1. Retention across the continuum of care in a cohort of HIV infected children in rural India G. Alvarez-Uria RDT Hospital, Department of Infectious Diseases, Bathalapalli, India

2. Disclosures None

3. HIV diagnosis Linkage Entry into care Retention ART initiation Retention Virological suppression Adherence

4. Background Although the cascade of care have been described in adults in different parts of the world, data about the retention across the continuum of care in children is not well know It is estimated that only one third of children who need ART are receiving it (UNAIDS 2012).

5. Methods Cohort study of children diagnosed with HIV between 2007 and 2012 in Bathalapalli RDT hospital, in Anantapur, a rural district in Andhra Pradesh We describe the attrition (loss to follow up [LTFU] or mortality) at each stage of care Children LTFU were actively searched for by phone calls and home visits

6. Statistical analysis Time to event methods Mortality, LTFU and the event of interest (entry into care, ART initiation) were considered competing events Competing risk analysis was used to estimate cumulative incidence and to perform univariate and multivariable analysis (Coviello 2004, Stata Journal 4:103)

8. Baseline characteristicsN (%) Age <18 months65 (12.43) 18-59 months197 (37.67) 5-9 years179 (34.23) 10-15 years82 (15.68) Gender Female267 (51.05) Male256 (48.95) HIV transmission Vertical512 (97.9) Other11 (2.1) Time to the clinic <=30 min139 (26.58) 31-90 min212 (40.54) >90 min172 (32.89) Status of parents Alive287 (54.84) Father died119 (22.75) Mother died51 (9.75) Both died66 (12.62)

12. Results (cont’d) Viral load was available in 82% of children who started ART 72.6% had viral load <400 copies/ml after a median of 31 months on ART (IQR 18–63)

14. Factors associated with delayed or no entry into care Age < 18 months Living >90 min from the hospital When HIV diagnosis of the child was made after the HIV diagnosis of the mother

15. Factors associated with attrition LTFU – Poor socio-economic conditions – Living >90 min from the hospital Mortality – Poor socio-economic conditions – Age >10 years – Low CD4 count (for age)

16. Limitations The proportion of children who did not enter into care is likely to be an underestimation, because we do not have data about all children diagnosed with HIV in the district Children LTFU might have enrolled in other HIV clinics / ART centres

17. Conclusions Fewer than half of children diagnosed with HIV followed all stages of care up to the achievement of virological suppression Half of the attrition occurred before starting ART. – Most research and funding have focused on the reduction of morbidity and mortality of children on ART. – We should place more emphasis on promoting research on interventions to reduce the attrition in the pre-ART period The cascade of care can be used as a tool for service providers and policy makers to examine gaps in the quality of care given to children living with HIV

18. Thank you