1210 (74%) children. Infant cumulative ART initiation incidence was 59.6, 71.3 and 78.0% at one, three and six months of follow-up. Infants were more likely to start ART if enrolled in 2012 [adjusted sub-hazard ratio (AsHR)=2.2, 95% confidence interval (CI): 1.7 to 2.8] or 2011 (AsHR=1.8, 95% CI: 1.4 to 2.3) compared to 2010; they were more likely to start ART from prevention of mother-to-child HIV transmission (AsHR=1.6, 95% CI: 1.3 to 2.1) and inpatient wards (AsHR=1.5, 95% CI: 1.2 to 2.0) versus being enrolled from voluntary counselling and testing centres. Attrition at 12 months on ART was 33.9% and was more likely among infants with WHO Stage 4 [adjusted hazard ratio (AHR)=3.1. 95% CI: 1.8 to 5.2] and severe malnutrition (AHR=1.4, 95% CI: 1.0 to 1.9).Among 599 children eligible for ART at enrollment, cumulative ART initiation incidence was 51.8, 68.6 and 76.1% at one, three, and six months. Children were more likely to start ART if enrolled in 2012 (AsHR=1.8, 95% CI: 1.4 to 2.3) or 2011 (AsHR=1.5, 95% CI: 1.2 to 1.8) compared to 2010; they were more likely to start ART at primary health facilities (AsHR=1.5, 95% CI: 1.1 to 2.0) and less likely at urban facilities (AsHR=0.6, 95% CI: 0.5 to 0.9) and facilities without CD4 testing on site (AsHR=0.7, 95% CI: 0.5 to 0.9). Attrition at 12 months on ART was 23.1% and was more likely with severe malnutrition (AHR=1.8, 95% CI: 1.1 to 3.0), WHO Stage 4 (AHR=3.0, 95% CI: 1.0 to 8.5) and outpatient enrolees (AHR=1.7, 95% CI: 1.1 to 2.7).
Conclusions:
Our findings suggest the gradual adoption of guidelines over calendar time. Interventions to expedite ART initiation and support retention on ART are needed.
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