1. Risk of death among those awaiting treatment for HIV infection in Zimbabwe: adolescents are at particular risk ZIMA CONGRESS 20-23 AUGUST 2015 VICTORIA FALLS

2. ARTICLE in JOURNAL OF THE INTERNATIONAL AIDS SOCIETY · FEBRUARY 2015 AUTHORS: Amir Shrouf,1, Wedu Ndebele2,3, Mary Nyathi2, Hilary Gunguwo2,3, Mark Dixon2,3, Jean F Saint-Sauveur1, Fabian Taziwa1, Mari C Vin ̃oles1 and Rashida A Ferrand4 Authors’ affiliations 1Me’decins Sans Frontie`res, Harare, Zimbabwe; 2Mpilo OI/ART Clinic, Bulawayo, Zimbabwe; 3Faculty of Medicine, National University of Science and Technology, Bulawayo, Zimbabwe; 4Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK Competing interest The authors declare that they have no conflicts of interest.

3. Introduction There has been a rapid scale up of ART in sub Saharan Africa over the last decade This has led to increased survival rates in HIV Focus has been on outcomes in those who start ART. Those awaiting ART, have largely been overlooked in most programmes Mortality and LTFU is high in this group

4. Introduction Delayed presenation and diagnosis are thought to be responsible for mortality in adolescents. A significant number of perinatally acquired HIV reach adolescence un diagnosed, in Zimbabwe Unnecessary further delay at registration can compound this. We therefore conducted a retrospective study to investigate the following:

5. Introduction Retention in care Mortality in the pre ART period Factors associated with early mortality in adults and adolescents at Mpilo central hospital HIV clinic.

6. Methods ART STARTED 2004 STUDY PERIOD ENROLLMENT 2004-2010 AT Mpilo At the time was done by Mpilo staff as well as partners like MSF. Eligibility were adults and adolescents(10- 19yrs WHO), at registration Pre ART, time from registration to initiation

7. Methods LTFU defined as missing scheduled appointment by 3 or more months Data collection: was entered into FUCHIA, software systematically Statistical analysis: used STATA version 10 Comparison of means and proportions were done using two tailed T-tests & Chi square test for normally distributed data & Man-Whitney U- test for non normal distribution data Linear regression was used for secular trends in early mortality.

8. Ethical consideration Only routine data was used hence no written consents were required, as no personal information was extracted. The Mpilo central hospital ethical board also approved the study

9. Results Dermographic and registration data was missing for 167 records, which were excluded 1973 adolescents & 11106 adults completed initial registration at this clinic 345 adolescents and 2056 had insufficient data to determine ART eligibilty hence were excluded from the study. There was no difference in the hazard of mortality between those excluded and the study p= 0,37

10. Results 1628 adolescents and 9050 adults were included in the study analysis 1382(85%) adolescents & 7557(84%) adults satisfied ART eligibility at that time of enrollment.

11. Results Baseline characteristics of patients characteristi cs totaladultsadolescentsP- value Total patients 1067890501628- Median age- years(IQR) 34,736,613,1- Male35%32%47%<0,001 Prev ARV Hx14%15%3%<0,001 VCT self referral 16%18%3%<0,001 %eligible for ART 84% 85%0,164 WHO stage 3/4 74%73%83%<0,001 Median CD4 count(IQR) 167162210<0,001 CD4 <20058%60%49%<0,001 Haemoglobi n < 11 g/dl 85%40%47%0,005 Pulmonary TB 10%9%11%0,055 Severe Pneumonia 3%2%4%<0,001

12. Results – secular trends in eligibility and early mortality yearNumbers Adolesc/ad ults Never started ART Ado/adults Median(IQT ) in days pre ART NO, who died in first year 200469/7849/183 21/0 ♯ 16/137 2005117/119413/21945/6513/123 2006170/119519/110 23/21 ♯ 15/59 ♯ 2007224/76828/6721/1913/43 2008259/116231/114 19,5/14 ♯ 12/22 ♯ 2009260/124615/100 14/14 ♯ 13/32 ♯ 2010283/120823/149 14/14 ♯ 21/12 ♯ ♯ P<0,05

13. Discussion Adolescents are significantly at higher risk of death than adults while awaiting ART, probably due to late diagnosis & more advanced disease. Most adolescent were treatment naïve If most were vertically infected then there was delayed diagnosis. There are inadequate current case finding strategies in children.( Is this ethical?)

14. Discussion VCT services though scaled up in this period, this was for adults Testing among adolescents was primarily in hospital, presenting with illness Delays in ART were possibly due to a number of factors: parent or gaurdian dependency, lack of money for transport, & lack of independent access to services. LTFU was 10%, reasons to explored in this study

15. Recommendations There is need for more innovative HIV case finding and testing services in adolescents, such as allowing access to VCT centers. There will be need to link this to care and treatment Defaulter tracing must include those who have yet started ART, especially in adolescents

16. Acknowledgements We would like to thank all the MOHCC, at Mpilo, Hospital MSF Staff who worked in OI The parents/gaurdians and clients who attended the clinic, at the time. All the reviewers, and authors.

17. Thank You and GOD BLESS YOU