Background:
Children living with HIV (CLHIV) < 5 years old (yo) not on antiretroviral treatment (ART) experience disproportionately high mortality. Mortality risk among those on ART is less clear. We aimed to describe and compare mortality risk among CLHIV < 5 yo on ART with that of older people living with HIV (PLHIV) ≥5 yo on ART.
Methods:
We analyzed US President’s Emergency Plan for AIDS relief (PEPFAR) Monitoring, Evaluation, and Reporting data collected quarterly from all PEPFAR-supported sites globally during October 2019-March 2022. We described the total number of deaths reported, proportion of those on ART who died (number of reported deaths in the current reporting quarter divided by the sum of PLHIV on ART in the previous reporting quarter and PLHIV started on ART in the current reporting quarter), and viral load suppression rates (VLS: proportion of PLHIV on ART with VL result reported who were virally suppressed [HIV RNA < 1000 copies/mL]). Crude mortality ratios (CMR) were calculated comparing proportion who died among CLHIV < 5 yo (stratified by < 1 and 1-4 yo to differentiate infants from other children < 5 yo) and PLHIV ≥5 yo (stratified by 5-14, 15-49, and ≥50 yo) on ART during Oct 2019-Mar 2022.
Results:
From Oct 2019-Mar 2022, on average 123,636 CLHIV < 5 yo were on ART each quarter (n=14,152 < 1 yo and n=109,484 1-4 yo); in total 7,949 CLHIV < 5 yo on ART died (n=1,510 < 1 yo and n=6,439 1-4 yo) over this period. CLHIV < 1 yo on ART were more likely to die compared to PLHIV on ART 5-14 yo (CMR 7.6, range by quarter 5.2-10.6), 15-49 yo (CMR 6.0, range 4.8-8.1) and ≥50 yo (CMR 3.1; range 2.2-4.1). CLHIV 1-4 yo on ART were also more likely to die compared to those 5-14 yo (CMR 4.2, range 2.9-5.0), 15-49 yo (CMR 3.3, range 2.3-4.0) and ≥50 yo (CMR 1.7; range 1.2-2.1, Figure). Average VLS among CLHIV < 1 and CLHIV 1-4 yo were 78% and 72%, respectively, compared to 84%, 94%, and 96% of those 5-14, 15-49 and ≥50 yo, respectively.
Conclusions:
PEPFAR program data suggest CLHIV < 5 yo on ART, specifically those < 1 and 1-4 yo, have higher risk of death compared to PLHIV 5-14, 15-49, and ≥50 yo on ART. Suboptimal VLS suggests inadequately treated HIV may be a factor. More granular data can help better understand confounding and causal factors related to mortality of CLHIV < 5 yo. These findings further highlight the health inequities that CLHIV < 5 yo experience and the importance of global efforts to improve their health.
Crude Mortality Ratios (CMR) comparing proportion who died among children < 5 years old (yo) living with HIV on antiretroviral treatment (ART) and older people ≥5 yo living with HIV on ART during October 2019-March 2022 in all PEPFAR supported sites. 