Pediatric HIV care and treatment services in Tanzania: implications for survival

The 2015 Spectrum model estimates 142,000 Tanzanian children, under the age of 15 years, are infected with human immunodeficiency virus (HIV) [1], and current guidelines state all should be given Antiretroviral Therapy (ART) [2]. Without ART approximately 50% of HIV infected children die before the age of two, and one-third of those who survive past two die before 5 years of age [3]. Improving child survival for HIV exposed and infected children remains an important agenda in Tanzania [4]. Promoting universal access to available HIV care and treatment services is important for improving survival of HIV-infected individuals, especially children [5].

The encouraging success of ART, which includes effective prevention of mother-to-child transmission, has led to ambitious calls to eliminate HIV as a public health threat by 2030 [6]. Achievement of these goals, including the United Nations Programme on HIV/AIDS (UNAIDS) 90–90-90 targets, which aim to have 90% of people living with HIV know their status, 90% of those detected treated with ART, and 90% of those receiving treatment achieving viral load suppression [7], requires a coordinated global scale-up of prevention programmes, pre-exposure prophylaxis (PrEP), and detection and treatment programmes [8].

On its part, the government of the United Republic of Tanzania has laid out goals aiming at zero new HIV infections, zero discrimination and zero HIV related deaths in the population, including children, by 2017 [9]. These goals guide interventions that contribute to improving access to HIV services, especially for vulnerable groups like children.

It is well known that universal access to HIV care and treatment services contributes to improved quality of life, and thus economic, social and political development of society [10], which is in keeping with the United Nations (UN) sustainable goals number 3 [11]. The National AIDS Control Programme (NACP) in Tanzania is aiming at providing antiretroviral medicines (ARVs) to People Living with HIV and AIDS (PLHIV). The main focus is to improve access to ART services in order to reduce HIV related morbidity and mortality, especially among children. Due to this, Ministry of Health in Tanzania requires that paediatric HIV statistics be made available and utilized for policy and decision-making. This report summarizes progress made in providing HIV care and treatment services to children in Tanzania and highlights challenges in achieving universal access for ART to HIV-infected children. The information in this report contributes to the monitoring of Pediatric HIV and AIDS program in Tanzania.

Our results show that the number of children enrolled into HIV care and treatment programme per year is between 6700 and 8000 and that the proportion of girls is slightly higher compared to boys. Almost 72% of the enrolled children were eligible for ART at the time of enrolment, and that almost half (46%) were in WHO stages III and IV, indicative of advanced disease stage. Mortality rate among the enrolees was about 8%, and the hazard was substantially higher among younger children not on ART compared to those on ART.

Provision of ART as soon as the child is diagnosed is the biggest factor in improving survival, with a hazard of mortality in the first year of life, at 15% for children on ART, compared to 26% for children not on ART. Children who were on ART had around 10–15% higher survival over time. However, from 4 years of age onwards, there was little difference in the hazards between children irrespective of ART status. It is likely that children who reach older ages without having started treatment are likely to be be “long term non-progressors”, refering to individuals who are infected with HIV, but maintain a CD4 count greater than 500 without antiretroviral therapy with a detectable viral load [14].

The benefits of ART observed in this study have been demonstrated in several studies showing significant reduction mortality with early ART initiation, within the first 12 weeks of life [15‐23], accompanied with a greater than 90% probability of survival into adulthood [24].

Our study revealed a number of significant challenges that need considerable attention by National AIDS Control Programme and other stakeholders involved in the provision of paediatric HIV care and treatment services in Tanzania. We noted that i) most children have advanced disease at the time of enrolment ii) approximately two-thirds of children were missing a baseline CD4 measurement and only 35% of children had either a CD4 count or percentage recorded, indicating limited access to CD4 testing services, and iii) 31% were lost to follow-up (LTFU).

It is therefore a critical public health priority to address these challenges for a successful expansion of paediatric HIV care and treatment services in Tanzania. Strategies for early diagnosis of HIV-infected children and linking them to care and treatment services are essential. Besides this, minimizing the current attrition rates, which have also been observed in clinical settings across all HIV programs in Africa, with overall attrition rates ranging from 10% to more than 50% at 24 months [25‐30], mainly because of loss to follow-up (LTFU) or AIDS-related death [27, 31]. One possible explanation of the high rates of LTFU could associated with the quality of the data collection and reporting systems, which is a common challenge of health information systems in resource-limited settings [32‐34]. Improving capacity for systematic monitoring and accurate reporting may reduce the number of patients LTFU, particularly for sites that rely on paper-based monitoring systems.

Despite these challenges it was encouraging to note that majority of children had good nutrition status, with only 2–4% of children severely malnourished and that nutritional status improved with time on ART. Furthermore, only 2–3% of children were diagnosed with TB at the time of enrolment and that the proportion of children on Cotrimoxazole was high (70–74%).

Significant progress has been made regarding provision of paediatric HIV care and treatment in Tanzania. On average 7000 children are enrolled annually, and that approximately two thirds of children diagnosed under the age of 2 years were initiated on ART within a month. Provision of ART as soon as the child is diagnosed is the biggest factor in improving survival, with a hazard of mortality in the first year of life, at 15% for children on ART, compared to 26% for children not on ART. However we noted that i) most children had advanced disease at the time of enrolment ii) approximately two-thirds of children were missing a baseline CD4 measurement and only 35% of children had either a CD4 count or percentage recorded, indicating limited access to CD4 testing services, and iii) 31% were lost to follow-up (LTFU). These challenges underscore the need for more aggressive strategies to increase enrolment and retention of children in such settings. Evidently more work is needed to link HIV-infected children to HIV services.