Survival Dynamics: Mortality Rates and its Predictors among HIV-Infected Pediatric Patients on Antiretroviral Therapy after the Era of Test and Treat Strategy in Amhara Region, Ethiopia

Abstract

Background Mortality rates after starting antiretroviral therapy (ART) remain higher in resource-limited areas compared to developed countries. In low-income settings, children often begin ART with higher viral loads and lower CD4 counts. Ethiopia’s national ART guidelines, introduced in 2014 based on WHO recommendations, advocate for universal ART for children to reduce mortality and improve health outcomes. However, there is limited data on mortality rates and their predictors since these guidelines were implemented. Therefore, this study was aimed to figure out these issues. Methods A retrospective cohort study was conducted on 612 children undergoing ART in Comprehensive Specialized Hospitals in the Amhara region of Ethiopia from January 1, 2015, to December 30, 2024. Participants were selected through simple random sampling. Data were processed using EPi Info 7 and analyzed in STATA-17, employing actuarial life table analysis to estimate mortality rates and Kaplan-Meier analysis for comparing time to death across groups. Cox proportional-hazard regression was applied to identify mortality predictors, using a significance level of P < 0.05. Results Of 602 included children initiated on ART during the follow-up period, 45(7.5%) died. The overall median (IQR) follow-up time was 47 (26-60) months. The overall death rate was 2.1 (95% CI: 1.6-2.8) per 100 person-years of follow-up. The predictors of mortality among children initiated ART were; Baseline CD4 count below the threshold [AHR: 2.6; 95% CI: 1.2-5.8], opportunistic infections [AHR: 3.7; 95% CI: 1.7-7.9], Poor adherence to treatment [AHR: 2.9; 95% CI: 1.4-5.7] and child caregiver with no formal education [AHR: 3.4; 95% CI: 1.1-11.6]. Conclusion The observed mortality rate exceeded the expected rate of under 5%. Key factors for higher mortality include low baseline CD4 counts, opportunistic infections, poor treatment adherence, and uneducated caregivers. Enhancing caregiver education, early detection of infections, and prompt ART initiation can help reduce mortality in these children.