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）项目的治疗脱落是资源受限地区接受照护的儿童面临的重大挑战。本研究旨在确定埃塞俄比亚接受ART治疗儿童的治疗脱落率及其预测因素。

方法：2014年12月至2016年9月，我们在埃塞俄比亚的8家医疗机构开展了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。研究结局为死亡和/或失访导致的治疗脱落。预测变量包括儿童的临床特征、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回归分析，探究预测因素与研究结局之间的关联。

结果：初始纳入的309名儿童中，最终有304名被纳入分析，其中52%为男性。受试者的中位年龄为9岁（四分位间距IQR：6~12岁）。ART启动时的中位CD4细胞计数为362个/mm³（IQR：231~499个/mm³），74.3%的儿童处于WHO疾病分期1或2期。在287.7人年（person-years of observation, PYO）的随访观察中，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名儿童死亡，死亡率为2.1例/100人年（95%CI：0.8~4.3）；18名失访（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。

调整后风险比（adjusted Hazard Ratio, aHR）分析显示，年龄小于3岁[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）<10g/dl（aHR=5.68，95%CI：2.03~6.23）的儿童，其治疗脱落风险显著升高。基线血红蛋白<10g/dl（aHR=16.63，95%CI：1.64~168.4）以及WHO疾病分期III或IV期（aHR=12.25，95%CI：1.26~119.05）则可预测儿童死亡风险升高。此外，父母双全且照护者为具有生物学亲缘关系的近亲的儿童，治疗脱落率更高。

结论：低龄儿童、农村地区儿童以及贫血儿童的治疗脱落风险更高，尤其是在治疗初期，因此应在治疗随访中对该类人群予以优先关注。未来的研究应进一步探究治疗脱落率偏高的潜在原因。