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Mainou E, Berendam SJ, Obregon-Perko V, Uffman EA, Phan CT, Shaw GM, Bar KJ, Kumar MR, Fray EJ, Siliciano JM, Siliciano RF, Silvestri G, Permar SR, Fouda GG, McCarthy J, Chahroudi A, Chan C, Conway JM. Assessing the impact of autologous neutralizing antibodies on rebound dynamics in postnatally SHIV-infected ART-treated infant rhesus macaques. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.01.596971. [PMID: 38895223 PMCID: PMC11185557 DOI: 10.1101/2024.06.01.596971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
The presence of antibodies against HIV in infected children is associated with a greater capacity to control viremia in the absence of therapy. While the benefits of early antiretroviral treatment (ART) in infants are well documented, early ART may interfere with the development of antibody responses. In contrast to adults, early treated children lack detectable HIV-specific antibodies, suggesting a fundamental difference in HIV pathogenesis. Despite this potential adverse effect, early ART may decrease the size of the latent reservoir established early in infection in infants, which can be beneficial in viral control. Understanding the virologic and immunologic aspects of pediatric HIV is crucial to inform innovative targeted strategies for treating children living with HIV. In this study, we investigate how ART initiation time sets the stage for trade-offs in the latent reservoir establishment and the development of humoral immunity and how these, in turn, affect posttreatment dynamics. We also elucidate the biological function of antibodies in pediatric HIV. We employ mathematical modeling coupled with experimental data from an infant nonhuman primate Simian/Human Immunodeficiency Virus (SHIV) infection model. Infant Rhesus macaques (RMs) were orally challenged with SHIV.C.CH505 375H dCT four weeks after birth and started treatment at different times after infection. In addition to viral load measurements, antibody responses and latent reservoir sizes were measured. We estimate model parameters by fitting viral load measurements to the standard HIV viral dynamics model within a nonlinear fixed effects framework. This approach allows us to capture differences between rhesus macaques (RMs) that develop antibody responses or exhibit high latent reservoir sizes compared to those that do not. We find that neutralizing antibody responses are associated with increased viral clearance and decreased viral infectivity but decreased death rate of infected cells. In addition, the presence of detectable latent reservoir is associated with less robust immune responses. These results demonstrate that both immune response and latent reservoir dynamics are needed to understand post-rebound dynamics and point to the necessity of a comprehensive approach in tailoring personalized medical interventions.
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Affiliation(s)
- Ellie Mainou
- Department of Biology, Pennsylvania State University, University Park, PA, USA
| | | | | | - Emilie A Uffman
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - Caroline T Phan
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - George M Shaw
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katharine J Bar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mithra R Kumar
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily J Fray
- Department of Biochemistry and Molecular Biology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet M Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert F Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Guido Silvestri
- Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, USA
| | - Sallie R Permar
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | | | - Janice McCarthy
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Ann Chahroudi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Jessica M Conway
- Department of Mathematics, Pennsylvania State University, University Park, PA, USA
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Mainou E, Berendam SJ, Obregon-Perko V, Uffman EA, Phan CT, Shaw GM, Bar KJ, Kumar MR, Fray EJ, Siliciano JM, Siliciano RF, Silvestri G, Permar SR, Fouda GG, McCarthy J, Chahroudi A, Chan C, Conway JM. Comparative analysis of within-host dynamics of acute infection and viral rebound dynamics in postnatally SHIV-infected ART-treated infant rhesus macaques. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.21.595130. [PMID: 38826467 PMCID: PMC11142125 DOI: 10.1101/2024.05.21.595130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Viral dynamics of acute HIV infection and HIV rebound following suspension of antiretroviral therapy may be qualitatively similar but must differ given, for one, development of adaptive immune responses. Understanding the differences of acute HIV infection and viral rebound dynamics in pediatric populations may provide insights into the mechanisms of viral control with potential implications for vaccine design and the development of effective targeted therapeutics for infants and children. Mathematical models have been a crucial tool to elucidate the complex processes driving viral infections within the host. Traditionally, acute HIV infection has been modeled with a standard model of viral dynamics initially developed to explore viral decay during treatment, while viral rebound has necessitated extensions of that standard model to incorporate explicit immune responses. Previous efforts to fit these models to viral load data have underscored differences between the two infection stages, such as increased viral clearance rate and increased death rate of infected cells during rebound. However, these findings have been predicated on viral load measurements from disparate adult individuals. In this study, we aim to bridge this gap, in infants, by comparing the dynamics of acute infection and viral rebound within the same individuals by leveraging an infant nonhuman primate Simian/Human Immunodeficiency Virus (SHIV) infection model. Ten infant Rhesus macaques (RMs) orally challenged with SHIV.C.CH505 375H dCT and given ART at 8 weeks post-infection. These infants were then monitored for up to 60 months post-infection with serial viral load and immune measurements. We use the HIV standard viral dynamics model fitted to viral load measurements in a nonlinear mixed effects framework. We find that the primary difference between acute infection and rebound is the increased death rate of infected cells during rebound. We use these findings to generate hypotheses on the effects of adaptive immune responses. We leverage these findings to formulate hypotheses to elucidate the observed results and provide arguments to support the notion that delayed viral rebound is characterized by a stronger CD8+ T cell response.
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Affiliation(s)
- Ellie Mainou
- Department of Biology, Pennsylvania State University, University Park, PA, USA
| | | | | | - Emilie A Uffman
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - Caroline T Phan
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - George M Shaw
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katharine J Bar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mithra R Kumar
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily J Fray
- Department of Biochemistry and Molecular Biology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet M Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert F Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Guido Silvestri
- Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, USA
| | - Sallie R Permar
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | | | - Janice McCarthy
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Ann Chahroudi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Jessica M Conway
- Department of Mathematics, Pennsylvania State University, University Park, PA, USA
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Berihun H, Bazie GW, Beyene A, Zewdie A, Kebede N. Viral suppression and associated factors among children tested for HIV viral load at Amhara Public Health Institute, Dessie Branch, Ethiopia: a cross-sectional study. BMJ Open 2023; 13:e068792. [PMID: 36720566 PMCID: PMC9890760 DOI: 10.1136/bmjopen-2022-068792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE This study aims to assess viral suppression and associated factors among children tested for HIV viral load at the Amhara Public Health Institute, Dessie Branch, Ethiopia. DESIGN An institutional cross-sectional study was conducted. An observational checklist was used to collect the data. Data were entered into EpiData and analysed using SPSS (V.25). The data were analysed descriptively. Variables with p=0.25 from the bivariable analysis were entered into a multivariable logistic regression model, and significant variables (p=0.05) were retained in the multivariable model. SETTING AND PARTICIPANTS This cross-sectional study was conducted among 522 randomly selected children tested for HIV viral load at the Amhara Public Health Institute, Dessie Branch, Ethiopia. The study included children under the age of 15 years with complete records. RESULTS Viral suppression was 73% (95% CI: 60.41% to 77.63%). Treatment duration on antiretroviral therapy (adjusted OR (AOR)=0.207; 95% CI: 0.094 to 0.456) and regimen substitution (AOR=0.490; 95% CI: 0.306 to 0.784) were significantly associated with viral suppression rate. CONCLUSIONS In this study, the overall magnitude of viral suppression in Amhara Public Health Institute, Dessie Branch is low as compared with the WHO's 95% viral suppression target. Viral suppression was significantly associated with antiretroviral therapy duration and regimen substitution.
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Affiliation(s)
- Hailu Berihun
- Department of Public Health, Zemen Postgraduate College of Health Science, Dessie, Ethiopia
| | - Getaw Walle Bazie
- Department of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Altaseb Beyene
- Department of Biomedical Science, Wollo University, Dessie, Ethiopia
| | - Amare Zewdie
- Department of Public Health, Wolkite University, Wolkite, Ethiopia
| | - Natnael Kebede
- Department of Health Promotion, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
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de Azevedo SSD, Delatorre E, Gaido CM, Silva-de-Jesus C, Guimarães ML, Couto-Fernandez JC, Morgado MG. HIV-1 Diversity and Drug Resistance in Treatment-Naïve Children and Adolescents from Rio de Janeiro, Brazil. Viruses 2022; 14:v14081761. [PMID: 36016383 PMCID: PMC9413768 DOI: 10.3390/v14081761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 12/02/2022] Open
Abstract
The human immunodeficiency virus type 1 (HIV-1) can be transmitted via parenteral, sexual, or vertical exposure routes. The number of HIV-1 cases detected yearly in children and adolescents in Brazil did not decrease over the last decade, representing ~5% of total cases described in the country. In recent years, the HIV-1 diversity and the prevalence of transmitted drug resistance mutations (TDRM) are moving toward a marked increase. In this study, we retrospectively evaluated the diversity of HIV-1 subtypes and the TDRM prevalence in 135 treatment-naïve HIV-1 vertically infected children and adolescents born in between 1993 and 2012. These children were assessed in either 2001–2007 or 2008–2012 when they were 0 to 17 years old. The individuals assessed in 2001–2007 (n = 38) had median CD4+ T cell counts of 1218 cells/mm3 (IQR: 738–2.084) and median HIV-1 plasma viral load of 4.18 log10 copies/mL (IQR: 3.88–4.08). The individuals (n = 97) evaluated in 2008–2012 showed median CD4+ T cell counts of 898.5 cells/mm3 (IQR: 591.3–1.821) and median HIV-1 plasma viral load of 4.69 log10 copies/mL (IQR: 4.26–5.33). A steady decrease in the median CD4 T+ cell counts was observed with age progression, as expected. The majority HIV-1 pol sequences (87%) were classified as pure HIV-1 subtypes (77% subtype B, 9% subtype F1 and 1.5% subtype C), while 13% of sequences were classified as recombinants (CRF45_cpx, n = 4; CRF28/29_BF1, n = 2; CRF02_AG, n = 1; CRF40_BF1, n = 1, CRF99_BF1, n = 1, URF_BF1, n = 8). The overall prevalence of TDRM was 14% (19/135), conferring resistance to the nucleoside reverse transcriptase inhibitors (NRTI, 13/135–9.6%), non-nucleoside reverse transcriptase inhibitors (NNRTI, 8/135–5.9%), and protease inhibitors (PI, 2/135–1.5%). The main TDRM observed for NNRTI was the K103N (n = 8), while the mutations T215I/Y/D/E (n = 7) and M184V (n = 4) were the main TDRM for NRTI. Only two TDRM were observed for PI in one individual each (M46I and V82A). Most TDRM were found in the HIV-1 subtype B (84%) sequences. This study reveals an HIV-1 epidemic with high diversity and moderate prevalence of TDRM in the pediatric population of Rio de Janeiro, indicating the existence of possible problems in the clinical management of prophylactic therapy to prevent mother-to-child transmission and future treatment options for the affected children.
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Affiliation(s)
- Suwellen Sardinha Dias de Azevedo
- Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz—FIOCRUZ, Rio de Janeiro 21045-900, Brazil
- Correspondence: or ; Tel.: +55-21-3865-8147; Fax: +55-21-3865-8173
| | - Edson Delatorre
- Centro de Ciências Exatas, Naturais e da Saúde, Departamento de Biologia—Universidade Federal do Espírito Santo—UFES, Espírito Santo 29500-000, Brazil
| | - Cibele Marina Gaido
- Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz—FIOCRUZ, Rio de Janeiro 21045-900, Brazil
| | - Carlos Silva-de-Jesus
- Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz—FIOCRUZ, Rio de Janeiro 21045-900, Brazil
| | | | - José Carlos Couto-Fernandez
- Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz—FIOCRUZ, Rio de Janeiro 21045-900, Brazil
| | - Mariza G. Morgado
- Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz—FIOCRUZ, Rio de Janeiro 21045-900, Brazil
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Boswell MT, Yindom LM, Hameiri-Bowen D, McHugh G, Dauya E, Bandason T, Mujuru H, Esbjörnsson J, Ferrand RA, Rowland-Jones S. TRIM22 genotype is not associated with markers of disease progression in children with HIV-1 infection. AIDS 2021; 35:2445-2450. [PMID: 34870928 PMCID: PMC7614957 DOI: 10.1097/qad.0000000000003053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Untreated perinatal HIV-1 infection is often associated with rapid disease progression in children with HIV (CWH), characterized by high viral loads and early mortality. TRIM22 is a host restriction factor, which directly inhibits HIV-1 transcription, and its genotype variation is associated with disease progression in adults. We tested the hypothesis that TRIM22 genotype is associated with disease progression in CWH. DESIGN ART-naive CWH, aged 6-16 years, were recruited from primary care clinics in Harare, Zimbabwe. We performed a candidate gene association study of TRIM22 genotype and haplotypes with markers of disease progression and indicators of advanced disease. METHODS TRIM22 exons three and four were sequenced by Sanger sequencing and single nucleotide polymorphisms were associated with markers of disease progression (CD4+ T-cell count and HIV viral load) and clinical indicators of advanced HIV disease (presence of stunting and chronic diarrhoea). Associations were tested using multivariate linear and logistic regression models. RESULTS A total of 241 children, median age 11.4 years, 50% female, were included. Stunting was present in 16% of participants. Five SNPs were analyzed including rs7935564, rs2291842, rs78484876, rs1063303 and rs61735273. The median CD4+ count was 342 (IQR: 195-533) cells/μl and median HIV-1 viral load 34 199 (IQR: 8211-90 662) IU/ml. TRIM22 genotype and haplotypes were not associated with CD4+ T-cell count, HIV-1 viral load, stunting or chronic diarrhoea. CONCLUSION TRIM22 genotype was not associated with markers of HIV disease progression markers or advanced disease in CWH.
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Affiliation(s)
| | | | | | - Grace McHugh
- Biomedical Research and Training Institute, Zimbabwe
| | - Ethel Dauya
- Biomedical Research and Training Institute, Zimbabwe
| | | | - Hilda Mujuru
- Department of Paediatrics, University of Zimbabwe, Zimbabwe
| | - Joakim Esbjörnsson
- Nuffield Department of Medicine, Oxford University, UK
- Department of Translational Medicine, Lund University, Sweden
| | - Rashida A Ferrand
- Biomedical Research and Training Institute, Zimbabwe
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, United Kingdom
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Zhou J, Chen W, Liu Y, Qu C, Jiang W, Yin J, Lin J, Mao W, Ye B, Zhou J, Ke L, Tong Z, Liu Y, Li W. Trajectories of Lymphocyte Counts in the Early Phase of Acute Pancreatitis Are Associated With Infected Pancreatic Necrosis. Clin Transl Gastroenterol 2021; 12:e00405. [PMID: 34597275 PMCID: PMC8462575 DOI: 10.14309/ctg.0000000000000405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/17/2021] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Infected pancreatic necrosis (IPN) is an important complication of acute pancreatitis (AP). Absolute lymphocyte count (ALC) was reported to be associated with immunosuppression and the development of IPN. The aim of this study was to describe the trajectory of ALC during the early phase of AP and assess its association with IPN. METHODS We retrospectively screened patients with AP admitted to our center between January 2016 and July 2019. The ALC levels for the first 7 days after admission were collected. Group-based trajectory modeling was performed to detect the trajectories. Cox proportional hazards regression model was adopted to identify potential risk factors of IPN. RESULTS Overall, 292 patients were enrolled for analysis. A triple-group trajectory model was developed, assigning 116 patients to the low-level ALC group, 133 to the medium-level ALC group, and 43 to the high-level ALC group. There was no overall significant difference regarding the incidence of IPN among the 3 groups (P = 0.066). In pairwise comparison, patients in the low-level ALC group had significantly higher incidence of IPN than those in the high-level ALC group (hazard ratio: 3.50; 95% confidence interval: 1.22-10.00, P = 0.020). Length of hospital stay and intensive care unit stay differed significantly among patients with different trajectories (P = 0.042 and 0.033, respectively). DISCUSSION Despite the fact that the trajectories of ALC is overall insignificant for the development of IPN, patients with persistent low ALC trajectories during the early phase of AP are more likely to develop IPN when compared with patients with high ALC trajectories.
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Affiliation(s)
- Jing Zhou
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Southeast University, Nanjing, China;
| | - Wensong Chen
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China;
| | - Yang Liu
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Cheng Qu
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wendi Jiang
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jiangtao Yin
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China;
| | - Jiajia Lin
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wenjian Mao
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China;
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China.
| | - Bo Ye
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jing Zhou
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- National Institute of Healthcare Data Science at Nanjing University
| | - Zhihui Tong
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yuxiu Liu
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China;
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China.
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Southeast University, Nanjing, China;
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- National Institute of Healthcare Data Science at Nanjing University
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Stover J, Glaubius R, Kassanjee R, Dugdale CM. Updates to the Spectrum/AIM model for the UNAIDS 2020 HIV estimates. J Int AIDS Soc 2021; 24 Suppl 5:e25778. [PMID: 34546648 PMCID: PMC8454674 DOI: 10.1002/jia2.25778] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The Spectrum/AIM model is used by national HIV programs and UNAIDS to prepare annual estimates of key HIV indicators. This article describes key updates to paediatric and adult models for the 2021 round of HIV estimates. METHODS Potential updates to Spectrum arise due to newly available data, new analyses of existing data, and the need for new issues to be addressed. Updates are guided by experts through the UNAIDS Reference Group on Estimates, Modelling and Projections. Changes are tested and assessed for impact before being accepted into the final model. RESULTS Spectrum tracks children living with HIV by CD4% for ages 0-4 and CD4 count for ages 5-14. Data from IeDEA treatment sites have been used to map the transition from CD4% to CD4 count at age 5. Breastfeeding patterns in sub-Saharan Africa have been updated with the latest survey data and estimates of continuation on antiretroviral therapy (ART) with breastfeeding have been revised based on recent studies. Model assumptions about the CD4 counts of people who drop out of ART have been revised to account for CD4 count increases while on treatment. If available, monthly data on numbers on ART can now be used to estimate the effects of COVID-19-related disruptions during 2020. CONCLUSIONS These changes are intended to provide more accurate estimates of HIV burden. The effects of these changes on paediatric indicators are small except in countries with new surveys that might have updated patterns of breastfeeding. Changes to the adult model have little effect on total new infections. AIDS-related deaths will be somewhat lower in countries that have data on ART drop out but might be increased by HIV care disruptions due to COVID-19. The updated model uses newly available data to improve the estimation of paediatric and adult HIV indicators.
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Affiliation(s)
- John Stover
- Center for Modeling, Planning and Policy AnalysisAvenir HealthGlastonburyCTUSA
| | - Robert Glaubius
- Center for Modeling, Planning and Policy AnalysisAvenir HealthGlastonburyCTUSA
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology and Research (CIDER)University of Cape TownCape TownSouth Africa
| | - Caitlin M. Dugdale
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
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Brice J, Sylla M, Desire N, Sayon S, Telly F, Bocar-Fofana D, Murphy R, Peytavin G, Diallo S, Nastouli E, Calvez V, Marcelin AG, Maiga AI, Lambert-Niclot S. Characterization of drug resistance and the defective HIV reservoir in virally suppressed vertically infected children in Mali. J Antimicrob Chemother 2021; 75:1272-1279. [PMID: 32073629 DOI: 10.1093/jac/dkaa002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/20/2019] [Accepted: 12/26/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In the perspective of ART-free HIV remission, vertically infected children treated with suppressive ART from early infancy represent an optimal population model to better understand the genetic complexity of the reservoir. OBJECTIVES To evaluate the proportion of defective viral population and the genotypic resistance patterns in cell-associated HIV DNA. METHODS In a cohort including 93 ART-treated vertically HIV-infected (VHIV) children in Mali with plasma HIV-1 RNA ≤50 copies/mL for at least 6 months, we studied total HIV DNA, percentage of defective genomes and resistance by reverse transcriptase and protease bulk sequencing from whole blood in dried blood spots. RESULTS Children had a median age of 9.9 years at the time of inclusion (IQR = 7.6-13.4) and 3.3 years (IQR = 2-7) at ART initiation; median ART duration was 5.5 years (IQR = 3.7-7.3). The median level of total HIV DNA was 470 copies/106 cells with one patient presenting undetectable HIV DNA (<66 copies/106 cells). We observed the presence of at least one stop codon in viruses from 34 patients (37%). The presence of stop codons was not correlated with the level of HIV DNA or duration of ART. We showed a high prevalence of HIV-1 resistance in DNA with 26% of children harbouring virus resistant to at least one NRTI and 40% to at least one NNRTI. CONCLUSIONS While these VHIV children were successfully treated for a long time, they showed high prevalence of resistance in HIV DNA and a moderate defective HIV reservoir.
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Affiliation(s)
- Josephine Brice
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Pitié Salpêtrière Hospital, Department of Virology, F-75013 Paris, France
| | - Mariam Sylla
- Department of Pediatrics, University Hospital Gabriel Toure, Bamako, Mali
| | - Nathalie Desire
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Pitié Salpêtrière Hospital, Department of Virology, F-75013 Paris, France
| | - Sophie Sayon
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Pitié Salpêtrière Hospital, Department of Virology, F-75013 Paris, France
| | - Fatoumata Telly
- Unité d'Epidémiologie Moléculaire de la Résistance du VIH aux ARV, SEREFO, FMOS, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Djeneba Bocar-Fofana
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Saint Antoine Hospital, Department of Virology, F-75012 Paris, France
| | - Robert Murphy
- Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Avenue, Suite 900, Chicago, IL 60611, USA
| | - Gilles Peytavin
- AP-HP, Department of Pharmacology, Bichat-Claude Bernard Hospital, F-75018 Paris, France
| | - Souleymane Diallo
- Unité d'Epidémiologie Moléculaire de la Résistance du VIH aux ARV, SEREFO, FMOS, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Eleni Nastouli
- Department of Population, Policy and Practice, University College London GOS Institute of Child Health, London, UK
| | - Vincent Calvez
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Pitié Salpêtrière Hospital, Department of Virology, F-75013 Paris, France
| | - Anne-Geneviève Marcelin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Pitié Salpêtrière Hospital, Department of Virology, F-75013 Paris, France
| | - Almoustapha Issiaka Maiga
- Unité d'Epidémiologie Moléculaire de la Résistance du VIH aux ARV, SEREFO, FMOS, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali.,Clinical and Microbiology Laboratory, University Hospital Gabriel Toure, Bamako, Mali
| | - Sidonie Lambert-Niclot
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Saint Antoine Hospital, Department of Virology, F-75012 Paris, France
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9
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Uganda's "EID Systems Strengthening" model produces significant gains in testing, linkage, and retention of HIV-exposed and infected infants: An impact evaluation. PLoS One 2021; 16:e0246546. [PMID: 33539425 PMCID: PMC7861549 DOI: 10.1371/journal.pone.0246546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 01/20/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction A review of Uganda’s HIV Early Infant Diagnosis (EID) program in 2010 revealed poor retention outcomes for HIV-exposed infants (HEI) after testing. The review informed development of the ‘EID Systems Strengthening’ model: a set of integrated initiatives at health facilities to improve testing, retention, and clinical care of HIV-exposed and infected infants. The program model was piloted at several facilities and later scaled countrywide. This mixed-methods study evaluates the program’s impact and assesses its implementation. Methods We conducted a retrospective cohort study at 12 health facilities in Uganda, comprising all HEI tested by DNA PCR from June 2011 to May 2014 (n = 707). Cohort data were collected manually at the health facilities and analyzed. To assess impact, retention outcomes were statistically compared to the baseline study’s cohort outcomes. We conducted a cross-sectional qualitative assessment of program implementation through 1) structured clinic observation and 2) key informant interviews with health workers, district officials, NGO technical managers, and EID trainers (n = 51). Results The evaluation cohort comprised 707 HEI (67 HIV+). The baseline study cohort contained 1268 HEI (244 HIV+). Among infants testing HIV+, retention in care at an ART clinic increased from 23% (57/244) to 66% (44/67) (p < .0001). Initiation of HIV+ infants on ART increased from 36% (27/75) to 92% (46/50) (p < .0001). HEI receiving 1st PCR results increased from 57% (718/1268) to 73% (518/707) (p < .0001). Among breastfeeding HEI with negative 1st PCR, 55% (192/352) received a confirmatory PCR test, a substantial increase from baseline period. Testing coverage improved significantly: HIV+ pregnant women who brought their infants for testing after birth increased from 18% (67/367) to 52% (175/334) (p < .0001). HEI were tested younger: mean age at DBS test decreased from 6.96 to 4.21 months (p < .0001). Clinical care for HEI was provided more consistently. Implementation fidelity was strong for most program components. The strongest contributory interventions were establishment of ‘EID Care Points’, integration of clinical care, longitudinal patient tracking, and regular health worker mentorship. Gaps included limited follow up of lost infants, inconsistent buy-in/ownership of health facility management, and challenges sustaining health worker motivation. Discussion Uganda’s ‘EID Systems Strengthening’ model has produced significant gains in testing and retention of HEI and HIV+ infants, yet the country still faces major challenges. The 3 core concepts of Uganda’s model are applicable to any country: establish a central service point for HEI, equip it to provide high-quality care and tracking, and develop systems to link HEI to the service point. Uganda’s experience has shown the importance of intensively targeting systemic bottlenecks to HEI retention at facility level, a necessary complement to deploying rapidly scalable technologies and other higher-level initiatives.
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10
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Patterns of Objectively and Self-Reported Sedentary Behavior in Children and Adolescents Living With Human Immunodeficiency Virus: The PositHIVe Health Study. Pediatr Exerc Sci 2020; 32:30-35. [PMID: 31584870 DOI: 10.1123/pes.2019-0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/26/2019] [Accepted: 07/30/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE Sedentary behavior (SB) has been shown to be associated with unhealthy outcomes in children, and it is not clear whether children living with human immunodeficiency virus (HIV) engage in different patterns of SB compared with healthy children. This cross-sectional study aimed to compare patterns of SB between children living with HIV and a healthy control group. METHODS A group of children with HIV and a paired control group wore accelerometers for 1 week and answered a questionnaire with items related to television viewing habits and computer usage. Accelerometer-derived and self-reported SB were compared between children living with HIV and controls and between treatment-based and viral load subgroups. RESULTS A total of 130 children (of which 53% are girls with a mean age of 12.1 y) participated in the study with 65 in each group. Children in the control group exhibited significantly more objectively measured SB daily when compared with the HIV group (515 vs 490 min/d, respectively), but no differences were found between the treatment-based and viral load subgroups. Children with HIV watched more television on weekdays, compared with the control group (P < .05). No other differences were found in comparisons of self-reported SB between the control and HIV and the treatment-based or viral load subgroups. CONCLUSION Children living with HIV spend less time being sedentary than those in the healthy control group. Future studies are important for clarifying the causes and consequences of these differences.
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11
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Eriksen J, Carlander C, Albert J, Flamholc L, Gisslén M, Navér L, Svedhem V, Yilmaz A, Sönnerborg A. Antiretroviral treatment for HIV infection: Swedish recommendations 2019. Infect Dis (Lond) 2020; 52:295-329. [PMID: 31928282 DOI: 10.1080/23744235.2019.1707867] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The Swedish Reference Group for Antiviral Therapy (RAV) published recommendations for the treatment of HIV infection in this journal most recently in 2017. An expert group under the guidance of RAV here provides updated recommendations. The most important updates in the present guidelines are the following: (a) The risk of HIV transmission through condomless sex from individuals with fully suppressed HIV viral load is effectively zero. (b) Pre-exposure prophylaxis (PrEP) is recommended for groups with a high risk of HIV infection. (c) Since the last update, two new substances have been registered: bictegravir and doravirine. (d) Dual treatment may be an alternative in selected patients, using lamivudine + dolutegravir or lamivudine + boosted darunavir/atazanavir. As with previous publications, recommendations are evidence-graded in accordance with the Oxford Centre for Evidence Based Medicine. This document does not cover treatment of opportunistic infections and tumours.
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Affiliation(s)
- Jaran Eriksen
- Unit of Infectious Diseases/Venhälsan, Södersjukhuset, Stockholm, Sweden.,Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Christina Carlander
- Department of Infectious Diseases, Västmanland County Hospital, Västerås, Sweden.,Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Jan Albert
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Leo Flamholc
- Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
| | - Magnus Gisslén
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Navér
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Paediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Veronica Svedhem
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Aylin Yilmaz
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Sönnerborg
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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12
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Boppana SB, Britt WJ, Fowler K, Hutto SC, James SH, Kimberlin DW, Poole C, Ross SA, Whitley RJ. Pathogenesis of Non-Zika Congenital Viral Infections. J Infect Dis 2019; 216:S912-S918. [PMID: 29267912 DOI: 10.1093/infdis/jix431] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A widespread epidemic of Zika virus (ZIKV) infection was reported in 2015 from South and Central America and the Caribbean. Although the full spectrum of ZIKV infection of the newborn has yet to be determined, other maternal viral infections resulting in transmission to the fetus provide instructive lessons that can be applied to the prospective evaluation of individuals with ZIKV infection. This review focuses on those other congenital infections, including rubella, congenital cytomegalovirus, human immunodeficiency virus, hepatitis B virus, and neonatal herpes simplex virus, from which lessons for the evaluation of ZIKV in the newborn can be applied.
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Affiliation(s)
- Suresh B Boppana
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham
| | - William J Britt
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham
| | - Karen Fowler
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham
| | - S Cecelia Hutto
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham
| | - Scott H James
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham
| | - David W Kimberlin
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham
| | - Claudette Poole
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham
| | - Shannon A Ross
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham
| | - Richard J Whitley
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham
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13
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Haeri Mazanderani A, Kufa T, Technau KG, Strehlau R, Patel F, Shiau S, Burke M, Kuhn L, Abrams EJ, Sherman GG. Early infant diagnosis HIV-1 PCR cycle-threshold predicts infant viral load at birth. J Clin Virol 2019; 114:21-25. [PMID: 30903987 DOI: 10.1016/j.jcv.2019.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 02/14/2019] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND HIV-1 viral load (VL) has been found to be an independent predictor for disease progression among untreated HIV-infected children. However, qualitative polymerase chain reaction (PCR) assays are routinely used for early infant diagnosis (EID). OBJECTIVES To predict HIV-1 VL at birth using qualitative EID real-time PCR cycle-threshold (Ct) values. STUDY DESIGN This study was a secondary analysis of results from a cohort of intrauterine HIV-1 infected neonates. Neonates were enrolled at Rahima Moosa Mother & Child Hospital in Johannesburg, South Africa between June 2014 and November 2017. Laboratory EID HIV-1 PCR testing was performed at birth using COBAS AmpliPrep/COBAS TaqMan HIV-1 Qualitative Test v2.0 (EID CAP/CTM). Some infants had simultaneous EID point-of-care (POC) testing using Xpert HIV-1 Qualitative assay (EID Xpert). Neonates with a confirmed HIV-1 detected EID result and plasma HIV-1 RNA VL test were included in this analysis. Bland-Altman analysis was used to determine extent of agreement between Ct values of both EID assays. Multivariable linear regression models adjusting for time between EID and VL testing were used to describe the association between EID Ct values and VL and to predict VL at given EID Ct values. RESULTS Among 107 HIV-1 infected neonates included in the study, 59 had POC EID testing. Median VL was 28 400 copies per millilitre (cps/ml) (IQR: 1 918-218 358) - two neonates had VL < 100 cps/ml prior to antiretroviral therapy initiation. There was good correlation between Ct values of both EID assays (Spearman correlation coefficient 0.9, 95% CI: 0.8-1.0). The limits of agreement between EID CAP/CTM and Xpert Ct values were 4-11 cycles. For every one cycle increase in Ct value there was 0.3 log10 RNA decrease (95% CI: -0.3 to -0.2) for both EID assays. An EID CAP/CTM Ct value ≤ 23 and an EID Xpert Ct value ≤ 31 predicted a VL of > 5.0 log10 cps/ml in 82.2% (95% CI: 73.9-88.3) and 84.7% (95% CI: 73.7-91.8) of cases, respectively. CONCLUSION EID Ct values at birth predict VL and accurately identify infants with VL > 5.0 log10 cps/ml.
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Affiliation(s)
- Ahmad Haeri Mazanderani
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
| | - Tendesayi Kufa
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karl G Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Renate Strehlau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Faeezah Patel
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephanie Shiau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Megan Burke
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Louise Kuhn
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Elaine J Abrams
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA; ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA; Department of Pediatrics, College of Physicians & Surgeons, Columbia University, New York, USA
| | - Gayle G Sherman
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Nelson CS, Fouda GG, Permar SR. Pediatric HIV-1 Acquisition and Lifelong Consequences of Infant Infection. CURRENT IMMUNOLOGY REVIEWS 2019; 15:131-138. [PMID: 33223981 PMCID: PMC7678020 DOI: 10.2174/1573395514666180531074047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 04/11/2018] [Accepted: 05/24/2018] [Indexed: 11/22/2022]
Abstract
Increased availability of antiretroviral therapy to pregnant and breastfeeding women in resource-limited areas has proven remarkably successful at reducing HIV vertical transmission rates over the past several decades. Yet, still more than 170,000 children are infected annually due to failures in therapy implementation, monitoring, and adherence. Mother-to-child transmission (MTCT) of HIV-1 can occur at one of several distinct stages of infant development - intrauterine, intrapartum, and postpartum. The heterogeneity of the maternal-fetal interface at each of these modes of transmission poses a challenge for the implementation of immune interventions to prevent all modes of HIV MTCT. However, using mother-infant human cohorts and nonhuman primate models of infant simian immunodeficiency virus (SIV) acquisition, investigators have made important observation about the biology of pediatric HIV infection and have identified unique protective immune factors for each mode of transmission. Knowledge of immune factors protective against HIV MTCT will be critical to the development of targeted immune therapies to prevent infant HIV acquisition and to bring an end to the pediatric AIDS epidemic.
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Affiliation(s)
- Cody S. Nelson
- Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Genevieve G.A. Fouda
- Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Sallie R. Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
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15
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Panayidou K, Davies M, Anderegg N, Egger M. Global temporal changes in the proportion of children with advanced disease at the start of combination antiretroviral therapy in an era of changing criteria for treatment initiation. J Int AIDS Soc 2018; 21:e25200. [PMID: 30614622 PMCID: PMC6275813 DOI: 10.1002/jia2.25200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 10/08/2018] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION The CD4 cell count and percent at initiation of combination antiretroviral therapy (cART) are measures of advanced HIV disease and thus are important indicators of programme performance for children living with HIV. In particular, World Health Organization (WHO) 2017 guidelines on advanced HIV disease noted that >80% of children aged <5 years started cART with WHO Stage 3 or 4 disease or severe immune suppression. We compared temporal trends in CD4 measures at cART start in children from low-, middle- and high-income countries, and examined the effect of WHO treatment initiation guidelines on reducing the proportion of children initiating cART with advanced disease. METHODS We included children aged <16 years from the International Epidemiology Databases to Evaluate acquired immunodeficiency syndrome (AIDS) (IeDEA) Collaboration (Caribbean, Central and South America, Asia-Pacific, and West, Central, East and Southern Africa), the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE), the North American Pediatric HIV/AIDS Cohort Study (PHACS) and International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) 219C study. Severe immunodeficiency was defined using WHO guidelines. We used generalized weighted additive mixed effect models to analyse temporal trends in CD4 measurements and piecewise regression to examine the impact of 2006 and 2010 WHO cART initiation guidelines. RESULTS We included 52,153 children from fourteen low-, eight lower middle-, five upper middle- and five high-income countries. From 2004 to 2013, the estimated percentage of children starting cART with severe immunodeficiency declined from 70% to 42% (low-income), 67% to 64% (lower middle-income) and 61% to 43% (upper middle-income countries). In high-income countries, severe immunodeficiency at cART initiation declined from 45% (1996) to 14% (2012). There were annual decreases in the percentage of children with severe immunodeficiency at cART initiation after the WHO guidelines revisions in 2006 (low-, lower middle- and upper middle-income countries) and 2010 (all countries). CONCLUSIONS By 2013, less than half of children initiating cART had severe immunodeficiency worldwide. WHO treatment initiation guidelines have contributed to reducing the proportion of children and adolescents starting cART with advanced disease. However, considerable global inequity remains, in 2013, >40% of children in low- and middle-income countries started cART with severe immunodeficiency compared to <20% in high-income countries.
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Affiliation(s)
- Klea Panayidou
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Nanina Anderegg
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | - Matthias Egger
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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16
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Kiyaga C, Narayan V, McConnell I, Elyanu P, Kisaakye LN, Kekitiinwa A, Price M, Grosz J. Retention outcomes and drivers of loss among HIV-exposed and infected infants in Uganda: a retrospective cohort study. BMC Infect Dis 2018; 18:416. [PMID: 30134851 PMCID: PMC6104004 DOI: 10.1186/s12879-018-3275-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 07/26/2018] [Indexed: 11/30/2022] Open
Abstract
Background Uganda’s HIV Early Infant Diagnosis (EID) program rapidly scaled up testing of HIV-exposed infants (HEI) in its early years. However, little was known about retention outcomes of HEI after testing. Provision of transport refunds to HEI caregivers was piloted at 3 hospitals to improve retention. This study was conducted to quantify retention outcomes of tested HEI, identify factors driving loss-to-follow-up, and assess the effect of transport refunds on HEI retention. Methods This mixed-methods study included 7 health facilities— retrospective cohort review at 3 hospitals and qualitative assessment at all facilities. The cohort comprised all HEI tested from September-2007 to February-2009. Retention data was collected manually at each hospital. Qualitative methods included health worker interviews and structured clinic observation. Qualitative data was synthesized, analyzed and triangulated to identify factors driving HEI loss-to-follow-up. Results The cohort included 1268 HEI, with 244 testing HIV-positive. Only 57% (718/1268) of tested HEI received results. The transport refund pilot increased the percent of HEI caregivers receiving test results from 54% (n = 763) to 58% (n = 505) (p = .08). HEI were tested at late ages (Mean = 7.0 months, n = 1268). Many HEI weren’t tested at all: at 1 hospital, only 18% (67/367) of HIV+ pregnant women brought their HEI for testing after birth. Among HIV+ infants, only 40% (98/244) received results and enrolled at an ART Clinic. Of enrolled HIV+ infants, only 43% (57/98) were still active in chronic care. 36% (27/75) of eligible HIV+ infants started ART. Our analysis identified 6 categories of factors driving HEI loss-to-follow-up: fragmentation of EID services across several clinics, with most poorly equipped for HEI care/follow-up; poor referral mechanisms and data management systems; inconsistent clinical care; substandard counseling; poor health worker knowledge of EID; long sample-result turnaround times. Discussion The poor outcomes for HEI and HIV+ infants have highlighted an urgent need to improve retention and linkage to care. To address the identified gaps, Uganda’s Ministry of Health and the Clinton Health Access Initiative developed a new implementation model, shifting EID from a lab-based diagnostic service to an integrated clinic-based chronic care model. This model was piloted at 21 facilities. An evaluation is needed.
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Affiliation(s)
- Charles Kiyaga
- Ministry of Health AIDS Control Programme, Kampala, Uganda
| | | | | | - Peter Elyanu
- Ministry of Health AIDS Control Programme, Kampala, Uganda
| | | | | | | | - Jeff Grosz
- Clinton Health Access Initiative, Kampala, Uganda
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Schultheiß M, Kling S, Lenker U, von Bibra M, Rosenkranz B, Klinker H. Lopinavir serum concentrations of critically ill infants: a pharmacokinetic investigation in South Africa. Med Microbiol Immunol 2018; 207:339-343. [PMID: 29974233 DOI: 10.1007/s00430-018-0550-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/29/2018] [Indexed: 10/28/2022]
Abstract
The role of therapeutic drug monitoring in pediatric antiretroviral therapy is unclear. A little pharmacokinetic datum from clinical practice exists beyond controlled approval studies including clinically stable children. The aim of this study is to quantify LPV exposure of critically ill infants in an ICU and-by identifying risk factors for inadequate exposure-to define sensible indications for TDM in pediatric HIV care; in addition, assume total drug adherence in ICU to compare LPV exposure with a setting of unknown adherence. In this prospective investigation, 15 blood samples from critically ill infants in the pediatric ICU at Tygerberg Hospital were analyzed for LPV-serum concentrations. They were then compared to those of 22 blood samples from out-patient children. Serum-level measurements were performed with an established high-performance liquid chromatography method. All LPV-serum levels of ICU patients were higher than a recommended Ctrough (= 1.000 ng/ml), 60% of levels were higher than Cmax (8.200 ng/ml). Partly, serum levels reached were extremely high (Maximum: 28.778 ng/ml). Low bodyweight and age correlated significantly with high LPV concentrations and were risk factors for serum levels higher than Cmax. Significantly fewer serum levels from infants in ICU care (mean: 11.552 ng/ml ± SD 7760 ng/ml) than from out-patient children (mean: 6.756 ng/ml ± SD 6.003 ng/ml) were subtherapeutic (0 vs. 28%, p = 0.008). Under total adherence in the ICU group, there were no subtherapeutic serum levels, while, in out-patient, children with unknown adherence 28% of serum levels were found subtherapeutic. Low bodyweight and age are risk factors for reaching potentially toxic LPV levels in this extremely fragile population. TDM can be a reasonable tool to secure sufficient and safe drug exposure in pediatric cART.
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Affiliation(s)
- Michael Schultheiß
- Medizinische Klinik und Poliklinik II, Schwerpunkt Infektiologie, Universitätsklinikum Würzburg, ZIM Haus A3/A4, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
| | - Sharon Kling
- Department of Pediatrics and Child Health, Ward A9, Tygerberg Hospital, University of Stellenbosch, Francie van Zijl Drive, Tygerberg, 7505, South Africa
| | - Ulrike Lenker
- Medizinische Klinik und Poliklinik II, Schwerpunkt Infektiologie, Universitätsklinikum Würzburg, ZIM Haus A3/A4, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Miriam von Bibra
- Medizinische Klinik und Poliklinik II, Schwerpunkt Infektiologie, Universitätsklinikum Würzburg, ZIM Haus A3/A4, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Bernd Rosenkranz
- Division of Clinical Pharmacology, Department of Medicine, Tygerberg Hospital, University of Stellenbosch, Francie van Zijl Drive, Tygerberg, 7505, South Africa
| | - Hartwig Klinker
- Medizinische Klinik und Poliklinik II, Schwerpunkt Infektiologie, Universitätsklinikum Würzburg, ZIM Haus A3/A4, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
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18
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Anigilaje EA, Aderibigbe SA. Mortality in a Cohort of HIV-Infected Children: A 12-Month Outcome of Antiretroviral Therapy in Makurdi, Nigeria. Adv Med 2018; 2018:6409134. [PMID: 30018988 PMCID: PMC6029505 DOI: 10.1155/2018/6409134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 04/15/2018] [Accepted: 05/02/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Recognizing the predictors of mortality among HIV-infected children will allow for concerted management that can reduce HIV-mortality in Nigeria. METHODOLOGY A retrospective cohort study in children aged 0-15 years, between October 2010 and December 2013, at the Federal Medical Centre, Makurdi, Nigeria. Kaplan-Meier method analysed the cumulative probability of early mortality (EM) occurring at or before 6 months and after 6 months of follow-up (late mortality-LM) on a 12-month antiretroviral therapy (ART). Multivariate Cox proportional regression models were used to test for hazard ratios (HR). RESULTS 368 children were included in the analysis contributing 81 children per 100 child-years to the 12-month ART follow-up. A significant reduction in EM rates was noted at 17.3 deaths per 100 child-years (30 deaths) to LM rates of 3.0 deaths per 100 child-years (10 deaths), p < 0.01. At multivariate analysis, children with a high pretreatment viral load (≥10,000 copies/ml) were found to be at risk of EM (aHR; 18. 089, 95% CI; 2.428-134.77, p=0.005). Having severe immunosuppression at/or before 6 months of ART was the predictor of LM (aHR; 17.28, 95% CI; 3.844-77.700, p ≤ 0.001). CONCLUSIONS Although a lower mortality rate is seen at 12 months of ART in our setting, predictors of HIV mortality are having high pretreatment HIV viral load and severe immunosuppression. While primary prevention of HIV infection is paramount, early identification of these predictors among our HIV-infected children for an early ART initiation can reduce further the mortality in our setting. In addition, measures to ensure a good standard of care and retention in care for a sustained virologic suppression cannot be ignored and are hereby underscored.
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Singh R, Mukherjee A, Singla M, Vajpayee M, Negi N, Kabra SK, Lodha R, Das BK. Impact of HIV infection and highly active antiretroviral therapy (HAART) on B cell subpopulations in children. J Med Virol 2018; 90:1222-1231. [PMID: 29575050 DOI: 10.1002/jmv.25074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/15/2018] [Indexed: 01/01/2023]
Abstract
B-cells play an important role in defending children against various infections. In view of scare data, we undertook this prospective cohort study to describe B cell compartment in HIV infected children (<5 years of age) and the effect of HAART on B cell subpopulations. HIV infected children (<5 years) from Pediatric HIV services of the Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, were recruited (April 2012-December 2015). The enrolled HIV-1 infected children (n = 59) were followed up regularly for 12 months; healthy controls (n = 51) included HIV uninfected children with no major illness. Flow cytometry was performed on fresh EDTA-treated blood samples to characterize B cell subpopulations. In HIV-infected children, marked depletion of naive (P = 0.003), non-switched memory (P = 0.02), mature (P = 0.0005), resting memory (P < 0.0001) B cells, and expansion of double negative memory (P < 0.0001), activated memory (P < 0.0001) and tissue like memory (P < 0.0001) B cells were observed as compared to healthy controls. In children started on HAART, at the end of 12 months of therapy, frequencies of non-switched memory (P = 0.04), switched memory (P = 0.01), and resting memory (P = 0.003) B cells were lower; activated memory (P = 0.04), and tissue-like memory (P = 0.0001) B cells were still higher than healthy controls. HIV infection resulted in reduced memory B cells in HIV infected children. Following HAART, there was normalization of some B cell subpopulations. The study emphasizes the need of re-vaccination in HIV infected children to maintain the memory B cell pool and adequate humoral immune response against infections.
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Affiliation(s)
- Ravinder Singh
- Department of Pediatrics, AIIMS, New Delhi, Delhi, India.,Department of Microbiology, AIIMS, New Delhi, Delhi, India
| | | | - Mohit Singla
- Department of Pediatrics, AIIMS, New Delhi, Delhi, India
| | - Madhu Vajpayee
- Department of Microbiology, AIIMS, New Delhi, Delhi, India
| | - Neema Negi
- Department of Microbiology, AIIMS, New Delhi, Delhi, India
| | - Sushil K Kabra
- Department of Pediatrics, AIIMS, New Delhi, Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, AIIMS, New Delhi, Delhi, India
| | - Bimal K Das
- Department of Microbiology, AIIMS, New Delhi, Delhi, India
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Alvarez P, Mwamzuka M, Marshed F, Kravietz A, Ilmet T, Ahmed A, Borkowsky W, Khaitan A. Immune activation despite preserved CD4 T cells in perinatally HIV-infected children and adolescents. PLoS One 2017; 12:e0190332. [PMID: 29287090 PMCID: PMC5747457 DOI: 10.1371/journal.pone.0190332] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/12/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND HIV disease progresses more rapidly in children than adults with mortality rates exceeding 50% by 2 years of age without antiretroviral therapy (ART) in sub-Saharan Africa. Recent World Health Organization (WHO) guidelines recommend universal treatment for all living persons with HIV, yet there is limited supporting evidence in pediatric populations. The objective of this study was to determine whether CD4 cell counts reflect immunological markers associated with disease progression in ART naïve perinatally-infected HIV+ children and adolescents and their response to ART. METHODS PBMC and plasma samples were collected from 71 HIV negative and 132 HIV+ children (65 ART naïve and 67 on ART) between ages 1-19 years from Mombasa, Kenya. Untreated HIV+ subjects were sub-categorized by high or low CD4 T cell counts. Immune activation markers CD38, HLA-DR and Ki67 were analyzed by flow cytometry. Plasma soluble CD14 (sCD14) was quantified by ELISA. RESULTS HIV-infected children and adolescents with preserved CD4 cell counts had depleted CD4 percentages and CD4:CD8 ratios, and high immune activation levels. ART initiation rapidly and persistently reversed T cell activation, but failed to normalize CD4:CD8 ratios and plasma sCD14 levels. CONCLUSIONS Diminished CD4 percentages and CD4:CD8 ratios along with profound immune activation occur independent of CD4 cell count thresholds in ART naïve HIV+ children and adolescents. Immediate ART initiation, as recommended in the most recent WHO guidelines may protect them from pathologic sequelae associated with persistent inflammation.
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Affiliation(s)
- Patricia Alvarez
- HIV-1 Molecular Epidemiology Laboratory, Department of Microbiology and Parasitology, Hospital Ramon y Cajal-IRYCIS and CIBERESP, Madrid, Spain
| | - Mussa Mwamzuka
- Bomu Hospital, Comprehensive Care Centre, Mombasa, Kenya
| | - Fatma Marshed
- Bomu Hospital, Comprehensive Care Centre, Mombasa, Kenya
| | - Adam Kravietz
- Department of Microbiology, New York University School of Medicine, New York, NY, United States of America
| | - Tiina Ilmet
- Department of Pediatrics, Division of Infectious Diseases and Immunology, New York University School of Medicine, New York, NY, United States of America
| | - Aabid Ahmed
- Bomu Hospital, Comprehensive Care Centre, Mombasa, Kenya
| | - William Borkowsky
- Department of Pediatrics, Division of Infectious Diseases and Immunology, New York University School of Medicine, New York, NY, United States of America
| | - Alka Khaitan
- Department of Pediatrics, Division of Infectious Diseases and Immunology, New York University School of Medicine, New York, NY, United States of America
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Melvin AJ, Warshaw M, Compagnucci A, Saidi Y, Harrison L, Turkova A, Tudor-Williams G. Hepatic, Renal, Hematologic, and Inflammatory Markers in HIV-Infected Children on Long-term Suppressive Antiretroviral Therapy. J Pediatric Infect Dis Soc 2017; 6:e109-e115. [PMID: 28903520 PMCID: PMC5907869 DOI: 10.1093/jpids/pix050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 06/03/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Data on long-term toxicity of antiretroviral therapy (ART) in HIV-infected children are sparse. PENPACT-1 was an open-label trial in which HIV-infected children were assigned randomly to receive protease inhibitor (PI)- or nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based ART. METHODS We examined changes in clinical, immunologic, and inflammatory markers from baseline to year 4 in the subset of children in the PENPACT-1 study who experienced viral suppression between week 24 and year 4 of ART. Liver enzyme, creatinine, and cholesterol levels and hematologic parameters were assessed during the trial. Cystatin C, high-sensitivity C-reactive protein (hs-CRP), interleukin 6 (IL-6), d-dimer, and soluble CD14 (sCD14) were assayed from cryopreserved specimens. RESULTS Ninety-nine children (52 on PI-based and 47 on NNRTI-based ART) met inclusion criteria. The median age at initiation of ART was 6.5 years (interquartile range [IQR], 3.7-13.4 years), and 22% were aged <3 years at ART initiation; 56% of the PI-treated children received lopinavir/ritonavir, and 70% of NNRTI-treated children received efavirenz initially. We found no evidence of significant clinical toxicity in either group; growth, liver, kidney, and hematologic parameters either remained unchanged or improved between baseline and year 4. Total cholesterol levels increased modestly, but no difference between the groups was found. IL-6 and hs-CRP levels decreased more after 4 years in the NNRTI-based ART group. The median change in IL-6 level was -0.35 pg/ml in the PI-based ART group and -1.0 in the NNRTI-based ART group (P = .05), and the median change in hs-CRP level was 0.25 µg/ml in the PI-based ART group and -0.95 µg/ml in the NNRTI-based ART group (P = .005). CONCLUSION These results support the safety of prolonged ART use in HIV-infected children and suggest that suppressive NNRTI-based regimens can be associated with lower levels of systemic inflammation.
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Affiliation(s)
- Ann J Melvin
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Washington and Seattle Children’s Research Institute
| | - Meredith Warshaw
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - Linda Harrison
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Anna Turkova
- Medical Research Council, Clinical Trials Unit, London, United Kingdom; and
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Abstract
PURPOSE OF REVIEW It is 20 years since the start of the combination antiretroviral therapy (cART) era and more than 10 years since cART scale-up began in resource-limited settings. We examined survival of vertically HIV-infected infants and children in the cART era. RECENT FINDINGS Good survival has been achieved on cART in all settings with up to 10-fold mortality reductions compared with before cART availability. Although mortality risk remains high in the first few months after cART initiation in young children with severe disease, it drops rapidly thereafter even for those who started with advanced disease, and longer term mortality risk is low. However, suboptimal retention on cART in routine programs threatens good survival outcomes and even on treatment children continue to experience high comorbidity risk; infections remain the major cause of death. Interventions to address infection risk include a cotrimoxazole prophylaxis, isoniazid preventive therapy, routine childhood and influenza immunization, and improving maternal survival. SUMMARY Pediatric survival has improved substantially with cART and HIV-infected children are aging into adulthood. It is important to ensure access to diagnosis and early cART, good program retention as well as optimal comorbidity prophylaxis and treatment to achieve the best possible long-term survival and health outcomes for vertically infected children.
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Growth and Mortality Outcomes for Different Antiretroviral Therapy Initiation Criteria in Children Ages 1-5 Years: A Causal Modeling Analysis. Epidemiology 2017; 27:237-46. [PMID: 26479876 DOI: 10.1097/ede.0000000000000412] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is limited evidence regarding the optimal timing of initiating antiretroviral therapy (ART) in children. We conducted a causal modeling analysis in children ages 1-5 years from the International Epidemiologic Databases to Evaluate AIDS West/Southern-Africa collaboration to determine growth and mortality differences related to different CD4-based treatment initiation criteria, age groups, and regions. METHODS ART-naïve children of ages 12-59 months at enrollment with at least one visit before ART initiation and one follow-up visit were included. We estimated 3-year growth and cumulative mortality from the start of follow-up for different CD4 criteria using g-computation. RESULTS About one quarter of the 5,826 included children was from West Africa (24.6%).The median (first; third quartile) CD4% at the first visit was 16% (11%; 23%), the median weight-for-age z-scores and height-for-age z-scores were -1.5 (-2.7; -0.6) and -2.5 (-3.5; -1.5), respectively. Estimated cumulative mortality was higher overall, and growth was slower, when initiating ART at lower CD4 thresholds. After 3 years of follow-up, the estimated mortality difference between starting ART routinely irrespective of CD4 count and starting ART if either CD4 count <750 cells/mm³ or CD4% <25% was 0.2% (95% CI = -0.2%; 0.3%), and the difference in the mean height-for-age z-scores of those who survived was -0.02 (95% CI = -0.04; 0.01). Younger children ages 1-2 and children in West Africa had worse outcomes. CONCLUSIONS Our results demonstrate that earlier treatment initiation yields overall better growth and mortality outcomes, although we could not show any differences in outcomes between immediate ART and delaying until CD4 count/% falls below 750/25%.
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HIV Infection in Children. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00100-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Eriksen J, Albert J, Blaxhult A, Carlander C, Flamholc L, Gisslén M, Josephson F, Karlström O, Navér L, Svedhem V, Yilmaz A, Sönnerborg A. Antiretroviral treatment for HIV infection: Swedish recommendations 2016. Infect Dis (Lond) 2016; 49:1-34. [PMID: 27804313 DOI: 10.1080/23744235.2016.1247495] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The Swedish Medical Products Agency and the Swedish Reference Group for Antiviral Therapy (RAV) have jointly published recommendations for the treatment of HIV infection on seven previous occasions (2002, 2003, 2005, 2007, 2009, 2011 and 2014). In February 2016, an expert group under the guidance of RAV once more revised the guidelines. The most important updates in the present guidelines are as follows: Tenofovir alafenamide (TAF) has recently been registered. TAF has several advantages over tenofovir disoproxilfumarate (TDF) and is recommended instead of TDF in most cases. First-line treatment for previously untreated individuals includes dolutegravir, boosted darunavir or efavirenz with either abacavir/lamivudine or tenofovir (TDF/TAF)/emtricitabine. Pre-exposure prophylaxis (PrEP) is recommended for high-risk individuals. As in the case of the previous publication, recommendations are evidence-graded in accordance with the Oxford Centre for Evidence Based Medicine ( http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ ) ( Table 1 ). This document does not cover treatment of opportunistic infections and tumours. [Table: see text].
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Affiliation(s)
- Jaran Eriksen
- a Department of Clinical Pharmacology , Karolinska University Hospital and Division of Clinical Pharmacology and Department of Laboratory Medicine, Karolinska Institutet , Stockholm , Sweden
| | - Jan Albert
- b Department of Microbiology, Tumor and Cell Biology , Karolinska Institutet and Department of Clinical Microbiology, Karolinska University Hospital , Stockholm , Sweden
| | - Anders Blaxhult
- c Venhälsan, Södersjukhuset and The Swedish Agency for Public Health , Stockholm , Sweden
| | - Christina Carlander
- d Clinic of Infectious Diseases , Västmanland County Hospital , Västerås , Sweden
| | - Leo Flamholc
- e Department of Infectious Diseases , Skåne University Hospital , Malmö , Sweden
| | - Magnus Gisslén
- f Department of Infectious Diseases , Sahlgrenska Academy, University of Gothenburg , Sweden
| | | | - Olof Karlström
- h The Swedish Medical Products Agency, Uppsala and Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Lars Navér
- i Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Pediatrics , Karolinska University Hospital , Stockholm , Sweden
| | - Veronica Svedhem
- j Department of Infectious Diseases , Karolinska University Hospital and Division of Infectious Diseases and Department of Medicine Huddinge, Karolinska Institutet , Stockholm , Sweden
| | - Aylin Yilmaz
- k Department of Infectious Diseases , Sahlgrenska Academy, University of Gothenburg , Sweden
| | - Anders Sönnerborg
- l Division of Infectious Diseases, Department of Medicine Huddinge , Karolinska Institutet , Stockholm , Sweden ; All members of the Swedish Reference Group for Antiviral Therapy
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Schafer JJ, Gill TK, Sherman EM, McNicholl IR. ASHP Guidelines on Pharmacist Involvement in HIV Care. Am J Health Syst Pharm 2016; 73:468-94. [PMID: 26892679 DOI: 10.2146/ajhp150623] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Jason J Schafer
- Department of Pharmacy Practice, Jefferson School of Pharmacy, Thomas Jefferson University, Philadelphia, PA
| | - Taylor K Gill
- Internal Medicine, Via Christi Hospitals Wichita, Wichita, KS
| | - Elizabeth M Sherman
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, and South Broward Community Health Services, Memorial Healthcare System, Hollywood, FL
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Contrasting Adult and Infant Immune Responses to HIV Infection and Vaccination. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2015; 23:84-94. [PMID: 26656117 DOI: 10.1128/cvi.00565-15] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Extensive studies have demonstrated that infant immune responses are distinct from those of adults. Despite these differences, infant immunization can elicit protective immune responses at levels comparable to or, in some cases, higher than adult immune responses to many vaccines. To date, only a few HIV vaccine candidates have been tested in infant populations, and none of them evaluated vaccine efficacy. Recent exciting studies showing that HIV-infected infants can develop broad neutralizing antibody responses and that some HIV vaccine regimens can elicit high levels of potentially protective antibodies in infants provide support for the development and testing of HIV vaccines in pediatric populations. In this review, we discuss the differences in adult and infant immune responses in the setting of HIV infection and vaccination.
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Turkova A, Chappell E, Judd A, Goodall RL, Welch SB, Foster C, Riordan A, Shingadia D, Shackley F, Doerholt K, Gibb DM, Collins IJ. Prevalence, incidence, and associated risk factors of tuberculosis in children with HIV living in the UK and Ireland (CHIPS): a cohort study. Lancet HIV 2015; 2:e530-9. [PMID: 26614967 DOI: 10.1016/s2352-3018(15)00200-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/15/2015] [Accepted: 09/18/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Tuberculosis is the most common serious co-infection in people living with HIV worldwide, but little is known about its incidence in HIV-infected children living in high-resource settings with low tuberculosis prevalence. We aimed to assess the incidence and prevalence of tuberculosis in children with HIV living in the UK and Ireland to understand rates, risk factors, and outcomes of the disease in this group. METHODS We did an analysis of children enrolled in CHIPS, an observational multicentre cohort of children receiving HIV care in the UK and Ireland. We assessed characteristics and prevalence of tuberculosis at baseline, measured incidence of disease through the follow-up period using the CHIPS database, and calculated associated risk factors in these children with multivariable logistic and Cox regression models. FINDINGS Between Jan 1, 1996, to Sept 18, 2014, data for 1848 children with 14 761 years of follow-up were reported to CHIPS. 57 (3%) children were diagnosed with tuberculosis: 29 children had tuberculosis at presentation (prevalent tuberculosis) and 29 had the disease diagnosed during follow-up (incident tuberculosis), including one child with recurrent tuberculosis events. Median age at diagnosis was 9 years (IQR 5-12). 25 (43%) children had pulmonary tuberculosis, 24 (41%) had extrapulmonary tuberculosis with or without pulmonary involvement, and the remainder (n=9; 16%) had unspecified-site tuberculosis. The overall incidence rate for the follow-up period was 196 cases per 100 000 person-years (95% CI 137-283). In our multivariable model, tuberculosis at presentation was associated with more severe WHO immunological stage at baseline (odds ratio 0·25, 95% CI 0·08-0·74; p=0·0331; for none vs severe) and being born abroad (odds ratio 0·28, 0·10-0·73; p=0·0036; for UK and Ireland vs abroad). Incident tuberculosis was associated with time-updated more severe WHO immunological stage (hazard ratio 0·15, 95% CI 0·06-0·41; p=0·0056; for none vs severe) and older age at baseline (1·11, 0·47-2·63; p=0·0027; for age >10 years vs 5-9 years). INTERPRETATION Tuberculosis rates in HIV-infected children in the UK and Ireland were higher than those reported in the general paediatric population. Further study is warranted of tuberculosis screening and preventive treatment for children at high-risk of this disease to avoid morbidity and mortality in this population. FUNDING NHS England, PENTA Foundation.
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Affiliation(s)
- Anna Turkova
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK; Imperial College Healthcare NHS Trust, London, UK.
| | - Elizabeth Chappell
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Ali Judd
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Ruth L Goodall
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | | | | | - Andrew Riordan
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Delane Shingadia
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Diana M Gibb
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Intira J Collins
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
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Porter M, Davies MA, Mapani MK, Rabie H, Phiri S, Nuttall J, Fairlie L, Technau KG, Stinson K, Wood R, Wellington M, Haas AD, Giddy J, Tanser F, Eley B. Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004-2012. J Acquir Immune Defic Syndr 2015; 69:593-601. [PMID: 26167620 PMCID: PMC4509628 DOI: 10.1097/qai.0000000000000683] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are limited published data on the outcomes of infants starting antiretroviral therapy (ART) in routine care in Southern Africa. This study aimed to examine the baseline characteristics and outcomes of infants initiating ART. METHODS We analyzed prospectively collected cohort data from routine ART initiation in infants from 11 cohorts contributing to the International Epidemiologic Database to Evaluate AIDS in Southern Africa. We included ART-naive HIV-infected infants aged <12 months initiating ≥3 antiretroviral drugs between 2004 and 2012. Kaplan-Meier estimates were calculated for mortality, loss to follow-up (LTFU), transfer out, and virological suppression. We used Cox proportional hazard models stratified by cohort to determine baseline characteristics associated with outcomes mortality and virological suppression. RESULTS The median (interquartile range) age at ART initiation of 4945 infants was 5.9 months (3.7-8.7) with follow-up of 11.2 months (2.8-20.0). At ART initiation, 77% had WHO clinical stage 3 or 4 disease and 87% were severely immunosuppressed. Three-year mortality probability was 16% and LTFU 29%. Severe immunosuppression, WHO stage 3 or 4, anemia, being severely underweight, and initiation of treatment before 2010 were associated with higher mortality. At 12 months after ART initiation, 17% of infants were severely immunosuppressed and the probability of attaining virological suppression was 56%. CONCLUSIONS Most infants initiating ART in Southern Africa had severe disease with high probability of LTFU and mortality on ART. Although the majority of infants remaining in care showed immune recovery and virological suppression, these responses were suboptimal.
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Affiliation(s)
- Mireille Porter
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | | | - Helena Rabie
- Tygerberg Academic Hospital and Stellenbosch University, Tygerberg, W Cape
| | - Sam Phiri
- Lighthouse Trust Clinic, Lilongwe, Malawi
| | - James Nuttall
- Red Cross War Memorial Children's Hospital, Cape Town, and School of Child and Adolescent Health, University of Cape Town, South Africa
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Karl-Günter Technau
- Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - Kathryn Stinson
- Médecins Sans Frontierès, Khayelitsha and School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Robin Wood
- Gugulethu Community Health Centre and Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, South Africa
| | | | - Andreas D. Haas
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
| | | | - Frank Tanser
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Brian Eley
- Red Cross War Memorial Children's Hospital, Cape Town, and School of Child and Adolescent Health, University of Cape Town, South Africa
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Gianesin K, Petrara R, Freguja R, Zanchetta M, Giaquinto C, De Rossi A. Host factors and early treatments to restrict paediatric HIV infection and early disease progression. J Virus Erad 2015. [DOI: 10.1016/s2055-6640(20)30509-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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PRINCE-1: safety and efficacy of atazanavir powder and ritonavir liquid in HIV-1-infected antiretroviral-naïve and -experienced infants and children aged ≥3 months to <6 years. J Int AIDS Soc 2015; 18:19467. [PMID: 26066346 PMCID: PMC4463476 DOI: 10.7448/ias.18.1.19467] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 03/05/2015] [Accepted: 04/13/2015] [Indexed: 12/30/2022] Open
Abstract
Introduction PRINCE-1 is an ongoing prospective, international, multicentre, nonrandomized, two-stage clinical trial assessing safety and efficacy of once-daily atazanavir (ATV) powder boosted with ritonavir (RTV) liquid plus optimized dual nucleoside reverse-transcriptase inhibitor (NRTI) background therapy in antiretroviral (ARV)-naïve and -experienced children with HIV-1 infection aged ≥3 months to <6 years. Methods Children with HIV-1 infection without prior ATV exposure and with a screening HIV-1 RNA ≥1000 copies/mL were enrolled. The dosing of ATV powder, boosted with 80 mg RTV liquid, was based on three baseline weight bands (5 to <10 kg=150 mg, 10 to <15 kg=200 mg and 15 to <25 kg=250 mg). Results Of the 56 treated patients, 46 completed 48 weeks of therapy, 67.9% were from Africa and 60.7% were ART-naïve. Median ages at baseline were 6, 35 and 55 months, and proportions with HIV-1 RNA >100,000 were 85.7, 52.6 and 25% in the three baseline weight bands, respectively. No unexpected safety events occurred and no deaths were reported. Over 48 weeks, upper respiratory tract infections, diarrhoea, vomiting and Grade 3 to 4 hyperbilirubinaemia occurred in 35.7, 35.7, 28.6, and 9.4% of patients, respectively; five patients (8.9%) discontinued due to adverse events (AEs); and 11 patients (19.6%) experienced serious adverse events. At Week 48, using a modified intent-to-treat analysis (two patients were excluded because they switched to ATV capsules before Week 48), 61.1 and 74.1% of patients overall had an HIV-1 RNA level <50 copies/mL and <400 copies/mL, respectively. Virologic suppression rates increased across the lowest to highest baseline weight bands (47.6, 68.4 and 71.4% had HIV-1 RNA <50 copies/mL, and 66.7, 73.7 and 85.7% had HIV-RNA <400 copies/mL, respectively) but did not differ meaningfully between ARV-naïve and -experienced patients. Overall, the median change from baseline in CD4 cell count was +363 cells/mm3, and the median change from baseline in CD4 percent was +7.5%. Conclusions ATV powder boosted with RTV liquid once daily plus optimized dual NRTI background therapy was effective and well tolerated in this ART-naïve or -experienced paediatric population aged ≥3 months to <6 years. No unexpected safety findings compared with those from previous ATV paediatric and adult studies were identified.
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Bamford A, Turkova A, Lyall H, Foster C, Klein N, Bastiaans D, Burger D, Bernadi S, Butler K, Chiappini E, Clayden P, Della Negra M, Giacomet V, Giaquinto C, Gibb D, Galli L, Hainaut M, Koros M, Marques L, Nastouli E, Niehues T, Noguera-Julian A, Rojo P, Rudin C, Scherpbier HJ, Tudor-Williams G, Welch SB. Paediatric European Network for Treatment of AIDS (PENTA) guidelines for treatment of paediatric HIV-1 infection 2015: optimizing health in preparation for adult life. HIV Med 2015; 19:e1-e42. [PMID: 25649230 PMCID: PMC5724658 DOI: 10.1111/hiv.12217] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2014] [Indexed: 02/06/2023]
Abstract
The 2015 Paediatric European Network for Treatment of AIDS (PENTA) guidelines provide practical recommendations on the management of HIV‐1 infection in children in Europe and are an update to those published in 2009. Aims of treatment have progressed significantly over the last decade, moving far beyond limitation of short‐term morbidity and mortality to optimizing health status for adult life and minimizing the impact of chronic HIV infection on immune system development and health in general. Additionally, there is a greater need for increased awareness and minimization of long‐term drug toxicity. The main updates to the previous guidelines include: an increase in the number of indications for antiretroviral therapy (ART) at all ages (higher CD4 thresholds for consideration of ART initiation and additional clinical indications), revised guidance on first‐ and second‐line ART recommendations, including more recently available drug classes, expanded guidance on management of coinfections (including tuberculosis, hepatitis B and hepatitis C) and additional emphasis on the needs of adolescents as they approach transition to adult services. There is a new section on the current ART ‘pipeline’ of drug development, a comprehensive summary table of currently recommended ART with dosing recommendations. Differences between PENTA and current US and World Health Organization guidelines are highlighted and explained.
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Affiliation(s)
- A Bamford
- Department of Paediatric Infectious Diseases and Immunology, Great Ormond Street Hospital NHS Trust, London, UK
| | - A Turkova
- Medical Research Council Clinical Trials Unit, London, UK
| | - H Lyall
- Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
| | - C Foster
- Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
| | - N Klein
- Institute of Child Health, University College London, London, UK
| | - D Bastiaans
- Radboud University Medical Center, Nijmegan, The Netherlands
| | - D Burger
- Radboud University Medical Center, Nijmegan, The Netherlands
| | - S Bernadi
- University Department of Immunology and Infectious Disease, Bambino Gesù Children's Hospital, Rome, Italy
| | - K Butler
- Our Lady's Children's Hospital Crumlin & University College Dublin, Dublin, Ireland
| | - E Chiappini
- Meyer University Hospital, Florence University, Florence, Italy
| | | | - M Della Negra
- Emilio Ribas Institute of Infectious Diseases, Sao Paulo, Brazil
| | - V Giacomet
- Paediatric Infectious Disease Unit, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - C Giaquinto
- Department of Paediatrics, University of Padua, Padua, Italy
| | - D Gibb
- Medical Research Council Clinical Trials Unit, London, UK
| | - L Galli
- Department of Health Sciences, Pediatric Unit, University of Florence, Florence, Italy
| | - M Hainaut
- Department of Pediatrics, CHU Saint-Pierre, Free University of Brussels, Brussels, Belgium
| | - M Koros
- Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - L Marques
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Pediatric Department, Porto Central Hospital, Porto, Portugal
| | - E Nastouli
- Department of Clinical Microbiology and Virology, University College London Hospitals, London, UK
| | - T Niehues
- Centre for Pediatric and Adolescent Medicine, HELIOS Hospital Krefeld, Krefeld, Germany
| | - A Noguera-Julian
- Infectious Diseases Unit, Pediatrics Department, Sant Joan de Déu Hospital, University of Barcelona, Barcelona, Spain
| | - P Rojo
- 12th of October Hospital, Madrid, Spain
| | - C Rudin
- University Children's Hospital, Basel, Switzerland
| | - H J Scherpbier
- Department of Paediatric Immunology and Infectious Diseases, Emma Children's Hospital Academic Medical Centre, Amsterdam, The Netherlands
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Tobin NH, Aldrovandi GM. Are infants unique in their ability to be "functionally cured" of HIV-1? Curr HIV/AIDS Rep 2014; 11:1-10. [PMID: 24390641 DOI: 10.1007/s11904-013-0189-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The recent report of an infant that appears to have achieved a "functional cure" of HIV-1 following receipt of antiretroviral therapy (ART) within 30 hours of birth raises many questions: was the child infected? Was this result due to unique features of this particular infant's immune system, the immune system of infants or the very early initiation of effective ART? In this manuscript, we discuss the pathogenesis of HIV-1 in infants, highlighting the unique features of infant immune development and how these may inform efforts to cure HIV infection. We will also compare the path to infant "cure" to cures in adults.
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Affiliation(s)
- Nicole H Tobin
- Department of Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS#51, Los Angeles, CA, 90027, USA
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Yin DE, Warshaw MG, Miller WC, Castro H, Fiscus SA, Harper LM, Harrison LJ, Klein NJ, Lewis J, Melvin AJ, Tudor-Williams G, McKinney RE. Using CD4 percentage and age to optimize pediatric antiretroviral therapy initiation. Pediatrics 2014; 134:e1104-16. [PMID: 25266426 PMCID: PMC4179097 DOI: 10.1542/peds.2014-0527] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Quantifying pediatric immunologic recovery by highly active antiretroviral therapy (HAART) initiation at different CD4 percentage (CD4%) and age thresholds may inform decisions about timing of treatment initiation. METHODS HIV-1-infected, HAART-naive children in Europe and the Americas were followed from 2002 through 2009 in PENPACT-1. Data from 162 vertically infected children, with at least World Health Organization "mild" immunosuppression and CD4% <10th percentile, were analyzed for improvement to a normal CD4% (≥10th percentile) within 4 years after HAART initiation. Data from 209 vertically infected children, regardless of immune status, were analyzed for CD4% outcomes at 4 years and viral failure within 4 years. RESULTS Seventy-two percent of baseline immunosuppressed children recovered to normal within 4 years. Compared with "severe" immunosuppression, more children with "mild" immunosuppression (difference 36%, 95% confidence interval [CI]: 22% to 49%) or "advanced" immunosuppression (difference 20.8%, 95% CI: 5.8% to 35.9%) recovered a normal CD4%. For each 5-year increase in baseline age, the proportion of children achieving a normal CD4% declined by 19% (95% CI: 11% to 27%). Combining baseline CD4% and age effects resulted in >90% recovery when initiating HAART with "mild" immunosuppression at any age or "advanced" immunosuppression at age <3 years. Baseline CD4% effects became greater with increasing age (P = .02). At 4 years, most immunologic benefits were still significant but diminished. Viral failure was highest in infancy (56%) and adolescence (63%). CONCLUSIONS Initiating HAART at higher CD4% and younger ages maximizes potential for immunologic recovery. Guidelines should weigh immunologic benefits against long-term risks.
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Affiliation(s)
- Dwight E. Yin
- Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina;,Department of Epidemiology, Gillings School of Global Public Health,,Division of Infectious Diseases, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri—Kansas City, Kansas City, Missouri
| | - Meredith G. Warshaw
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts
| | - William C. Miller
- Department of Epidemiology, Gillings School of Global Public Health,,Division Infectious Diseases, Department of Medicine, School of Medicine, and
| | - Hannah Castro
- Infections Group, Medical Research Council Clinical Trials Unit
| | - Susan A. Fiscus
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lynda M. Harper
- Infections Group, Medical Research Council Clinical Trials Unit
| | - Linda J. Harrison
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts
| | - Nigel J. Klein
- Infectious Diseases and Microbiology Unit, Institute of Child Health, and
| | - Joanna Lewis
- Institute of Child Health and CoMPLEX, University College London, London, United Kingdom
| | - Ann J. Melvin
- Division of Pediatric Infectious Disease, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, Washington; and
| | | | - Ross E. McKinney
- Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
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Sunohara D, Nishimata S, Kondo A, Ishii C, Kashiwagi Y, Kawashima H. Current status of pediatric human immunodeficiency virus infection in Japan. J Infect Chemother 2014; 20:661-5. [PMID: 25179394 DOI: 10.1016/j.jiac.2014.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 07/29/2014] [Accepted: 07/29/2014] [Indexed: 11/30/2022]
Abstract
There are currently very few English reports about Japanese pediatric human immunodeficiency virus (HIV). In this study, we introduce our experience with pediatric HIV in a single hospital, and review the present status of HIV infections in children in Japan. In Japan, the main infection routes of HIV include sexual activity, mother-to-child transmission (MTCT), blood or blood product transfusion, and drug use. Most pediatric HIV patients have been infected by MTCT in recent years. One survey showed that in Japan, 52 babies were infected by MTCT between 1984 and 2011. Only 2 cases of pediatric HIV infection have been reported since 2010. The MTCT rate has decreased to 0.5% owing to several preventive interventions. In addition, the HIV antibody test is now performed in more than 98.3% of pregnant women in Japan.
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Affiliation(s)
- Daisuke Sunohara
- Department of Pediatrics, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Shigeo Nishimata
- Department of Pediatrics, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Atsushi Kondo
- Department of Pediatrics, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Chiako Ishii
- Department of Pediatrics, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Yasuyo Kashiwagi
- Department of Pediatrics, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Hisashi Kawashima
- Department of Pediatrics, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan.
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Lindsey JC, Hughes MD, Violari A, Eshleman SH, Abrams EJ, Bwakura-Dangarembizi M, Barlow-Mosha L, Kamthunzi P, Sambo PM, Cotton MF, Moultrie H, Khadse S, Schimana W, Bobat R, Zimmer B, Petzold E, Mofenson LM, Jean-Philippe P, Palumbo P. Predictors of virologic and clinical response to nevirapine versus lopinavir/ritonavir-based antiretroviral therapy in young children with and without prior nevirapine exposure for the prevention of mother-to-child HIV transmission. Pediatr Infect Dis J 2014; 33:846-54. [PMID: 25222305 PMCID: PMC4166566 DOI: 10.1097/inf.0000000000000337] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In a randomized trial comparing nevirapine (NVP)-based versus lopinavir/ritonavir (LPV/r)-based antiretroviral therapy (ART) in HIV-infected children [primary endpoint discontinuation of study treatment for any reason or virologic failure by week 24] aged 2 months to 3 years, we assessed whether clinical, virologic, immunologic and safety outcomes varied by prior single-dose NVP exposure (PrNVP) for prevention of mother-to-child HIV transmission and other covariates. METHODS Efficacy was assessed by time to ART discontinuation or virologic failure, virologic failure/death and death; safety by time to ART discontinuation because of a protocol-defined toxicity and first ≥ grade 3 adverse event; immunology and growth by changes in CD4%, weight/height World Health Organization z-scores from entry to week 48. Cox proportional hazards and linear regression models were used to test whether treatment differences depended on PrNVP exposure and other covariates. RESULTS Over a median follow up of 48 (PrNVP) and 72 (no PrNVP) weeks, there was no evidence of differential treatment effects by PrNVP exposure or any other covariates. LPV/r-based ART was superior to NVP-based ART for efficacy and safety outcomes; however, those on NVP had larger improvements in CD4%, weight and height z-scores. Lower pretreatment CD4% and higher HIV-1 RNA levels were associated with reduced efficacy, lower pretreatment CD4% with shorter time to ART discontinuation because of a protocol-defined toxicity, and no PrNVP with shorter time to first grade ≥ 3 adverse event. CONCLUSIONS Differences between LPV/r and NVP ART in efficacy, safety, immunologic and growth outcomes did not depend on PrNVP exposure, prior breast-feeding, sex, HIV-1 subtype, age, pretreatment CD4%, HIV-1 RNA or World Health Organization disease stage. This finding should be considered when selecting an ART regimen for young children.
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Affiliation(s)
- Jane C Lindsey
- From the *Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, MA; †University of Witwatersrand, Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Johannesburg, South Africa; ‡Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD; §Department of Epidemiology, ICAP, Mailman School of Public Health and College of Physicians and Surgeons, Columbia University, New York, NY; ¶Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe; ‖Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda; **University of North Carolina Project, Lilongwe, Malawi; ††University Teaching Hospital, Lusaka, Zambia; ‡‡Division of Paediatrics and Infectious Diseases, Tygerberg Children's Hospital, Stellenbosch University, Tygerberg; §§University of the Witwatersrand Reproductive Health and HIV Institute, Faculty of Health Sciences, Johannesburg, South Africa; ¶¶Department of Pediatrics, BJ Medical College and Sassoon General Hospital, Pune, India; ‖‖Duke University-Kilimanjaro Christian Medical Center Collaboration, Moshi, Tanzania; ***Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; †††Frontier Science and Technology Research Foundation, Amherst, NY; ‡‡‡Social and Scientific Systems, Durham, NC; §§§Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD; ¶¶¶HJF-DAIDS, a Division of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Contractor to NIAID, NIH, DHHS, Bethesda, MD; and ‖‖‖Division of Infectious Diseases and International Health, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH
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Abstract
Purpose of review Recent WHO guidelines recommend immediate initiation of lifelong antiretroviral therapy (ART) in all children below 5 years, irrespective of immune/clinical status, to improve access to paediatric ART. Interim trial results provide strong evidence for immediate ART during infancy because of high short-term risk of mortality and disease progression, but there is wider debate regarding the potential risks and benefits of immediate ART in asymptomatic children aged above 1 year. Concerns include long-term toxicities and treatment failure, particularly in resource-constrained settings with limited paediatric treatment options. Recent findings Benefits of immediate ART among infants appear to be maintained in the mid-term to long-term, with low risk of treatment failure, and better neurodevelopmental outcomes. In contrast, a trial reported no benefits of immediate versus deferred ART in asymptomatic children aged above 1 year. However, observational studies suggest that ART initiation at older ages and lower CD4 reduces the probability of immune reconstitution, with unclear implications on risk of clinical events or treatment change. A recent trial on treatment interruption following early intensive ART suggest that this may be a safe alternative approach. Summary Although there are clear benefits of immediate ART among infants, there remains conflicting evidence on the benefits for older children.
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Davies MA, May M, Bolton-Moore C, Chimbetete C, Eley B, Garone D, Giddy J, Moultrie H, Ndirangu J, Phiri S, Rabie H, Technau K, Wood R, Boulle A, Egger M, Keiser O. Prognosis of children with HIV-1 infection starting antiretroviral therapy in Southern Africa: a collaborative analysis of treatment programs. Pediatr Infect Dis J 2014; 33:608-16. [PMID: 24378936 PMCID: PMC4349941 DOI: 10.1097/inf.0000000000000214] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prognostic models for children starting antiretroviral therapy (ART) in Africa are lacking. We developed models to estimate the probability of death during the first year receiving ART in Southern Africa. METHODS We analyzed data from children ≤10 years of age who started ART in Malawi, South Africa, Zambia or Zimbabwe from 2004 to 2010. Children lost to follow up or transferred were excluded. The primary outcome was all-cause mortality in the first year of ART. We used Weibull survival models to construct 2 prognostic models: 1 with CD4%, age, World Health Organization clinical stage, weight-for-age z-score (WAZ) and anemia and the other without CD4%, because it is not routinely measured in many programs. We used multiple imputation to account for missing data. RESULTS Among 12,655 children, 877 (6.9%) died in the first year of ART. We excluded 1780 children who were lost to follow up/transferred from main analyses; 10,875 children were therefore included. With the CD4% model probability of death at 1 year ranged from 1.8% [95% confidence interval (CI): 1.5-2.3] in children 5-10 years with CD4% ≥10%, World Health Organization stage I/II, WAZ ≥ -2 and without severe anemia to 46.3% (95% CI: 38.2-55.2) in children <1 year with CD4% < 5%, stage III/IV, WAZ< -3 and severe anemia. The corresponding range for the model without CD4% was 2.2% (95% CI: 1.8-2.7) to 33.4% (95% CI: 28.2-39.3). Agreement between predicted and observed mortality was good (C-statistics = 0.753 and 0.745 for models with and without CD4%, respectively). CONCLUSIONS These models may be useful to counsel children/caregivers, for program planning and to assess program outcomes after allowing for differences in patient disease severity characteristics.
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Affiliation(s)
- Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Margaret May
- School of Social and Community Medicine, University of Bristol, UK
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia and University of North Caroline at Chapel Hill, USA
| | | | - Brian Eley
- Red Cross Children’s Hospital and School of Child and Adolescent Health, University of Cape Town, South Africa
| | - Daniela Garone
- Médecins Sans Frontières (MSF) South Africa and Khayelitsha ART Programme, Cape Town, South Africa
| | - Janet Giddy
- Sinikithemba Clinic, McCord Hospital, Durban, South Africa
| | - Harry Moultrie
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg and Harriet Shezi Children’s Clinic, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - James Ndirangu
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Sam Phiri
- Lighthouse Trust Clinic, Kamuzu Central Hospital, Lilongwe, Malawi and Liverpool School of Tropical Medicine Liverpool, UK
| | - Helena Rabie
- Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch, South Africa
| | - Karl Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, and University of Witwatersrand, Johannesburg, South Africa
| | - Robin Wood
- Gugulethu ART Programme and Desmond Tutu HIV Centre, University of Cape Town, South Africa
| | - Andrew Boulle
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Matthias Egger
- School of Public Health and Family Medicine, University of Cape Town, South Africa
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
| | - Olivia Keiser
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
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Ciaranello A, Lu Z, Ayaya S, Losina E, Musick B, Vreeman R, Freedberg KA, Abrams EJ, Dillabaugh L, Doherty K, Ssali J, Yiannoutsos CT, Wools-Kaloustian K. Incidence of World Health Organization stage 3 and 4 events, tuberculosis and mortality in untreated, HIV-infected children enrolling in care before 1 year of age: an IeDEA (International Epidemiologic Databases To Evaluate AIDS) East Africa regional analysis. Pediatr Infect Dis J 2014; 33:623-9. [PMID: 24378935 PMCID: PMC4024340 DOI: 10.1097/inf.0000000000000223] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Few studies have reported CD4%- and age-stratified rates of World Health Organization Stage 3 (WHO3) events, World Health Organization Stage 4 (WHO4) events, tuberculosis (TB) and mortality in HIV-infected infants before initiation of antiretroviral therapy. METHODS HIV-infected children enrolled before 1 year of age in the International Epidemiologic Databases to Evaluate AIDS East Africa region (October 1, 2002, to November, 2008) were included. We estimated incidence rates of earliest clinical event (WHO3, WHO4 and TB), before antiretroviral therapy initiation per local guidelines, stratified by current age (< or ≥6 months) and current CD4% (<15%, 15-24%, ≥25%). CD4%-stratified mortality rates were estimated separately for children who did not experience a clinical event ("background" mortality) and for children who experienced an event, including "acute" mortality (≤30 days post event) and "later" mortality (>30 days post event). RESULTS Among 847 children (median enrollment age: 4.8 months; median pre-antiretroviral therapy follow up: 10.8 months; 603 (71%) with ≥1 CD4% recorded), event rates were comparable for those aged <6 and ≥6 months. Current CD4% was associated with risk of WHO4 events for children <6 months of age and with all evaluated events for children ≥6 months old (P < 0.05). "Background" mortality was 3.7-8.4/100 person-years (PY). "Acute" mortality (≤30 days post event) was 33.8/100 PY (after TB) and 41.1/100 PY (after WHO3 or WHO4). "Later" mortality (>30 days post event) ranged by CD4% from 4.7 to 29.1/100 PY. CONCLUSIONS In treatment-naïve, HIV-infected infants, WHO3, WHO4 and TB events were common before and after 6 months of age and led to substantial increases in mortality. Early infant HIV diagnosis and treatment are critically important, regardless of CD4%.
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Affiliation(s)
- Andrea Ciaranello
- Division of Infectious Diseases and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Zhigang Lu
- Division of General Medicine and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Samuel Ayaya
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, KENYA
| | - Elena Losina
- Division of General Medicine and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Beverly Musick
- Department of Biostatistics, Indiana University, Indianapolis, IN, USA
| | - Rachel Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth A. Freedberg
- Division of Infectious Diseases and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA,Division of General Medicine and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Elaine J. Abrams
- ICAP, Mailman School of Public Health, Columbia University and College of Physicians & Surgeons, Columbia University, NY, USA
| | - Lisa Dillabaugh
- Family AIDS Care and Education Service (FACES) program, Kisumu, KENYA, and Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Katie Doherty
- Division of General Medicine and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - John Ssali
- Masaka Regional Referral Hospital, AHF-Uganda Cares Masaka, Uganda
| | | | - Kara Wools-Kaloustian
- Division of Infectious Disease, Indiana University School of Medicine, Indianapolis, IN, USA
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Shahrin L, Leung DT, Matin N, Kawser CA, Pervez MM, Chisti MJ. Clinical profile of hospitalized HIV-infected children in Bangladesh, a low-HIV-prevalence country. Paediatr Int Child Health 2014; 34:133-7. [PMID: 24164974 DOI: 10.1179/2046905513y.0000000100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Bangladesh has a low HIV prevalence and data on the risk factors and clinical presentation of HIV-infected children are lacking. OBJECTIVE To describe the clinical characteristics of hospitalized HIV-infected children in Bangladesh and determine the factors associated with a low CD4 count. METHODS An anonymous, retrospective review was undertaken of the medical records of all patients admitted to the HIV unit of the iccdr,b Dhaka Hospital between February 2009 and July 2012. Demographic, clinical and laboratory data were extracted from the electronic medical record system. HIV-infected children with a low absolute CD4 count (<200 cells/μl) were compared with HIV-infected children with a CD4 count ≧200 cells/μl. RESULTS Of 266 HIV-infected patients, 24 were children (9%), 13 (54%) of whom were male. Ages ranged from 2 to 17 years (median 7). Of the 21 (88%) children who acquired the infection by vertical transmission, median age at diagnosis was 5·2 years, and the parents of 19 (79%) reported a history of external migration. Children commonly presented with prolonged fever (n = 14, 58%), recurrent cough (n = 14, 58%), failure to thrive (n = 11, 46%) and recurrent diarrhoea (n = 4, 17%). Six (25%) patients had tuberculosis, four (16·7%) had herpes zoster and four (16·7%) were diagnosed with Pneumocystis jirovecii pneumonia. One child died during hospitalization. Children with a low CD4 count (<200 cells/μl) more often had severe wasting (95% CI 1·2-453·97) and severe under-nutrition (95% CI 1·39-196·25) than those with a higher CD4 count*. CONCLUSION The majority of HIV-infected children presenting to an inpatient speciality ward in Dhaka acquired HIV through vertical transmission, and most of the parents had a history of external migration. Further studies are needed to determine the optimal strategy for preventing mother-to-child transmission and for early identification and treatment of HIV-infected children in this low-prevalence country.
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Bazin GR, Gaspar MCS, Silva NCXMD, Mendes CDC, Oliveira CPD, Bastos LS, Cardoso CAA. Terapia antirretroviral em crianças e adolescentes infectados pelo HIV: o que sabemos após 30 anos de epidemia. CAD SAUDE PUBLICA 2014; 30:687-702. [DOI: 10.1590/0102-311x00075413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 01/22/2014] [Indexed: 11/22/2022] Open
Abstract
Este estudo tem como objetivo avaliar o uso da terapia antirretroviral combinada em crianças e adolescentes com AIDS. Foram captados 247 resumos nos portais PubMed e LILACS, publicados entre 1983 e 2013, sendo utilizados 69 artigos para as referências bibliográficas. A atenção atribuída às pesquisas na faixa etária pediátrica durante os trinta anos de epidemia de AIDS se justifica por características imunológicas próprias, sendo a progressão da AIDS mais rápida em crianças que em adultos. Pesquisas recentes abordam estratégias de intervenção medicamentosa de alta potência antes do aparecimento dos sintomas iniciais. A introdução precoce da terapia antirretroviral combinada foi implantada com eficácia e segurança em populações com poucos recursos fixos, com melhora significativa da sobrevida desses pacientes. O desafio atual é lidar com uma doença crônica com intercorrências agudas. Novas pesquisas serão necessárias, atentando para as especificidades populacionais e particularizando as necessidades individuais dos pacientes pediátricos.
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Abstract
Most infants born to human immunodeficiency virus (HIV)-infected women escape HIV infection. Infants evade infection despite an immature immune system and, in the case of breastfeeding, prolonged repetitive exposure. If infants become infected, the course of their infection and response to treatment differs dramatically depending upon the timing (in utero, intrapartum, or during breastfeeding) and potentially the route of their infection. Perinatally acquired HIV infection occurs during a critical window of immune development. HIV's perturbation of this dynamic process may account for the striking age-dependent differences in HIV disease progression. HIV infection also profoundly disrupts the maternal immune system upon which infants rely for protection and immune instruction. Therefore, it is not surprising that infants who escape HIV infection still suffer adverse effects. In this review, we highlight the unique aspects of pediatric HIV transmission and pathogenesis with a focus on mechanisms by which HIV infection during immune ontogeny may allow discovery of key elements for protection and control from HIV.
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Abstract
With the widespread availability of antiretroviral therapy, there is a dramatic decline in HIV related morbidity and mortality in both developed and developing countries. Further, the current antiretroviral drug combinations are safer and the availability of newer monitoring assays and guidelines has vastly improved the patient management. The clinician needs to evaluate several key issues prior to institution of antiretroviral regimen including the correct stage of starting the treatment and the kind of regimen to initiate. In addition to various disease related factors, it is also critical to assess the patient's general condition including nutritional status, presence of co-morbidities and mental preparedness prior to starting the therapy. The patients need to develop an overall understanding of the treatment and its benefits and the importance of lifelong adherence to the drugs. The presence of special situations like pediatric age, older patients, pregnancy, lactation and presence of opportunistic infections also require modification of the therapy. This review briefly summarizes issues relevant to the clinician prior to the initiation of antiretroviral therapy.
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Affiliation(s)
- Deepika Pandhi
- Department of Dermatology and Sexually Transmitted Diseases, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, University of Delhi, Delhi, India
| | - Pallavi Ailawadi
- Department of Dermatology and Sexually Transmitted Diseases, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, University of Delhi, Delhi, India
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When to start antiretroviral therapy in children aged 2-5 years: a collaborative causal modelling analysis of cohort studies from southern Africa. PLoS Med 2013; 10:e1001555. [PMID: 24260029 PMCID: PMC3833834 DOI: 10.1371/journal.pmed.1001555] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Accepted: 10/09/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is limited evidence on the optimal timing of antiretroviral therapy (ART) initiation in children 2-5 y of age. We conducted a causal modelling analysis using the International Epidemiologic Databases to Evaluate AIDS-Southern Africa (IeDEA-SA) collaborative dataset to determine the difference in mortality when starting ART in children aged 2-5 y immediately (irrespective of CD4 criteria), as recommended in the World Health Organization (WHO) 2013 guidelines, compared to deferring to lower CD4 thresholds, for example, the WHO 2010 recommended threshold of CD4 count <750 cells/mm(3) or CD4 percentage (CD4%) <25%. METHODS AND FINDINGS ART-naïve children enrolling in HIV care at IeDEA-SA sites who were between 24 and 59 mo of age at first visit and with ≥1 visit prior to ART initiation and ≥1 follow-up visit were included. We estimated mortality for ART initiation at different CD4 thresholds for up to 3 y using g-computation, adjusting for measured time-dependent confounding of CD4 percent, CD4 count, and weight-for-age z-score. Confidence intervals were constructed using bootstrapping. The median (first; third quartile) age at first visit of 2,934 children (51% male) included in the analysis was 3.3 y (2.6; 4.1), with a median (first; third quartile) CD4 count of 592 cells/mm(3) (356; 895) and median (first; third quartile) CD4% of 16% (10%; 23%). The estimated cumulative mortality after 3 y for ART initiation at different CD4 thresholds ranged from 3.4% (95% CI: 2.1-6.5) (no ART) to 2.1% (95% CI: 1.3%-3.5%) (ART irrespective of CD4 value). Estimated mortality was overall higher when initiating ART at lower CD4 values or not at all. There was no mortality difference between starting ART immediately, irrespective of CD4 value, and ART initiation at the WHO 2010 recommended threshold of CD4 count <750 cells/mm(3) or CD4% <25%, with mortality estimates of 2.1% (95% CI: 1.3%-3.5%) and 2.2% (95% CI: 1.4%-3.5%) after 3 y, respectively. The analysis was limited by loss to follow-up and the unavailability of WHO staging data. CONCLUSIONS The results indicate no mortality difference for up to 3 y between ART initiation irrespective of CD4 value and ART initiation at a threshold of CD4 count <750 cells/mm(3) or CD4% <25%, but there are overall higher point estimates for mortality when ART is initiated at lower CD4 values. Please see later in the article for the Editors' Summary.
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Ramos Jr. AN, Matida LH, Alencar CH, Hearst N, Heukelbach J. Late-stage diagnosis of HIV infection in Brazilian children: evidence from two national cohort studies. CAD SAUDE PUBLICA 2013; 29:1291-300. [DOI: 10.1590/s0102-311x2013000700004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 02/14/2013] [Indexed: 11/22/2022] Open
Abstract
This study analyzed data from two consecutive retrospective cohort samples (1983 to 1998 and 1999 to 2002) of Brazilian children with AIDS (N = 1,758) through mother-to-child-transmission. Late-stage diagnosis (CDC category C) was investigated in relation to the following variables: year of birth, year of HIV diagnosis, and time periods related to changes in government treatment guidelines. Late-stage diagnosis occurred in 731 (41.6%) of cases and was more prevalent in infants under 12 months of age. The rate of late-stage diagnosis decreased from 48% to 36% between the two periods studied. We also observed a reduction in the proportion of late-stage diagnoses and the time lapse between HIV diagnosis and ART initiation. A significant association was found between timely diagnosis and having been born in recent years (OR = 0.62; p = 0.009) and year of HIV diagnosis (OR = 0.72; p = 0.002/OR = 0.62; p < 0.001). Infants under the age of 12 months were more likely to be diagnosed at a late stage than older children (OR = 1.70; p = 0.004). Despite advances, there is a need to improve the effectiveness of policies and programs focused on improving early diagnosis and management of HIV/AIDS.
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Routine versus clinically driven laboratory monitoring and first-line antiretroviral therapy strategies in African children with HIV (ARROW): a 5-year open-label randomised factorial trial. Lancet 2013; 381:1391-1403. [PMID: 23473847 PMCID: PMC3641608 DOI: 10.1016/s0140-6736(12)62198-9] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND No trials have investigated routine laboratory monitoring for children with HIV, nor four-drug induction strategies to increase durability of first-line antiretroviral therapy (ART). METHODS In this open-label parallel-group trial, Ugandan and Zimbabwean children or adolescents with HIV, aged 3 months to 17 years and eligible for ART, were randomly assigned in a factorial design. Randomisation was to either clinically driven monitoring or routine laboratory and clinical monitoring for toxicity (haematology and biochemistry) and efficacy (CD4 cell counts; non-inferiority monitoring randomisation); and simultaneously to standard three-drug or to four-drug induction first-line ART, in three groups: three-drug treatment (non-nucleoside reverse transcriptase inhibitor [NNRTI], lamivudine, abacavir; group A) versus four-drug induction (NNRTI, lamivudine, abacavir, zidovudine; groups B and C), decreasing after week 36 to three-drug NNRTI, lamivudine, plus abacavir (group B) or lamivudine, abacavir, plus zidovudine (group C; superiority ART-strategy randomisation). For patients assigned to routine laboratory monitoring, results were returned every 12 weeks to clinicians; for clinically driven monitoring, toxicity results were only returned for requested clinical reasons or if grade 4. Children switched to second-line ART for WHO stage 3 or 4 events or (routine laboratory monitoring only) age-dependent WHO CD4 criteria. Randomisation used computer-generated sequentially numbered tables incorporated securely within the database. Primary efficacy endpoints were new WHO stage 4 events or death for monitoring and change in CD4 percentage at 72 and 144 weeks for ART-strategy randomisations; the co-primary toxicity endpoint was grade 3 or 4 adverse events. Analysis was by intention to treat. This trial is registered, ISRCTN24791884. FINDINGS 1206 children were randomly assigned to clinically driven (n=606) versus routine laboratory monitoring (n=600), and groups A (n=397), B (n=404), and C (n=405). 47 (8%) children on clinically driven monitoring versus 39 (7%) on routine laboratory monitoring had a new WHO stage 4 event or died (hazard ratio [HR] 1·13, 95% CI 0·73-1·73, p=0·59; non-inferiority criterion met). However, in years 2-5, rates were higher in children on clinically driven monitoring (1·3 vs 0·4 per 100 child-years, difference 0·99, 0·37-1·60, p=0·002). One or more grade 3 or 4 adverse events occurred in 283 (47%) children on clinically driven versus 282 (47%) on routine laboratory monitoring (HR 0·98, 0·83-1·16, p=0·83). Mean CD4 percentage change did not differ between ART groups at week 72 (16·5% [SD 8·6] vs 17·1% [8·5] vs 17·3% [8·0], p=0·33) or week 144 (p=0·69), but four-drug groups (B, C) were superior to three-drug group A at week 36 (12·4% [7·2] vs 14·1% [7·1] vs 14·6% [7·3], p<0·0001). Excess grade 3 or 4 events in groups B (one or more events reported by 157 [40%] children in A, 190 [47%] in B; HR [B:A] 1·32, 1·07-1·63) and C (218 [54%] children in C; HR [C:A] 1·58, 1·29-1·94; global p=0·0001) were driven by asymptomatic neutropenia in zidovudine-containing groups (B, C; 86 group A, 133 group B, 184 group C), but resulted in drug substitutions in only zero versus two versus four children, respectively. INTERPRETATION NNRTI plus NRTI-based three-drug or four-drug ART can be given across childhood without routine toxicity monitoring; CD4 monitoring provided clinical benefit after the first year on ART, but event rates were very low and long-term survival high, suggesting ART rollout should take priority. CD4 benefits from four-drug induction were not durable, but three-NRTI long-term maintenance was immunologically and clinically similar to NNRTI-based ART and could be valuable during tuberculosis co-treatment. FUNDING UK Medical Research Council, the UK Department for International Development; drugs donated and viral load assays funded by ViiV Healthcare and GlaxoSmithKline.
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Fayorsey RN, Saito S, Carter RJ, Gusmao E, Frederix K, Koech-Keter E, Tene G, Panya M, Abrams EJ. Decentralization of pediatric HIV care and treatment in five sub-Saharan African countries. J Acquir Immune Defic Syndr 2013; 62:e124-30. [PMID: 23337367 PMCID: PMC5902810 DOI: 10.1097/qai.0b013e3182869558] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In resource-limited settings, decentralization of HIV care and treatment is a cornerstone of universal care and rapid scale-up. We compared trends in pediatric enrollment and outcomes at primary (PHFs) vs secondary/tertiary health facilities (SHFs). METHODS Using aggregate program data reported quarterly from 274 public facilities in Kenya, Lesotho, Mozambique, Rwanda, and Tanzania from January 2008 to March 2010, we examined trends in number of children younger than 15 years of age initiating antiretroviral treatment (ART) by facility type. We compared clinic-level lost to follow-up (LTFU) and mortality per 100 person-years (PYs) on ART during the period by facility type. RESULTS During the 2-year period, 17,155 children enrolled in HIV care and 8475 initiated ART in 182 (66%) PHFs and 92(34%) SHFs. PHFs increased from 56 to 182, whereas SHFs increased from 72 to 92 sites. SHFs accounted for 71% of children initiating ART; however, the proportion of children initiating ART each quarter at PHFs increased from 17% (129) to 44% (463) in conjunction with an increase in PHFs during observation period. The average LTFU and mortality rates for children on ART were 9.8/100 PYs and 5.2/100 PYs, respectively, at PHFs and 20.2/100 PYs and 6.0/100 PYs, respectively, at SHFs. Adjusted models show PHFs associated with lower LTFU (adjusted rate ratio = 0.55; P = 0.022) and lower mortality (adjusted rate ratio = 0.66; P = 0.028). CONCLUSIONS The expansion of pediatric services to PHFs has resulted in increased numbers of children on ART. Early findings suggest lower rates of LTFU and mortality at PHFs. Successful scale-up will require further expansion of pediatric services within PHFs.
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Affiliation(s)
- Ruby N Fayorsey
- Clinical and Training Unit, ICAP, Columbia University Mailman School of Public Health, New York, NY 10031, USA.
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Giacomet V, Fabiano V, Lo Muto R, Caiazzo MA, Curto A, Rampon O, Zuccotti GV, Garattini L. Resource utilization and direct costs of pediatric HIV in Italy. AIDS Care 2013; 25:1392-8. [PMID: 23414422 DOI: 10.1080/09540121.2013.769494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This multicenter, prospective, observational study assessed the global economic impact of HIV care in a large cohort of HIV-infected children and adolescents in Italy. Three pediatric departments of reference participated on a voluntary basis. Centers were asked to enroll all their children during the period April 2010-March 2011. At enrollment, a pediatrician completed a questionnaire for each patient, including the type of service at access (outpatient consultation or day hospital), laboratory tests, instrumental examinations, specialists' consultations, antiretroviral therapy and opportunistic illness prophylaxis. Eligible patients had a confirmed diagnosis of HIV infection caused by direct vertical maternal-fetal transmission, their age ranging from 0 to 24 years. Since patients routinely have quarterly check-ups in all three centers, we adopted a three-month time horizon. Health-care services were priced using outpatient and inpatient tariffs. Drug costs were calculated by multiplying the daily dose by the public price for each active ingredient. A total of 142 patients were enrolled. More than half the patients were female and the mean age was 14 years, with no significant differences by center. There were substantial differences in health-care management among the three centers, particularly as regards the type of access. One center enrolled the majority of its patients in day-hospital and prescribed a large number of clinical tests, while children accessed another center almost exclusively through outpatient consultation. Drug therapy was the main cost component and was very similar in all three centers. The day-hospital was the second highest cost component, much higher than outpatient consultation (including examinations), leading to significant differences between total costs per center. These findings suggest that a recommendation to the Italian National Health Service would be to use more outpatient consultation for patients' access in order to increase their efficiency in treating pediatric HIV infection.
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Affiliation(s)
- V Giacomet
- a Department of Pediatrics , Università degli Studi di Milano , Luigi Sacco Hospital, Milan , Italy
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de Jose MI, Jiménez de Ory S, Espiau M, Fortuny C, Navarro ML, Soler-Palacín P, Muñoz-Fernandez MA. A new tool for the paediatric HIV research: general data from the Cohort of the Spanish Paediatric HIV Network (CoRISpe). BMC Infect Dis 2013; 13:2. [PMID: 23282073 PMCID: PMC3544738 DOI: 10.1186/1471-2334-13-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 12/18/2012] [Indexed: 12/20/2022] Open
Abstract
There are approximately from 1,100 to 1,200 HIV-infected children in a follow-up in Spain. In 2008 an open, multicentral, retrospective and prospective Cohort of the Spanish Paediatric HIV Network (CoRISpe) was founded. The CoRISpe is divided into the node 1 and node 2 representing geographically almost the whole territory of Spain. Since 2008 seventy-five hospitals have been participating in the CoRISpe. All the retrospective data of the HIV-infected children have been kept in the CoRISpe since 1995 and prospective data since 2008. In this article we are going to present the notion of CoRISpe, its role, the structure, how the CoRISpe works and the process how a child is transferred from Paediatric to Adults Units. The main objective of the CoRISpe is to contribute to furthering scientific knowledge on paediatric HIV infection by providing demographic, sociopsychological, clinical and laboratory data from HIV-infected paediatric patients. Its aim is to enable high-quality research studies on HIV-infected children.
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Affiliation(s)
- Ma Isabel de Jose
- Servicio Infecciosas Infantil, Hospital Universitario “La Paz”, Paseo de la Castellana 26, Madrid, 128046, Spain
| | - Santiago Jiménez de Ory
- Laboratorio de Inmuno-Biología Molecular. Spanish HIV HGM BioBank. Hospital General Universitario “Gregorio Marañón” and Instituto de Investigación Sanitaria Gregorio Marañón, C/Dr. Esquerdo 46, Madrid, 28007, Spain
| | - Maria Espiau
- Unitat de Patologia Infecciosa i Immunodeficiències de Pediatria, Hospital Universitari Vall d` Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Claudia Fortuny
- Servicio Infecciosas Infantil, Hospital Sant Joan de Dèu, Esplugues de Llobregat, Barcelona, Spain
| | - Ma Luisa Navarro
- Sección de Enfermedades Infecciosas. Servicio de Pediatría. Hospital General Universitario “Gregorio Marañón”, Madrid, Spain
| | - Pere Soler-Palacín
- Unitat de Patologia Infecciosa i Immunodeficiències de Pediatria, Hospital Universitari Vall d` Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ma Angeles Muñoz-Fernandez
- Laboratorio de Inmuno-Biología Molecular. Spanish HIV HGM BioBank. Hospital General Universitario “Gregorio Marañón” and Instituto de Investigación Sanitaria Gregorio Marañón, C/Dr. Esquerdo 46, Madrid, 28007, Spain
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Turkova A, Webb RH, Lyall H. When to start, what to start and other treatment controversies in pediatric HIV infection. Paediatr Drugs 2012; 14:361-76. [PMID: 23013459 DOI: 10.2165/11599640-000000000-00000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Over the last decade there have been dramatic changes in the management of pediatric HIV infection. Whilst observational studies and several randomized control trials (RCTs) have addressed some questions about when to start antiretroviral therapy (ART) in children and what antiretrovirals to start, many others remain unanswered. In infants, early initiation of ART greatly reduces mortality and disease progression. Treatment guidelines now recommend ART in all infants younger than 1 or 2 years of age depending on geographical setting. In children >1 year of age, US, European (Paediatric European Network for Treatment of AIDS; PENTA) and WHO guidelines differ and debate is ongoing. Recent data from an RCT in Thailand in children with moderate immune suppression indicate that it is safe to monitor asymptomatic children closely without initiating ART, although earlier treatment was associated with improved growth. Untreated HIV progression in children aged over 5 years is similar to that in adults, and traditionally adult treatment thresholds are applied. Recent adult observational and modeling studies showed a survival advantage and reduction of age-associated complications with early treatment. The current US guidelines have lowered CD4+ cell count thresholds for ART initiation for children aged >5 years to 500 cells/mm3. Co-infections influence the choice of drugs and the timing of starting ART. Drug interactions, overlapping toxicities and adherence problems secondary to increased pill burden are important issues. Rapid changes in the pharmacokinetics of antiretrovirals in the first years of life, limited pharmacokinetic data in children and genetic variation in metabolism of many antiretrovirals make correct dosing difficult. Adherence should always be addressed prior to starting ART or switching regimens. The initial ART regimen depends on previous exposure, including perinatal administration for prevention of mother to child transmission (PMTCT), adherence, co-infections, drug availability and licensing. A European cohort study in infants indicated that treatment with four drugs produced superior virologic suppression and immune recovery. Protease inhibitor (PI)-based ART has the advantage of a high barrier to viral resistance. A recent RCT conducted in several African countries showed PI-based ART to be advantageous in children aged <3 years compared with nevirapine-based ART irrespective of previous nevirapine exposure. Another trial in older children from resource rich settings showed both regimens were equally effective. Treatment interruption remains a controversial issue in children, but one study in Europe demonstrated no short-term detrimental effects. ART in children is a rapidly evolving area with many new antiretrovirals being developed and undergoing trials. The aim of ART has shifted from avoiding mortality and morbidity to achieving a normal life expectancy and quality of life, minimizing toxicities and preventing early cancers and age-related illnesses.
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Affiliation(s)
- Anna Turkova
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Trust, London, UK
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