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Background: Eighty percent of adolescents living with perinatally- and behaviourally-acquired HIV live in sub-Saharan Africa (SSA), a continent with marked economic inequality. Extending our previous global description of adolescents living with perinatally-acquired HIV (APH), this analysis aimed to describe APH outcomes in SSA by country income group (CIG).
Methods: Through the CIPHER cohort collaboration, individual retrospective data from 12 cohort networks across 5 continents were pooled; 7 networks representing SSA were included here. APH included were HIV-infected children with entry into care at age < 10 years (proxy for perinatally-acquired HIV), and follow-up at age >10 years. CIG was classified according to World Bank classification at median year of first visit by country. Cumulative incidence functions were calculated by competing risks analysis for mortality, transfer-out and loss-to-follow-up.
Results: 30,296 APH were included; 75.7% resident in low income countries (LIC), 4.6% in lower-middle income countries (LMIC) and 19.8% in upper-middle income countries (UMIC). 64% of APH were born ≥2000. Median (interquartile range [IQR]) age at antiretroviral therapy (ART) start (8 [6;9] years) and at last follow-up (12 [11;14] years) were equivalent across CIG. 26,018 (85.9%) ever started ART and 3,352 (12.5%) started at age >10 years, both significantly different between CIG (p< 0.001) (Table 1). Individual CD4 count improved between ART start and last visit in all CIG (p< 0.001). Half of APH had height-for-age Z-score (HAZ) < -2 at ART start that improved by last visit in LIC (p< 0.001) and UMIC (p< 0.001) but not LMIC (p=0.18). Mortality between age 10-15 years was lowest in UMIC however loss-to-follow-up was highest in UMIC.

 LIC N=22,925LMIC N=1,386UMIC N=5,985
Ever started ART - n (%)19,114 (83.4)1,207 (87.1)5,697 (95.2)
Started ART age >10 years - n (%)2,829 (14.8)141 (11.7)382 (6.7)
CD4 count (cells/µl) at ART start - median [IQR] (N=15,254)310 [165; 520]292 [174; 417]318 [162; 558]
CD4 count (cells/µl) at last visit - median [IQR] (N=24,223)668 [434; 945]735 [532; 985]729 [513; 971]
HAZ at ART start - median [IQR] (N=16,181)-2.01 [-2.97; -1.08]-2.08 [-2.95; -1.33]-2.02 [-2.86; -1.17]
HAZ at last visit - median [IQR] (N=25,333)-1.77 [-2.60; -0.95]-2.02 [-2.77; -1.30]-1.54 [-2.31; -0.77]
Cumulative incidence of mortality - % (95%CI)3.5 (3.1; 3.8)3.9 (2.7; 5.4)1.1 (0.8; 1.4)
Cumulative incidence of transfer-out - % (95%CI)17.5 (16.8; 18.3)27.5 (24.2; 31.0)23.7 (22.4; 25.1)
Cumulative incidence of loss-to-follow-up - % (95%CI)13.1 (12.4; 13.8)8.3 (6.3; 10.6)14.0 (12.9; 15.3)
[Table 1: APH characteristics by CIG (N=30,296)]


Conclusions: Despite starting ART late, improvements in height and CD4 count were observed in most APH surviving to adolescence. Mortality rates are likely under-estimated. However, results highlight inequalities in mortality and access to ART according to CIG in SSA.