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AIDS. 2019 Sep 2. doi: 10.1097/QAD.0000000000002366. [Epub ahead of print]

Attrition of HIV-positive children from HIV services in low- and middle-income countries: a systematic review and meta-analysis.

Author information

Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
These authors contributed equally to the work.
Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA.
School of Nursing, Vanderbilt University, Nashville, Tennessee, USA.
Yale School of Public Health, Yale University, New Haven, Connecticut, USA.
Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut, USA.



Identification and retention of HIV-positive children in HIV services is essential to ensure optimal health outcomes. This systematic review and meta-analysis examines the magnitude of attrition (loss to follow-up [LTFU] and death) of HIV-positive children from HIV services in low- and middle-income countries (LMICs).


We performed a comprehensive multi-database search of original studies reporting retention/attrition data for HIV-positive children in LMICs through April 2016. Outcomes included LTFU, death, and overall attrition (LTFU + death) at intervals up to 60 months of follow-up. At least two authors determined study eligibility, performed data extraction, and made quality assessments. We used random effects meta-analytic methods to aggregate effect sizes and perform meta-regression analyses.


We identified 3,040 unique studies; 91 met eligibility criteria and were included in the analysis. This represents 147,129 HIV-positive children; most were from Africa (83%). LTFU definitions varied widely, with significant variability in outcomes across studies. Most attrition occurred in the first six months of follow-up, increasing to 23% by 36 months. HIV-positive children receiving antiretroviral therapy (ART) had significantly better retention in care than those not on ART. Studies that performed case-finding/tracing for those LTFU had better retention in care up to 24 months of follow-up.


These findings underscore the high attrition of children from HIV services in LMICs. Early ART initiation and decentralized patient support services (e.g., tracing for those LTFU) have potential to improve retention in care. Implementation research and resources are urgently needed to improve retention among this vulnerable population.

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