Prevalence and Predictors of Pediatric HIV Therapy Failure in a Tertiary Hospital in Asmara, Eritrea: A 15-year Retrospective Cohort Study

Introduction: Timely recognition of combined antiretroviral therapy (cART) failure in resource-constrained settings is cumbersome. This study investigated the prevalence, incidence, and predictors of first-line cART failure using the virologic (plasma viral load), immunologic and clinical criteria among HIV-infected children. Methods: : A retrospective cohort study of all the children who followed in Orotta National Pediatric Referral Hospital from January 2005 to December 2020 was conducted. Predictors for cART failure from baseline and follow-up characteristics were explored in unadjusted and adjusted Cox-proportional hazard regression models. Results: : Out of 724 children with at least 24 weeks follow-up 279 experienced therapy failure (TF) making prevalence of 38.5% (95% CI 35-42.2), with a crude incidence of failure of 6.5 events per 100-person-years (95% CI 5.8-7.3). In the adjusted Cox proportional hazards model, independent predictors of TF were suboptimal adherence (Adjusted Hazard Ratio (AHR)=2.9, 95% CI 2.2–3.9, p < 0.001), cART backbone other than Zidovudine and Lamivudine (AHR=1.6, 95% CI 1.1–2.2, p=0.01), severe immunosuppression (AHR = 1.5, 95% CI 1–2.4, p =0.04), wasting or weight for height z < -2 (AHR = 1.5, 95% CI 1.1–2.1, p =0.02), late cART initiation calendar years (AHR =1.15, 95% CI 1.1-1.3, p < 0.001), and older age at cART initiation (AHR =1.01, 95% CI 1-1.02, p < 0.001). Conclusions: : Seven in hundred children on first-line cART are likely to develop TF every year. Efforts should be made in; exploring factors associated with suboptimal adherence, adherence support, and integrating nutritional care into the clinic. Empowering the setup with the capacity to perform viral loads regularly and studies on resistance-associated mutations (RAMs) would increase the likelihood of early detection and timely management of TF.