Background
Despite accounting for 3% of all people living with HIV, children (<15 yo) represented 12% of all AIDS-related deaths globally in 2023. Interruptions in HIV treatment (IIT) have been associated with higher mortality among children living with HIV (CLHIV). To explore this association further, we analyzed IIT and mortality data among CLHIV in PEPFAR-supported countries in the last 4 fiscal years, FY21 – FY24.
Methods
We analyzed PEPFAR Monitoring, Evaluation, and Reporting data for all CLHIV <15 yo on ART with IIT between October 2020 and June 2024 (FY21-FY24) from 32 PEPFAR-supported country and regional programs. IIT was defined as having no clinical contact or ART pick-up for >28 days since the last clinical encounter. IIT data was disaggregated based on cause and included transferred out, refused treatment, unknown IIT after <3 months, 3-5 months, or 6+ months on ART, or died. Mortality data was further disaggregated by cause of death including HIV disease resulting in tuberculosis (TB), cancer, infectious or parasitic disease, or other HIV disease; other natural causes; non-natural causes; and not reported cause. Prevalence of these outcomes were calculated across quarters and by five-year age bands.
Results
Among 490,000 CLHIV on ART in PEPFAR-supported countries, 22,329 experienced IIT in FY24. IIT occurred most frequently after 6+ months on ART among all CLHIV, except for those <1 (Figure 1). Among CLHIV on ART, IIT due to death was highest among children <5 yo, ranging from 0.47% to 1.88% (Figure 1). In FY24, HIV-related mortality accounted for 43% of all reported causes. This proportion remained relatively unchanged across the analysis period, but TB-related deaths increased from 6% in FY21 to 9% in FY24 (Figure 2). Data completeness improved as 80% of deaths in FY24 included an identified reported cause compared to 65% in FY21.
Conclusions
CLHIV experienced notable rates of IIT and mortality, with CLHIV <5yo experiencing a disproportionate share of these outcomes, underscoring the importance of targeted interventions such as early diagnosis of HIV and differentiated service delivery models that support retention in care. Further analyses are needed to better understand the drivers of IIT and causes of mortality among CLHIV on ART. Improving pediatric data reporting is crucial to accurately determine HIV-related deaths (i.e. death audits), identify programmatic gaps and focus resources on reducing preventable deaths.
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