Nigerian Journal of Paediatrics

4Outcomes of Paediatrics HIV care at the University of Nigeria Teaching Hospital Ituku Ozalla Enugu after ten years of service

Niger J Paediatr 2017; 44 (1): 22 – 25

ORIGINAL

Ubesie AC

Outcomes of Paediatrics HIV care

Iloh KK

Ayuk CA

at the University of Nigeria

Ibeziako SN

Teaching Hospital, Ituku-Ozalla,

Emodi JI

Enugu after ten years of service

Obumneme-Anyim I

DOI:http://dx.doi.org/10.4314/njp.v44i1.4

Accepted: 6th December 2016

Abstract : Background:

Anti-

teen of 555 enrolled children with

retroviral therapy is associated

complete data were included in the

Ubesie AC (

)

with improved survival among

data analysis. Two hundred and

Iloh KK, Ayuk CA, Ibeziako SN

HIV-infected children. In Nigeria,

sixty-seven (51.4%) were females.

Emodi JI

Department of Paediatrics,

HIV treatment scale up was ex-

Three hundred and thirty-nine par-

Faculty of Medical Sciences, College of

tended to children over a decade

ticipants (65.3%) were still in care,

Medicine, University of Nigeria, Enugu

ago. This poses new challenges of

12345 (23.7%) had been lost to

Campus. Enugu, Nigeria

sustained quality care.

follow up,

or 22 (4.2%) dead

Email: agozie.ubesie@unn.edu.ng

Aim: To determine the outcomes

while 35 (6.87%) were transferred

for HIV infected children and

out to other health facilities or into

Obumneme-Anyim I

factors that influenced retention in

the adult ART clinic. Factors asso-

Department of Paediatrics,

care at the University of Nigeria

ciated with retention in care were

University of Nigeria, Teaching

Teaching Hospital, Ituku/Ozalla,

both parents being HIV positive

Hospital, Ituku/Ozalla, Enugu Nigeria

Enugu.

(p<0.0001), commencement of

Methods: This was a study of HIV

HAART (p<0.0001) and HIV dis-

-infected children seen between

closure status of the child (Fisher’s

September 2004 and October

exact Test =0.003).

2015 and at the Paediatric HIV

Conclusions: About a quarter of

clinic of the University of Nigeria

our HIV-infected children were

Teaching Hospital, Ituku Ozalla,

lost to follow up. Prompt initiation

Enugu. Data collected include

of HAART and HIV disclosure

socio-demographics,

HAART

will positively influence retention

regimen and outcomes. Data

in care.

analysis were done with Statistical

Package

for Social Sciences

Key words: Paediatric HIV, chil-

(SPSS) version 19 (Chicago IL).

dren, outcomes, Enugu.

Results: Five hundred and nine-

Introduction

2004 with success stories.

6, 7

However, ARV treatment

scale-up among children in developing countries pre-

Since the beginning of the HIV epidemic, almost 78

sented both benefits and challenges. The benefits in-

million people have been infected with the virus and

cluded improved survival to adulthood, as well as reduc-

tion in HIV-related morbidity and mortality. There still

about 39 million people have died of HIV. In sub- Sa-

haran Africa, many communities and countries have

remain the persisting challenges to optimize scale-up

suffered from the ravages of the epidemic, making the

effectiveness especially in sub Saharan Africa. Treat-

sub-continent the epicenter of the scourge. More than

ment-eligible children living with HIV in sub-Saharan

90% of the children who acquired HIV infection live in

Africa are only about half as likely to receive antiretro-

viral therapy as HIV-positive adults. Non-disclosure of

sub-Saharan Africa and Nigeria has the highest burden

of paediatric HIV disease. The advent of highly active

HIV status to peri-natally infected children and adoles-

antiretroviral therapy (HAART) in mid-1990s revolu-

cents is still a major concern in the sub-region. These

tionized HIV treatment, and brought significant reduc-

have implications for adherence and treatment failure.

tion in HIV morbidity and mortality.

4, 5

The introduction

The life-long therapy also presents the challenge of

of HAART changed HIV disease from a nearly univer-

treatment fatigue, non-adherence to care and treatment

sally fatal and catastrophic illness to what is now often a

and loss to follow up among these children. All of these

manageable chronic illness. Subsequently, there was a

outcomes have implications for treatment failure in set-

scale-up of anti-retroviral (ARV) therapy around the

tings of already limited ARV options occasioned by

world. In Nigeria, ARV treatment scale-up started in

global financial meltdown. There is also the emerging

issue of transiting adolescents from the pediatric to adult

Results

care during which period emotional instability and peer

Characteristics

pressure may affect smooth and complete transition

among these adolescents.

Five hundred and nineteen of 555 enrolled children had

The University of Nigeria Teaching Hospital (UNTH) is

complete data and were included in the data analysis.

the largest HIV treatment center in south-east Nigeria

Two hundred and sixty-seven (51.4%) were females.

for over a decade. This study sought to evaluate the

The mean age of the participants was 9.9 ± 4.6 years

outcomes for HIV infected children at UNTH, Enugu

while the mean age at HIV diagnosis 5.2 ± 3.9 years.

since its inception of HIV services more than a decade

The median age of the study participants was 9.0 (range,

ago.

0.2 – 22.0) while the median age at HIV diagnosis was

4.2 (range, 0.1 – 16.6) as shown in Table 1. Two hun-

dred and thirty children (44.3%) had been orphaned

{(paternal, 103 (19.8%); maternal, 63 (12.1%); and dou-

Materials and methods

ble 64 (12.3%)}. Mother-to-child transmission ac-

Study site

counted for 481 (92.7%) of HIV transmission. Four hun-

dred and four (77.8%) were on HAART. Fifty-six of

The Paediatric HIV clinic was established at University

404 children on HAART (13.9%) had been switched to

of Nigeria Teaching Hospital, Enugu in March 2004. It

second line regimen. The longest duration on first and

is a weekly clinic created to provide care and treatment

second line HAART regimens were 10.8 and 6.0 years

for HIV-infected children. The clinic receives referrals

respectively. The mean duration of first and second line

from health facilities within and outside Enugu. It was

ARVs were 4.4 ± 2.6 and 4.5 ± 1.6 years respectively.

the pioneer Paediatric HIV Clinic in South-east Nigeria

The median duration (IQR) of first and second line regi-

but currently, more centers including missionary hospi-

mens were 3.8 (2.6 – 6.3) and 5.3 (3.5 – 5.7) years re-

tals now offer HIV care and treatment to children in the

spectively.

region.

Study population

Table 1: Characteristics of the study participants

Age of study participants (years)

All HIV positive children enrolled into care at the paedi-

Mean (SD)

9.9 (4.6)

atric HIV clinic since its inception.

Median (Range)

9.0 (0.2 – 22.0)

Age at HIV diagnosis

Data collection

Mean (SD)

5.2 (3.9)

Median (Range)

4.2 (0.1 – 16.6)

This was a retrospective study. The electronic medical

Sex

n (%)

records of all enrolled HIV infected children between

Male

252 (48.6)

September 2004 and October 2015 were critically re-

Female

267 (51.4)

viewed. Data extracted included gender, current age, age

Mode of HIV transmission

MTCT

481 (92.7)

at HIV diagnosis, socio economic class, use of first or

Blood transfusion/Sharps

17 (3.3)

second line ARV regimens (with duration), parental

Sexual abuse

2 (0.4)

HIV status and clinic outcomes (still in care, dead or

Unknown

19 (3.6)

lost to follow up (LTFU), referred/ transferred out).

Orphan status

n (%)

None

289 (55.8)

Data analysis

Maternal

63 (12.1)

Paternal

103 (19.8)

Retrieved data were analyzed using the Statistical Pack-

Double

64 (12.3)

age for Social Sciences (SPSS) version 19.0 (Chicago

HIV positive mothers

446 (85.9)

HIV positive fathers

319 (61.5)

IL). Descriptive statistics (mean and median) were used

Socio-economic class

n (%)

to summarize quantitative variables (age of study par-

Upper

24 (4.8)

ticipants, age at HIV diagnosis and ARV duration). Stu-

Middle

137 (27.4)

dent t test and Analysis of Variance (ANOVA) were

Lower

339 (67.8)

used to compare the means of continuous variables

Outcomes

n (%)

while chi- squared and Fisher’s exact tests were used to

Still in care

339 (65.3)

test for significant association of categorical variables.

LTFU

123 (23. 7)

All statistical tests were done at the 5% level of signifi-

Transferred/Referred

35 (6.8%)

cance and a p-value less than 0.05 was considered statis-

Dead

22 (4.2)

tically significant.

MTCT=mother-to-child transmission, LTFU=loss to follow

up, SD =standard deviation

Ethical Consideration

Ethical approval was obtained from the Health Research

and Ethics Committee of UNTH Enugu.

Three hundred and thirty-nine participants (65.3%) were

Table 3: HAART and retention in care

still in care, 12345 (23.7.3%) had been lost to follow up,

Still in Care

Dead/LTFU

p-value

or 22 (4.2%) were dead while 35 (6.87%) were trans-

HAART Regimen

n (%)

ferred out to other health facilities or into the adult ART

First-line

clinic. HIV statuses were known in 475 of the mothers

Yes

312 (83.4)

62 (16.6)

<0.0001

and 437 of the fathers. Four hundred and forty six of the

27 (24.5)

83 (75.5)

mothers (93.9 %) and 319 of fathers (73.0 %) were HIV-

Second-line

infected. Both parents of 316 participants (60.9%) were

Yes

43 (87.8)

6 (12.2)

0.54

279 (83.1)

55 (16.9)

HIV-infected while 203 (39.1%) were discordant cou-

ple. Data on HIV status disclosure was available in 361

LTFU = Lost To Follow Up, HAART = Highly active anti-

study participants. Seventy-four of them (20.5%) knew

retroviral therapy

their HIV status.

Determinants of the Outcomes

Age and Gender

Discussion

The mean age of those still in care, LTFU/dead and

An approximate two-third of the clients in our center

transferred/referred were 9.6 ± 4.4, 9.6 ± 4.5 and 13. 1 ±

was still in care while a third had either died or lost to

4.3 years respectively (F=9.49, df = 2, p<0.001). One

follow up. Our rate of retention in care was lower than

the previously reported 84.7% to 94.8% in Uganda. A

hundred and seventy-two of 267 (64.4%) females com-

pared to 167 of 252 (66.3%) males were still in care.

possible explanation could be the longer period of care

There was no statistically significant difference in the

in this study (11 years), compared to 7 years in the

proportion of males and females who had various out-

Ugandan study. A Malawian study showed that 50% of

comes ( χ = 0.52, df =2, p = 0.77).

HIV-infected persons initially classified as lost-to-

follow up were actually dead when contact tracing was

done. Although we did not do contact tracing, a size-

Parental HIV status

able proportion of children lost-to-follow up in this

Two hundred and twenty-five of 296 (76%) participants

study could be dead. There is also the possibility that

whose both parents were HIV positive compared to 114

clients initially accessing services transferred to treat-

of 188 (60.6%) HIV negative or discordant parents were

ment centers near their homes in the course of scale up.

still in care (p <0.001).

Our clients were more likely to remain in care and less

likely to die/ lost to follow up if both parents were HIV-

Orphan status

infected. Children need adults to access care and having

both parents requiring the same care invariably improve

One hundred and ninety-six of 222 non-orphans

the chances of children’s access to HIV care and treat-

(72.1%), 43 of 60 maternal (71.1%), 61 of 93 paternal

ment programs. In contrast, there was a higher rate of

(65.6%) and 39 of 59 double orphans were still in care

attrition among children of HIV discordant couples. This

( χ = 1.92, p = 0.59) as shown in Table 2.

may not be unrelated to the high social stigma surround-

ing HIV in our context. Lack of support from spouse

Table 2: Orphan status and retention in care

and non- disclosure to the extended family affects child’s

access to care and treatment. A cost-effective model for

Still in Care

Dead/LTFU

responding to the challenges of HIV prevention, treat-

Orphaned status

n (%)

ment and care in resource poor settings is family-

None

196 (72.1)

26 (27.9)

centered approach.

Maternal

43 (71.7)

17 (28.3)

Paternal

61 (65.6)

32 (34.4)

Double

39 (66.1)

20 (33.9)

Surprisingly orphan status did not affect adherence to

care and treatment. This is a good testament of the ex-

LTFU = Lost To Follow Up. χ = 1.92, p = 0.59

tended family support system in Africa. A study done in

Uganda demonstrated that extended families remain an

HAART Regimen

important source of care and support for AIDS orphaned

children and adolescents.

Thus, the HIV-infected or-

Three hundred and twelve of 378 (83.4%) study partici-

phan in Africa is guaranteed care and support through

pants on first line compared to 27 of 110 (24.5%) who

the extended family system.

were not on HAART were still in care (p<0.0001) as

shown in Table 3.

HIV-infected children on HAART were more likely to

remain in care compared to their counterparts who were

HIV Disclosure

yet to commence HAART. Receiving free anti-retroviral

drugs could have been an incentive to keep coming

Sixty of 65 participants (92.5%) whose knew their HIV

back. In the early years of the epidemic, there were

status compared to 206 of 271 (76%) with non-disclosed

stricter criteria for initiating children into HAART.

HIV status were still in care (Fisher’s exact Test

Adults were more likely to be initiated into HAART

than children. This obviously contributed to high rates

=0.003).

of deaths and lost-to-follow up among ARV naïve

children.

Conclusion

In this study, disclosure of HIV status to the child en-

sured adherence to care and treatment. HIV disclosure to

There is high rate of death/lost-to-follow up among our

infected children is empowering and makes them to be

cohort of HIV-infected children. Prompt initiation of

part of the decision making process concerning their

HAART, HIV disclosure and having both parents that

own health.

Though only about one-fifth of partici-

were HIV-infected were associated with retention in

pants who had data on disclosure status knew their HIV

care.

status despite the benefits associated with pediatric HIV

disclosure. There is need to sustain efforts in HIV dis-

closure among children especially those who were in-

fected peri-natally.

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