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I nternational E pidemiologic D atabases to E valuate AIDS

18-month mortality and loss to follow-up in ART-treated children in Asia and Africa The pediatric IeDEA multiregional collaboration Leroy, V.1, Malateste K. 1, Rabie H. 2, Pagakrong L.3, Ayaya S. 4, Dicko, F. 5,

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I nternational E pidemiologic D atabases to E valuate AIDS

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  1. 18-month mortality and loss to follow-up • in ART-treated children in Asia and Africa • The pediatric IeDEA multiregional collaboration • Leroy, V.1, Malateste K. 1, Rabie H. 2, Pagakrong L.3, Ayaya S. 4, Dicko, F. 5, • Davies MA. 6, Kariminia A. 7, Wools-Kaloustian K. 8, Aka, A. 9,, Aurpibul, L 10, Yiannoutsos, C. 8, Signaté-Sy, H, 11, Dabis, F. 1 • for the International IeDEA pediatric Working Group. • Inserm U897, Bordeaux 2 University, Bordeaux, France. • Tygerberg Children's Hosp., Stellenbosch Univ., Cape Town, South Africa. • Khon Kaen Univ., Thailand. • Moi Teaching and Referral Hosp., Eldoret Kenya. • Hop Gabriel Touré, Bamako, Mali. • Center for Infectious Diseases Epidemiology and Research, School of Public Health and Family Med., Univ. of Cape Town, South Africa. • National Centre in HIV Epidemiology and Clinical Research, Sydney, Australia. • Indiana Univ. School of Medicine, Indianapolis, USA. • Centre de Prise en Charge, de Recherche et de Formation, CePReF, Abidjan, Côte d’Ivoire. • Chiang Mai University, Thaïland. • 11. Hopital Albert Royer, Dakar, Sénégal. International Epidemiologic Databases to Evaluate AIDS Abstract-MOAB0202 XVIII International AIDS Conference, July 2010, Vienna, Austria

  2. 18-month pediatric mortality and loss to follow-up in IeDEA • Background: • Updated information on mortality and loss to follow-up (LTFU) on ART are needed • Hypotheses: 1) high mortality among children LTFU and 2) higher LTFU with rapid ART scale-up • Requires large data sets, well-suited for multi-regional analysis • Objective: To study 18-month mortality and LTFU rates after ART initiation, and baseline patient and programmatic determinants in a multiregional analysis

  3. Methods (1) • IeDEA is a global collaboration of HIV treatment cohorts • Eligible study sites: IeDEA pediatric clinical centres • Africa (4), Asia-Pacific (1), Central/South America (1) • Standardized data collection • Inclusion criteria: • Positive PCR <18 mo or EIA ≥18 mo • Age: 0 to 15 years at HAART initiation • ARV-naive • Except for exposure to perinatal PMTCT prophylaxis • Starting HAART (≥3 ARV drugs)

  4. Methods (2) • Baseline: date of HAART initiation • Outcomes • Mortality • LTFU: >6 months since the last visit • Statistical analysis • 6-, 12-, and 18-month Kaplan-Meier probabilities • Cox model analysis of baseline determinants stratified by region • Programmatic and patient variables

  5. Sites characteristics by region *between-region heterogeneity p <0.01

  6. Baseline characteristics at HAART initiation by region *between-region heterogeneity p <0.01

  7. Mortality and LTFU at 18 months by region *>6 months since last visit **between-region heterogeneity p <0.01

  8. 18-month Kaplan-Meier probability of death

  9. Correlates of 18-month mortality, adjusted analysis

  10. 18-month Kaplan-Meier probability of LTFU

  11. Correlates of 18-month LTFU, adjusted analysis

  12. Programmatic correlates of 18-month LTFU, adjusted analysis

  13. Methodologic challenges • Multiple sources of heterogeneity • Operational definition of LTFU • Variability by site in patient tracking system and access to free services • Informative censoring • Missing data was not uncommon for the outcomes and predictors • The impact varied by outcome • Demonstrates need to ascertain outcomes of those LTFU

  14. Conclusions • The 18-month risks of death and LTFU differed substantially across regions • Reflects impact of delayed HAART and importance of retention • Recent initiation of HAART and increased cohort size were associated with higher LTFU • Overload of health facilities • Requiring patients to pay for care is associated with LTFU • Need to advocate for free access to all HIV services for children • Innovative and feasible approaches to retain children in ART programs are urgently required

  15. BETHESDA, ETATS UNIS Acknowledgments • All the patients followed up in the IeDEA pediatric centers • IeDEA West Africa principal investigators • François Dabis • Emmanuel Bissagnéné • Bordeaux and Abidjan IeDEA West Africa Regional Center staff: • Charlotte Lewden, Elodie Rabourdin, Valériane Leroy, Didier K. Ekouévi, Karen Malateste, Rodolphe Thiebaut • Gérard Allou, JC Azani, Patrick Coffie, Hughes Djétouan, Bertin Kouadio • All the investigators and pediatric coordinators from the Pediatric IeDEA Regions contributing to the project: Asia (Annette Sohn), East Africa (Kara Wools-Kaloustian), Southern Africa (Mary-Ann Davies), Western Africa (A. Azondekon) • The IeDEA Pediatric Working Group: Mary-Ann Davies (Chair), Melanie Bacon, Andrea Ciaranello, Rosemary McKaig, Lynne Mofenson, Robin Huebner, Lori Schwarze • Funders: NIAID, NICHD, NCI

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