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PLoS One. 2013 Dec 9;8(12):e81037. doi: 10.1371/journal.pone.0081037. eCollection 2013.

Temporal trends in the characteristics of children at antiretroviral therapy initiation in southern Africa: the IeDEA-SA Collaboration.

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School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
Lighthouse Trust Clinic, Kamuzu Central Hospital, Lilongwe, Malawi.
Gugulethu Community Health Centre and Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
Newlands Clinic, Harare, Zimbabwe.
Médecins Sans Frontières South Africa and Khayelitsha ART Programme, Khayelitsha, Cape Town, South Africa.
Centre for Infectious Disease Research in Zambia, Lusaka, Zambia and University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa.
Wits Reproductive Health and HIV Institute, Harriet Shezi Children's Clinic, Chris Hani Baragwanath Hospital, Faculty of Health Sciences, University of Witwatersrand, Soweto, Johannesburg, South Africa.
Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa.
Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch, South Africa.
Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital and University of Witwatersrand, Johannesburg, South Africa.
Sinikithemba Clinic, McCord Hospital, Durban, South Africa.
Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
Red Cross Children's Hospital and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa.



Since 2005, increasing numbers of children have started antiretroviral therapy (ART) in sub-Saharan Africa and, in recent years, WHO and country treatment guidelines have recommended ART initiation for all infants and very young children, and at higher CD4 thresholds for older children. We examined temporal changes in patient and regimen characteristics at ART start using data from 12 cohorts in 4 countries participating in the IeDEA-SA collaboration.


Data from 30,300 ART-naïve children aged <16 years at ART initiation who started therapy between 2005 and 2010 were analysed. We examined changes in median values for continuous variables using the Cuzick's test for trend over time. We also examined changes in the proportions of patients with particular disease severity characteristics (expressed as a binary variable e.g. WHO Stage III/IV vs I/II) using logistic regression. Between 2005 and 2010 the number of children starting ART each year increased and median age declined from 63 months (2006) to 56 months (2010). Both the proportion of children <1 year and ≥10 years of age increased from 12 to 19% and 18 to 22% respectively. Children had less severe disease at ART initiation in later years with significant declines in the percentage with severe immunosuppression (81 to 63%), WHO Stage III/IV disease (75 to 62%), severe anemia (12 to 7%) and weight-for-age z-score<-3 (31 to 28%). Similar results were seen when restricting to infants with significant declines in the proportion with severe immunodeficiency (98 to 82%) and Stage III/IV disease (81 to 63%). First-line regimen use followed country guidelines.


Between 2005 and 2010 increasing numbers of children have initiated ART with a decline in disease severity at start of therapy. However, even in 2010, a substantial number of infants and children started ART with advanced disease. These results highlight the importance of efforts to improve access to HIV diagnostic testing and ART in children.

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