Mortality rate among HIV-positive children on ART in Northwest Ethiopia: a historical cohort study

Alebel et al. BMC Public Health (2020) 20:1303 https://doi.org/10.1186/s12889-020-09418-6 RESEARCH ARTICLE Open Access Mortality rate among HIV-positive children on ART in Northwest Ethiopia: a historical cohort study Animut Alebel1,2* , Eshetu Haileselassie Engeda3, Mengistu Mekonnen Kelkay3, Pammla Petrucka4,5, Getiye Dejenu Kibret1,2, Fasil Wagnew1, Getnet Asmare6, Zebenay Workneh Bitew7, Daniel Bekele Ketema1, Getnet Gedif1, Belisty Temesgen8, Yitbarek Tenaw Hibstie8, Mamaru Wubale Melkamu8 and Setegn Eshetie3 Abstract Background: Though highly active antiretroviral therapy (HAART) has been available for more than a decade in Ethiopia, information regarding mortality rates of human immunodeficiency virus (HIV)-positive children after antiretroviral therapy antiretroviral therapy (ART) initiation is very scarce. Thus, this study intends to determine the predictors of mortality among HIV-positive children receiving ART in Amhara Region. Methods: A multicenter facility-based historical cohort study was conducted in 538 HIV-positive children on ART from January 2012 to February 2017. We employed a standardized data extraction tool, adapted from ART entry and follow-up forms. Descriptive analyses were summarized using the Kaplan-Meier survival curve and log rank test. Then, the Cox-proportional hazard regression model was employed to estimate the hazard of death up to five-years after ART initiation. Variables with p-values ≤0.25 in bivariable analysis were candidates to the multivariable analysis. Finally, variables with p-values < 0.05 were considered as significant variables. Results: The cohort contributed a total follow-up time of 14,600 child-months, with an overall mortality rate of 3.2 (95% CI: 2.3, 4.3) per 100 child-years. This study also indicated that HIV-infected children presenting with opportunistic infections (OIs) (AHR: 2.5, 95% CI: 1.04, 5.9), anemia (AHR: 3.1, 95% CI: 1.4, 6.7), severe immunodeficiency (AHR: 4.4, 95% CI: 1.7, 11.7), severe stunting (AHR: 3.3, 95% CI: 1.4, 8.0), severe wasting (AHR: 3.1, 95% CI: 1.3, 7.3), and advanced disease staging (III and IV) (AHR: 3.0, 95% CI: 1.2, 7.1) were at higher risk of mortality. Conclusion: A higher rate of mortality was observed in our study as compared to previous Ethiopian studies. HIVpositive children presenting with anemia, OIs, severe immunodeficiency, advanced disease staging (III and IV), severe stunting, and severe wasting were at higher risk of mortality. Keywords: Amhara region, Ethiopia, ART, HIV-positive, Mortality * Correspondence: 1 College of Health Science, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia 2 Australian Centre for Public and Population Health Research, School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Alebel et al. BMC Public Health (2020) 20:1303 Background Human immunodeficiency virus (HIV) remains a serious public health concern worldwide, but low and middleincome countries (LMICs) are the most affected. In 2018, approximately 37.9 million people were living with HIV worldwide, of whom 1.8 million were children (age < 15 years) [1]. Sub-Saharan Africa (SSA) is a disproportionally affected region contributing to approximately 91% of HIV-positive children in 2012 [2]. Globally, Acquired Immune Deficiency Syndrome (AIDS) remains the leading cause of mortality among children, resulting in 190,000 children deaths in 2013 [3]. In Ethiopia, 109,133 children are living with HIV and approximately 2420 are newly infected with HIV annually [4]. The use of anti-retroviral therapy (ART) has been effective in reducing mortality markedly among infected children and adolescents [5]. In this regard, the World Health Organization (WHO) exceeded its target of 15 million ART users by the end of 2015. Likewise, the Ethiopian government launched cost-based ART in 2003 and cost-free ART in 2005, delivered as part of comprehensive HIV/AIDS care [6]. As a result, ART coverage among children in Ethiopia has increased from 9% in 2013 to 58% in 2018 [7]. According to the recent Ethiopian Demographic and Health Survey (EDHS, 2016), child mortality in Ethiopia was reported as 67 per 1, 000 live births. In our study area (Amhara Region), child mortality rate was reported as 85 per 1, 000 live births [8]. Despite different interventions undertaken by the Ethiopian government, the mortality rate among HIV infected children remains higher than the general pediatric population. Previous studies done in Ethiopia reported that the mortality rate in HIV-positive children receiving ART ranged from 1.4 deaths per 100 child-years of observation [9] to 4 deaths per 100 child-years of observation [5]. These studies also reported that many factors significantly increased the risk of mortality in this population. For example, baseline anemia (Hgb < 10 g/dL) [5, 9], low CD4 count [5], advanced WHO clinical disease staging (III & IV) [5, 9], poor ART drug adherence [10], and malnutrition [11] were reported as factors significantly increasing risk of mortality in HIV-positive children receiving ART. Obtusely, well-organized and up-to-date information concerning mortality rate of HIV-positive children after ART initiation is highly recommended to provide quality care to HIV-positive children. However, although Amhara region has a particularly high child mortality rate, a minimal number of studies have been conducted in this area. Further, even though a few studies have been conducted in Ethiopia, these studies have failed to consider important predictors, such as malnutrition and developmental status of the children, which significantly affect Page 2 of 11 the mortality rate of HIV-positive children [11, 12]. Thus, this study was conducted to address this knowledge and evidentiary gap by identifying the predicto (...truncated)