Temporal trends in baseline characteristics and treatment outcomes of children starting antiretroviral treatment: an analysis in four provinces in South Africa, 2004-2009.

BACKGROUND: Few studies describe temporal trends in pediatric antiretroviral treatment (ART) programs in sub-Saharan Africa. Adult studies show deteriorating patient retention in recent years. We describe temporal trends in baseline characteristics and treatment outcomes amongst ART-naive children between 2004 and 2009 at 30 facilities in 4 South African provinces. METHODS: Linear trend in baseline parameters between annual enrolment cohorts was assessed. Corrected mortality estimates were calculated, correcting for deaths amongst those lost to follow-up using probability-weighted Kaplan-Meier functions. On-treatment immunologic changes were modelled using generalized estimating equations. RESULTS: Three thousand and seven children (median age 6.4 years) were included. Monthly enrollment increased from 1.9 children in 2004 to 106 in 2009. Proportions with severe baseline immunodeficiency decreased from 85.5% to 64.5% between 2004/2005 and 2009, P < 0.0005. Proportions with baseline World Health Organization clinical stages III and IV reduced from 72.9% to 49.0% between 2006 and 2009, P < 0.0005. Later calendar cohorts had independently and progressively reduced on-treatment probabilities of severe immunodeficiency despite adjusting for baseline immunological status, adjusted odds ratio: 0.38 [confidence interval (CI): 0.26 to 0.55; P < 0.0005; 2008/2009 compared with 2004/2005]. After 24 months, corrected mortality was 6.1% (CI: 5.1% to 7.3%) and loss to follow-up was 6.8% (CI: 5.7% to 8.2%), with no deterioration amongst more recently enrolled cohorts (P = 0.50 and P = 0.55, respectively). After 4 years, program retention was 84.1% (CI: 80.9% to 86.7%). CONCLUSIONS: Childrens' baseline condition when starting ART has improved considerably. Improving immunological treatment outcomes, the high medium-term patient retention with lack of temporal deterioration despite rapid patient number increases, provide evidence that pediatric ART programs are increasingly effective for those accessing them. However, children must start treatment when younger, following current international guidelines.