Delays in Initiation of Antiretroviral Therapy Among HIV-Infected Children in Rural Zambia.

Background: Although care and treatment are available to many HIV-infected children, barriers remain that delay initiation of antiretroviral therapy (ART). Minimizing these barriers is critical to starting ART at earlier ages. Methods: Reasons for delay were evaluated among 200 children younger than 15 years of age initiating treatment in an HIV clinic in rural Zambia from 2011 to 2013. Results: The median age of children at ART eligibility was 2.9 years, and 49% were male. After being determined eligible, 60% of children delayed ART initiation for a median of 28 days (interquartile range: 14, 75). Primary reasons for delay included waiting for test results, adherence issues and concurrent treatment for tuberculosis. When reasons for delay were categorized by type, 36% of children had family-related delays, 32% had delays because of clinic logistics, 27% had health-related delays and 6% had other or no identified reasons for delay. The median time between eligibility and ART initiation was shortest for children with delays because of clinic logistics (median: 18 days; interquartile range: 14, 35). Children with family-related delays tended to be older and orphaned, whereas children with delays because of clinic logistics tended to be younger, and children with health-related delays tended to have more advanced disease. In the first year of ART, no association was found between adherence and type of delay. CD4(+) T-cell percentages and weight-for-age Z scores were lower for children with health-related delays. Conclusions: Strategies to reduce delays in ART initiation will need to address a diverse set of issues, so children can benefit from earlier treatment.