Desmonde S, et al. - Researchers explored this analysis in order to better understand the continuum of care from HIV diagnosis to antiretroviral therapy (ART) initiation in HIV-infected children and in collaboration with WHO as well as examined the time from enrollment into HIV care to ART initiation in HIV-infected children within the International Epidemiology Databases to Evaluate AIDS (IeDEA) Global Cohort Consortium. By 24 months, 68% of HIV-infected children started ART. Findings suggested that there was a substantial risk of loss to follow-up [LTFU] before ART initiation, which could also represent undocumented mortality. Many obstacles to ART initiation remained, with substantial inequities in 2015. In order to reach the target of treating 90% of HIV-infected children with ART, more effective and targeted interventions to improve access was required.

Methods

• For this analysis, 135,479 HIV-1-infected children, aged 0–19 years and ART-naïve at enrollment, between 1 January 2004 and 31 December 2015, in IeDEA cohorts from Central Africa (3 countries; n = 4,948), East Africa (3 countries; n = 22,827), West Africa (7 countries; n = 7,372), Southern Africa (6 countries; n = 93,799), Asia-Pacific (6 countries; n = 4,045), and Latin America (7 countries; n = 2,488) was included.
• In these cohorts, follow-up was typically every 3–6 months.
• Time to ART initiation and missed opportunities (death or loss to follow-up [LTFU]: last clinical visit >6 months) since baseline (the date of HIV diagnosis or, if unavailable, date of enrollment) was described.
• Finally, cumulative incidence functions (CIFs) for and determinants of ART initiation were computed, with death and LTFU as competing risks. 

Results

• The study findings suggested that among the 135,479 children involved, 99,404 (73.4%) initiated ART, 1.9% died, 1.4% were transferred out, and 20.4% were lost to follow-up before ART initiation.
• It was observed that the 24-month CIF for ART initiation was 68.2% (95% CI: 67.9%–68.4%); it was lower in sub-Saharan Africa—ranging from 49.8% (95% CI: 48.4%–51.2%) in Central Africa to 72.5% (95% CI: 71.5%–73.5%) in West Africa—compared to Latin America (71.0%, 95% CI: 69.1%–72.7%) and the Asia-Pacific (78.3%, 95% CI: 76.9%–79.6%).
• The findings demonstrated that adolescents aged 15–19 years and infants <1 year had the lowest cumulative incidence of ART initiation compared to other ages: 62.2% (95% CI: 61.6%–62.8%) and 66.4% (95% CI: 65.7%–67.0%), respectively.
• It was noted that 49.1% were ART-eligible per local guidelines at baseline, of whom 80.6% initiated ART.
• Lower cumulative incidence of ART initiation was found in the following children: female children (p < 0.01); those aged <1 year, 2–4 years, 5–9 years, and 15–19 years (vs those aged 10–14 years, p < 0.01); those who became eligible during follow-up (vs eligible at enrollment, p < 0.01); and those receiving care in low-income or lower-middle-income countries (p < 0.01).
• Left truncation and survivor bias, caused by deaths of children prior to enrollment, and use of enrollment date as a proxy for missing data on date of HIV diagnosis, which could have led to underestimation of the time between HIV diagnosis and ART initiation were the included main limitations of the study.