Data from: Rates and predictors of attrition among children on antiretroviral therapy in Ethiopia: a prospective cohort study

Introduction: Attrition from antiretroviral therapy (ART) programmes is a critical challenge among children receiving care in resource-limited settings. Our objective was to determine the rates and predictors of attrition among children on ART in Ethiopia.
Methods: Between December 2014 and September 2016, we conducted a prospective cohort study in eight health facilities in Ethiopia. Eligibility criteria included age 3 months-14 years; being on ART for not more than a month. Outcome was attrition due to death and/or loss to follow-up. Predictor variables were child clinical and socio-demographic characteristics, and caregiver socio-demographic characteristics. We used Cox Regression analyses to examine the association between predictors and outcome.
Results: Of 309 children, 304 were included, 52% were male. Their median age was 9 years (Inter-quartile range, IQR, 6-12). At ART initiation, their median CD4 was 362 cells/mm3 (IQR 231-499); and 74.3% had WHO stage 1 or 2 disease. During 287.7 person-years of observation (PYO), 24 attritions were recorded, yielding an attrition rate of 8.3 per 100 PYO (95% CI 5.4-12.1). Of these, six children were reported dead, leading to a mortality rate of 2.1 per 100 PYO (95% CI 0.8-4.3). Eighteen were lost to follow-up (LTFU) leading to LTFU rate of 6.26 per 100 PYO (95% CI: 3.83-9.70). The majority, 14 (58%) of attrition occurred during the first six months of treatment.
Age below three years [aHR]= 5.14 (95% CI: 2.07-12.96), rural residence (aHR = 3.97, 95% CI: 1.34-11.78) and baseline Hgb in g/dl < 10 g/dl [aHR]= 5.68 (95% CI: 2.03-6.23) predicted higher risk of attrition. Baseline Hgb < 10 g/dl (aHR= 16.63, 95% CI: 1.64-168.4) and WHO stage III or IV (aHR= 12.25, 95% CI: 1.26-119.05) predicted the death of the child. Higher attrition was documented among children of both biological parents alive and biologically related close family caregivers.
Conclusion: Younger children, those from rural areas, and children with anaemia were at higher risk of attrition, especially during the early months of treatment, and therefore should be prioritized during treatment follow-up. Further studies should examine underlying reasons for higher attrition

引言：抗逆转录病毒治疗（antiretroviral therapy, ART）项目的脱落问题，是资源有限地区接受诊疗的儿童群体所面临的一项严峻挑战。本研究旨在明确埃塞俄比亚接受ART治疗的儿童的脱落率及其预测因素。
研究方法：2014年12月至2016年9月期间，本研究于埃塞俄比亚的8家医疗卫生机构开展一项前瞻性队列研究。纳入标准为：年龄3个月至14岁，且接受ART治疗时长不超过1个月。研究结局为因死亡或失访导致的治疗脱落。预测变量包括患儿临床特征、社会人口学特征以及照护者的社会人口学特征。本研究采用Cox回归（Cox Regression）分析，以探究预测因素与研究结局之间的关联。
研究结果：本研究共纳入304名儿童（初始招募309名），其中男性占比52%。患儿的中位年龄为9岁（四分位数间距（Inter-quartile range, IQR）：6~12岁）。在启动ART治疗时，患儿的中位CD4细胞计数为362个/mm³（IQR：231~499个/mm³），74.3%的患儿处于世界卫生组织（WHO）疾病分期1期或2期。在287.7人年（person-years of observation, PYO）的随访观察期内，共记录到24例治疗脱落事件，脱落率为8.3例/100人年（95%置信区间CI：5.4~12.1）。其中6名患儿死亡，病死率为2.1例/100人年（95%CI：0.8~4.3）；18名患儿失访（loss to follow-up, LTFU），失访率为6.26例/100人年（95%CI：3.83~9.70）。大部分脱落事件（14例，占58%）发生在治疗的前6个月内。
多因素分析显示，年龄低于3岁[调整后风险比（adjusted Hazard Ratio, aHR）=5.14，95%CI：2.07~12.96]、居住在农村地区（aHR=3.97，95%CI：1.34~11.78）以及基线血红蛋白（hemoglobin, Hgb）水平<10g/dl（aHR=5.68，95%CI：2.03~6.23）是治疗脱落的高危因素。基线Hgb<10g/dl（aHR=16.63，95%CI：1.64~168.4）以及WHO疾病分期3期或4期（aHR=12.25，95%CI：1.26~119.05）则与患儿死亡风险升高显著相关。此外，父母双全且照护者为具有生物学亲缘关系的近亲的患儿，其治疗脱落风险更高。
研究结论：低龄儿童、农村地区患儿以及合并贫血的患儿，其治疗脱落风险更高，且该风险在治疗初期尤为显著，因此在治疗随访过程中应对此类群体予以优先关注。未来的研究应进一步探究此类高脱落风险的潜在成因。