Adherence to antiretroviral therapy of Brazilian HIV-infected children and their caregivers

Perfil sociodemográfico e farmacoepidemiológico de crianças infectadas pelo HIV

RESUMO A terapia antirretroviral interfere na replicação do vírus HIV, impede a progressão da infecção para a Aids e previne a mortalidade precoce das crianças infectadas. Esta pesquisa investigou o perfil sociodemográfico e os parâmetros relacionados com o tratamento antirretroviral das crianças HIV positivas residentes no estado do Paraná. Trata-se de um estudo observacional descritivo e analítico realizado com dados secundários do ano de 2020 referentes às crianças com até 12 anos de idade. Foram investigados: perfil, prevalência, medicamentos em uso, abandono da terapia, resistência e supressão viral. Foram identificadas 148 crianças, com uma prevalência igual a 8,1/100 mil no Paraná. Apesar de todas as crianças diagnosticadas com HIV terem iniciado o tratamento, 17,2% encontravam-se em abandono da terapia antirretroviral. Entre as crianças que permaneciam em tratamento, 9,8% não atingiram a supressão viral e suas cargas virais comumente ultrapassavam mil cópias virais/mL. Houve um predomínio de esquemas medicamentosos provavelmente prescritos após falhas terapêuticas. Os resultados indicam que o Paraná apresenta bons resultados quanto ao início rápido da terapia e à supressão viral das crianças. Entretanto, existe um número considerável de abandonos da terapia e de falhas terapêuticas, indicando a necessidade de reforçar a vinculação desta população aos serviços de saúde.

Advances in Pediatric HIV-1 Cure Therapies and Reservoir Assays

Significant advances in the field of HIV-1 therapeutics to achieve antiretroviral treatment (ART)-free remission and cure for persons living with HIV-1 are being made with the advent of broadly neutralizing antibodies and very early ART in perinatal infection. The need for HIV-1 remission and cure arises due to the inability of ART to eradicate the major reservoir for HIV-1 in resting memory CD4+ T cells (the latent reservoir), and the strict adherence to lifelong treatment. To measure the efficacy of these cure interventions on reservoir size and to dissect reservoir dynamics, assays that are sensitive and specific to intact proviruses are critical. In this review, we provided a broad overview of some of the key interventions underway to purge the reservoir in adults living with HIV-1 and ones under study in pediatric populations to reduce and control the latent reservoir, primarily focusing on very early treatment in combination with broadly neutralizing antibodies. We also summarized assays currently in use to measure HIV-1 reservoirs and their feasibility and considerations for studies in children.

Disparities in HIV continuum of care in the paediatric population: A real-life study in Brazil

INTRODUCTION

Paediatric HIV follow-up is challenging, and treatment indicators are markedly far from Joint United Nations Programme on HIV/AIDS (UNAIDS) goals. In this study, we describe the 2019 Brazilian HIV cascade according to age categories and sociodemographic variables and address temporal trends between 2009 and 2019.

METHODS

We obtained data from the Brazilian Ministry of Health monitoring database. Cascade outcomes included retention in care, antiretroviral use, and viral suppression. We assessed the effect of age on timely initiation of antiretroviral treatment (ART; initiation with CD4⁺ T-cell count ≥350 cells/mm³ or a first ART dispensation ≤30 days after the first CD4⁺ T-cell measurement) and detectable HIV viral load (>50 copies/mL) in univariable and multivariable analysis adjusted for sex, race, and social vulnerability index (SVI). Temporal trends in timely ART initiation and viral suppression were evaluated graphically.

RESULTS

Among 771 774 people living with HIV, those in the youngest age categories had poorer indicators in the care cascade. Those in younger age groups, those with higher SVI, and those declaring Black and native Brazilian race/ethnicity had higher odds of having detectable viral load and delayed ART initiation. Although children living with HIV tend to start ART with higher CD4⁺ T-cell counts, time-series analysis suggests that improvements in treatment indicators seen in the adult population are not observed in the paediatric population.

CONCLUSION

Our results highlight the challenges faced by children and adolescents living with HIV in achieving UNAIDS goals. Lower access to ART among children is a central barrier to improved paediatric care.

HIV-1 subtypes and drug resistance in children during antiretroviral therapy in Brazil

We evaluate the genetic characterization of 132 HIV-1 pol sequences from children and adolescents undergoing antiretroviral therapy in Northeast Brazil. Phylogenetic and recombination analyses were performed using the maximum likelihood method using SeaView version 4 and SIMPLOT software. Most individuals harbored HIV-1 B (84.8%) and BF recombinants (9.8%), although other non-B subtypes were detected: HIV-1 C (1.5%), HIV-1 F (2.4%), and BC recombinants (1.5%). Antiretroviral resistance was 47% (95% confidence interval [CI]: 38.7%-55.4%). Non-nucleoside reverse transcriptase inhibitors (NNRTIs) showed higher frequencies of primary mutations, with 40.9% (95% CI: 32.9%-49.4%), followed by nucleoside reverse transcriptase inhibitors (NRTI) and protease inhibitors (PIs) with 34.8% (95% CI: 27.3-43.3) and 6.1% (95% CI: 3.1%-11.5%), respectively. Among NRTIs, higher resistance levels were observed for abacavir, emtricitabine, and lamivudine; for NNRTI, nevirapine and efavirenz. The most common primary mutations found were M184V (29.5%), K103N (25%), M41L (9.8%), T215Y (8.3%), and G190A (8.3%). Our findings highlight the importance of surveillance of resistance mutations, which contributes to the continuous updating and implementation of preventive measures to decrease mother-to-child-transmission and transmitted drug resistance.

Drug resistance in HIV-infected children living in rural South Africa: Implications of an antiretroviral therapy initiated during the first year of life

INTRODUCTION

Management of antiretroviral-drug resistance in HIV-infected children is a global health concern. We compared the long-term virological outcomes of two cohorts of children living in a rural setting of South Africa. The first cohort initiated treatment before one year and the second after two years of age. The aim of this study was to describe the long-term consequences of early treatment initiation in terms of viral load and drug-resistance.

METHODS

This retrospective study was conducted at the Edendale Hospital located in a peri-urban area of KwaZulu-Natal. Children were included during their planned appointment. Drug resistance was assessed genotypically on proviral DNA.

RESULTS

From the 161 children included in this study, 93 samples were successfully genotyped. Both cohorts had comparable viral loads, but children treated early more often presented NRTI or NNRTI mutations, while there was no difference for PI mutations rates.

CONCLUSIONS

Treatment was highly effective when comparing virological outcomes in both early- and late-treated cohorts. The persistence of NNRTI mutations could lead to treatment failures in children older than 3 years initiating their therapy with a NNRTI, or for those switching from a PI to NNRTI based regimen. The accumulation of NRTI mutations may lead to a functional PI monotherapy and consequently to viral escape. To promote access to HIV genotyping in resource-limited settings is challenging but essential to avoid inappropriate therapy switches in case of virological failure, and to adapt national treatment guidelines in line with the epidemiology of resistance.

Factors associated with adherence to ARV treatment in people living with HIV/AIDS in a rural area (Koula-Moutou) in East Gabon

The goal of this study was to evaluate the impact of socio-clinical factors on adherence to antiretroviral treatment in people living with HIV/AIDS in Koula-Moutou (a rural area of Gabon). Two adherence assessment methods based on patient declaration and compliance with pharmacy visits were used to determine qualitative and quantitative aspects of adherence to antiretroviral therapy (ART). The quantitative (82.2%) and qualitative (79.5%) adherences to ART declared by patients were higher than those obtained through pharmacy visit assessment methods (15.8% and 45.2%, respectively). Moreover, the declarative and pharmacy visit compliance methods showed fair agreement (quantitative Kappa = 0.317; qualitative Kappa = 0.311). A better quantitative or qualitative declarative adherence was associated with a lower level of education (P = 0.05 and P = 0.025 respectively). This study reported for the first time the factors influencing adherence to ART in a rural area of East Gabon. We recommend further investigations in a large cohort to better assess the impact of socio-clinical factors on ART adherence in a vulnerable group of patients.

Current opinions and recommendations of paediatric healthcare professionals - The importance of tablets: Emerging orally disintegrating versus traditional tablets

The appropriate prescribing of paediatric dosage forms is paramount in providing the desired therapeutic effect alongside successful medication adherence with the paediatric population. Often it is the opinion of the healthcare practitioner that dictates which type of dosage form would be most appropriate for the paediatric patient, with liquids being both the most commonly available and most commonly used. Orally disintegrating tablets (ODTs) are an emerging dosage form which provide many benefits over traditional dosage forms for paediatric patients, such as rapid disintegration within the oral cavity, and the reduction in the risk of choking. However the opinion and professional use of healthcare practitioners regarding ODT's is not known. This study was designed to assess the opinions of several types of healthcare professionals (n = 41) regarding ODTs, using a survey across two hospital sites. Results reaffirmed the popularity of liquids for prescribing in paediatrics, with 58.0% of participants preferring this dosage form. ODTs emerged as the second most popular dosage form (30.0%), with healthcare practitioners indicating an increasing popularity amongst patients in the hospital setting, belief with 63.0% of practitioners agreeing that many liquid formulations could be substituted with a suitable ODT. The desired properties of an ideal ODT were also identified by healthcare practitioners preferring a small, fast disintegrating tablet (90.2% and 95.1% respectively), with the taste, disintegration time and flavour being the three most important attributes identified (29.5%, 28.7% and 21.7% respectively). This study provided a pragmatic approach in assessing healthcare professional's opinions on ODTs, highlighting the ideas and thoughts of practitioners who are on the frontline of paediatric prescribing and treatment and gave an indication to their preference for ODT properties.

Caregiver role in HIV medication adherence among HIV-infected orphans in Tanzania

Youth living with HIV in sub-Saharan Africa face numerous challenges in adhering to HIV treatment. The AIDS epidemic has left many of these youth orphaned due to AIDS-related death of one or both parents. It is imperative to understand the family context of youth living with HIV in order to develop responsive interventions to improve adherence to antiretroviral therapy. We conducted qualitative in-depth interviews with 17 HIV-infected AIDS orphans, ages 13-24 years, screened positive for mental health difficulties according to the Patient Health Questionaire-9 (PHQ-9) or UCLA PTSD Reaction Index (PTSD-RI), and receiving outpatient HIV care at an adolescent medical clinic in Moshi, Tanzania. Treatment-related support varied by orphan status. Paternal orphans cared for by their biological mothers and maternal orphans cared for by grandmothers described adherence support such as assistance taking medication and attending clinic. Double orphans did not report adherence support. Several maternal and double orphans faced direct interference from caregivers and household members when they attempted to take their medications. Caregivers play a significant role in treatment adherence and must be considered in interventions to increase medication adherence in HIV-infected orphans. Findings from this study informed caregiver participation in Sauti ya Vijana (The Voice of Youth), a mental health intervention for youth living with HIV in Tanzania.

Quality of life, anxiety and depression in patients with HIV/AIDS who present poor adherence to antiretroviral therapy: a cross-sectional study in Salvador, Brazil

The introduction of highly active antiretroviral therapy marked a major gain in efficacy of HIV/AIDS treatment and a reduction in morbidity and mortality of the infected patients. However, high levels of adherence are required to obtain virologic suppression. In Brazil, the policy of free and universal access to antiretroviral therapy has been in place since 1996, although there are reports of poor adherence.

Objective

To define the clinical, demographic and psychological characteristics, and quality of life of patients with HIV/AIDS who present poor adherence to highly active antiretroviral therapy.

Methods

This was a cross-sectional study. To be included in the study patients had to be 18 through 65 years old, diagnosed with HIV/AIDS, having the two previous viral loads above 500 copies, a surrogate for poor adherence to antiretrovirals. The following instruments were applied to all eligible patients: the sociodemographic questionnaire “Adherence Follow-up Questionnaire”, the Beck Depression Inventory (BDI-II), the Beck Anxiety Inventory (BAI), and the 36-Item Short Form Survey.

Results

47 patients were evaluated, 70.2% were female, mean age of 41.9 years (±10.5), 46.8% were single, 51.1% self-reported adherence ≥95%, 46.8% mentioned depression as the main reason for not taking the medication, 59.5% presented symptoms of moderate to severe depression, and 44.7% presented symptoms of moderate to severe anxiety. Finally, regarding health-related quality of life these patients obtained low scores in all dimensions, physical component summary of 43.96 (±9.64) and mental component summary of 33.19 (±13.35).

Conclusion

The psychological component is considered to be fundamental in the management of HIV/AIDS patients. Psychoeducation should be conducted at the initial evaluation to reduce negative beliefs regarding antiretroviral therapy Assessment of anxiety and depression symptoms should be done throughout therapy as both psycological conditions are associated with patient adherence, success of treatment, and ultimately with patients’ quality of life.