Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) Global Cohort Collaboration. Incidence of switching to second-line antiretroviral therapy and associated factors in children with HIV: an international cohort collaboration

Incidence of switching to second-line antiretroviral therapy and its predictors among children on antiretroviral therapy at general hospitals, Northern Ethiopia: A survival analysis

BACKGROUND

With expanding access to pediatric antiretroviral therapy, several patients in the developing world were switched to the second-line regimen, and some require third-line medications. A delay in a second-line switch is associated with an increased risk of mortality and other undesired therapeutic outcomes, drives up program costs, and challenges the pediatric antiretroviral therapy service. Nevertheless, there remain limited and often conflicting estimates on second-line antiretroviral therapy use during childhood, especially in resource-limited settings like Ethiopia. Thus, this study intended to determine the incidence and predictors of switching to second-line antiretroviral therapy among children.

METHODS

A retrospective cohort study was conducted by reviewing records of 424 randomly selected children on first-line antiretroviral therapy from January 2014 to December 2018 at public hospitals in the Central and Southern Zones of Tigray, Northern Ethiopia. Data were collected using extraction tool; entered into Epi-data; cleaned, and analyzed by STATA version-14. Kaplan-Meier curve, log-rank test, and life table were used for data description and adjusted hazard ratios and p-value for analysis by Cox proportional hazard regression. Variables at a P-value of ≤0.20 in the bi-variable analysis were taken to multivariable analysis. Finally, statistical significance was declared at a P-value of ≤0.05.

RESULTS AND CONCLUSION

Analysis was conducted on 424 charts with a total person-time observation of 11686.1 child-months and an incidence switch rate of 5.6 (95%CI: 4.36-7.09) per 1000 child-month-observations. Being orphan [AHR = 2.36; 95%CI: 1.10-5.07], suboptimal adherence [AHR = 2.10; 95% CI: 1.12-3.92], drug toxicity [AHR = 7.05; 95% CI: 3.61-13.75], advanced latest clinical stage [AHR = 2.75; 95%CI: 1.05-7.15], and tuberculosis co-infection at baseline [AHR = 3.08; 95%CI: 1.26-7.51] were significantly associated with switch to second-line antiretroviral therapy regimen. Moreover, a long duration of follow-up [AHR = 0.75; 95% CI: 0.71-0.81] was associated with decreased risk of switching. Hence, it is better to prioritize strengthening the focused evaluation of tuberculosis co-infection and treatment failure with continuous adherence monitoring. Further research is also needed to evaluate the effect of drug resistance.

Virological failure and its predictors among human immunodeficiency virus infected individuals on second line antiretroviral treatment in North-East Ethiopia, 2021

INTRODUCTION

Acquired immune deficiency syndrome (AIDS) becomes a manageable chronic disease due to the presence of effective prevention, diagnosis, treatment, and care accesses. Viral load cascade analyses are important to identify gaps in human immunodeficiency virus (HIV)/AIDS treatment and care for quality improvements.

OBJECTIVE

Time to Virological Failure and its Predictors among HIV Infected Individuals on Second Line Antiretroviral Treatment (SLART) in North-East Ethiopia, 2021.

METHODS

Institution-based retrospective follow-up study was conducted on 474 HIV-infected individuals who were on SLART between September 2016 and April 2020. A universal sampling technique was used to recruit study participants. Data were entered by EpiData-3.3.1 and analyzed by STATA-14. Cox proportional hazard assumptions were checked to determine the effect of predictor variables on virological failure (VF). The study was conducted from February 1 to April 30, 2021.

RESULTS

The rate of VF in this study was 15.4% with an incidence rate of 4.93 per 100 person-years. As participants' age and duration of ART use increased by 1 year the hazards of VF was reduced by 2.9% (AHR: 0.971, 95% CI: 0.945, 0.995) and 10.6% (AHR: 0.894, 95% CI: 0.828, 0.963), respectively. The hazards of VF were twice higher among those who were on a non-protease inhibitor-based regimen. Individuals who had a history of making enhanced adherence counseling (EAC) sessions during SLART had three times more risk to develop VF (AHR: 3.374, 95% CI: 1.790, 6.361).

CONCLUSION AND RECOMMENDATIONS

The rate of VF among SLART users was high. Keeping SLART users on PI-based regimens may improve virological outcomes in HIV care and treatment. Making EAC sessions effective in promoting better ART adherence might reduce VF.

Failure to Attain HIV Viral Suppression After Intensified Adherence Counselling-What Can We Learn About Its Factors?

Background

Introduction and expansion of antiretroviral therapy (ART) have turned the tide of HIV pandemic, thus helping people living with HIV (PLHIV) achieve viral suppression. This success may need to be complemented by intensified adherence counseling (IAC) to improve adherence to treatment. However, some PLHIV still face higher than acceptable viral loads despite being on treatment.

Purpose

We investigated the factors associated with the failure to suppress HIV viral load after three months of IAC sessions.

Patients and Methods

This cross-sectional study analyzed secondary data from PLHIV-attended care and treatment clinics in Mwanza between January 2018 and December 2019 who had unsuppressed VL after being on ART for at least six months. We identified PLHIV in first-line ART with viral load evaluation before receiving IAC and had viral load results done at 90 days after IAC. We conducted descriptive statistics to examine the magnitude of viral suppression. Wilcoxon signed-rank test used to compare the median viral load before and after IAC sessions, and logistic regressions predicted the factors associated with failure.

Results

This study included 212 subjects. After intervention, most participants 85.9% (182) had significantly improved adherence compared to baseline. More than half 75.5% (160) of the participants had viral suppression after the intervention. Participants aged 18-25 years (AOR = 5.6, 95% CI, 1.1-29.6), unstable client during ART initiation (AOR = 0.3, 95% CI, 0.13-0.62), and poor adherence to ART (AOR = 4, 95% CI, 1.3-12.3) remained the main predictors of virological failure after IAC intervention.

Conclusion

Even though virological suppression is influenced by ART adherence, the findings in this study have shown co-existence of other factors to be addressed. Unstable during ART initiation is a new factor identified in this study.

Clinic-based SAMBA-II vs centralized laboratory viral load assays among HIV-1 infected children, adolescents and young adults in rural Zimbabwe: A randomized controlled trial

BACKGROUND

In Zimbabwe, children, adolescents and young adults living with HIV (CALWH) who are on public health antiretroviral therapy (ART) have inadequate viral load (VL) suppression. We assessed whether a clinic-based VL monitoring could decrease 12-month virologic failure rates among these CALWH.

METHODS

The study was registered on ClinicalTrials.gov: NCT03986099. CALWH in care at Chidamoyo Christian Hospital (CCH) and 8 rural outreach sites (ROS) on long-term community-based ART were randomized (1:1) to 6 monthly VL monitoring by COBAS®Ampliprep®/Taqman48® HIV-1 at the provincial referral laboratory (PRL) as per standard of care (SOC) or by the clinic-based SAMBA II assay, Diagnostics for the Real World, at CCH. VL suppression, turn-around-time (TAT) for VL results, drug switching and drug resistance in second-line failure were assessed at 12 months.

RESULTS

Of 390 CALWH enrolled 347 (89%) completed 12 months follow-up. Median (IQR) age and ART duration were 14.1 (9.7-18.2) and 6.4 (3.7-7.9) years, respectively. Over half (57%) of the participants were female. At enrolment, 78 (20%) had VL ≥1,000 copies/ml and VL suppression of 80% was unchanged after 12 months, with no significant difference between the SOC (81%) and the clinic-based (80%) arms (p = 0.528). Median (IQR) months to confirmatory VL result at CCH vs PRL was 4.0 (2.1-4.4) vs 4.5 (3.5-6.3) respectively; p = 0.027 at 12 months. Drug switching was documented among 26/347 (7%) participants with no difference between the median (IQR) time to switch in SOC vs clinic-based arms (5.1 (3.9-10.0) months vs 4.4 (2.5-8.4) respectively; p = 0.569). Out of 24 confirmed second-line failures, only 4/19 (21%) had protease inhibitor resistance.

CONCLUSION

In rural Zimbabwe, the clinic-based SAMBA II assay was able to provide confirmatory VL results faster than the SOC VL assay at the PRL. However, this rapid TAT did not allow for a more efficient drug switch among these CALWH.

First line antiretroviral treatment failure and its association with drug substitution and sex among children in Ethiopia: systematic review and meta-analysis

Antiretroviral Treatment (ART) has significantly decreased HIV-related morbidity and mortality among children despite the issue of drug resistance and subsequent treatment failure appearing as a challenge. Different studies have been conducted in Ethiopia regarding the prevalence of first-line ART failure among children but the magnitudes of these studies were inconsistent and had great variability. This review aimed to estimate the pooled prevalence of first line ART failure among children and its association with drug substitution and sex of children among first-line ART users in Ethiopia. The review was conducted using both published and unpublished studies until September 2020 in Ethiopia. MEDLINE, PubMed, Hinari, Web of Science, Google Scholar, Africa journal online (AJOL), Open gray literature, and online repository articles were searched. The quality of individual studies was assessed by Joanna Briggs Institute's (JBI) critical appraisal checklist. The statistical analysis was done by STATA-14 software and a random effect model was used. Heterogeneity was assessed using forest plot Cochrane Q-test and I-squared statistic. Publication bias was checked by using a funnel plot and Egger's and Begg's statistical tests. The interpretation was made by an odds ratio and with their respective 95% confidence intervals. The heterogeneity rate was 90% and Begg's and Egger's for publication bias were insignificant with p-values of 0.89 and 0.11 respectively. The pooled prevalence of pediatric first line ART failure in Ethiopia was 14.98% (95% CI 11.74, 18.21). Subgroup analysis showed that the highest failure rate was virological (9.13%). Female children had 1.4 times more risk of first-line ART failure (OR = 1.42; 95% CI 1.08, 1.85). First-line ART failure among children in Ethiopia is considerably high. Being female increases the likelihood of facing first line ART failure. More attention should be given to female children.

Sustained Virologic Suppression Reduces HIV-1 DNA Proviral Levels and HIV Antibodies in Perinatally HIV-Infected Children Followed from Birth

The extent to which perinatally HIV-infected children, following cART initiation, develop a low proviral reservoir burden over time, as measured by HIV DNA droplet-digital polymerase chain reaction (ddPCR) and the effect on HIV antibody is not well characterized. We measured proviral HIV DNA and plasma RNA virus load (VL) in 37 perinatally HIV-infected children at 6 months of age who initiated stable cART. At 6-11 years of age, HIV proviral DNA, HIV VL (RNA), and HIV antibody by Western Blot (WB) were assessed. CART was initiated before 6 months of age in 13 children and after 6 months in 24. At school age, the HIV DNA levels did not differ by the timing of cART, and the HIV DNA levels were lower in children with negative/indeterminate WB (p = 0.0256). Children with undetectable HIV RNA VL > 50% of the time since cART initiation had lower median DNA VL than children with undetectable VL < 50% of the time (p = 0.07). Long-term viral suppression in perinatally HIV-infected children is associated with a decrease in HIV antibodies and reduced HIV reservoirs.

Incidence and predictors of initial antiretroviral therapy regimen change among children in public health facilities of Bahir Dar City, Northwest Ethiopia, 2021: multicenter retrospective follow-up study

Background

The inconsistent use of antiretroviral therapy can lead to the risk of cross-resistance between drugs. This reduces subsequent antiretroviral drug options. The burden of initial antiretroviral therapy ranges from 11.3% in South Africa to 71.8% in Malaysia. There is evidence that it is important to maintain children’s initial antiretroviral therapy regimens. However, the incidence and predictive factors of initial antiretroviral therapy regimen changes in the research context are still unknown in the study setting. So, the study was aimed to assess incidence and predictors of initial antiretroviral therapy regimen changes among children in public health facilities of Bahir Dar city.

Methods

A retrospective follow-up study was conducted in 485 children who received antiretroviral therapy between January 1, 2011 and December 30, 2020. These children were selected using simple random sampling techniques. The data were entered by Epi data 3.1 and the analysis was completed by STATA 14.0. The missing data was treated with multiple imputation method. The data were also summarized by median or mean, interquartile range or standard deviation, proportion and frequency. The survival time was determined using the Kaplan Meier curve. The Cox Proportional Hazard model was fitted to identify predictors of initial antiretroviral therapy regimen change. The global and Shoenfeld graphical proportional hazard tests were checked. Any statistical test was considered significant at P-value < 0.05. Finally, the data were presented in the form of tables, graphics and text.

Result

Among the 459 study participants, 315 of them underwent initial regimen changes during the study accumulation period. The shortest and longest follow up time of the study were 1 month and 118 months, respectively. The overall incidence rate of initial regimen change was 1.85, 95% CI (1.66–2.07) per 100 person-month observation and the median follow up time of 49 (IQR 45, 53) months. The independent predictors of initial regimen changes were poor adherence (AHR = 1.49, 95%CI [1.16, 1.92]), NVP based regimen (AHR = 1.45, 95%CI [1.15, 1.84]) comparing to EFV based regimen, LPVr based regimen (AHR = 0.22, 95%CI: (0.07, 0.70)) comparing to EFV based regimen, history of tuberculosis (AHR = 1.59, 95%CI [1.14, 2.23]) and being male (AHR = 1.28, 95%CI [1.02, 1.60]).

Conclusions and recommendations

In this study, the incidence of initial regimen change was high. The risk of initial regimen change would be increased by being male, poor adherence, having history of tuberculosis and NVP based initial regimen. Therefore, strengthening the health care providers’ adherence counseling capability, strengthening tuberculosis screening and prevention strategies and care of initial regimen type choice needs attention in the HIV/AIDS care and treatment programs.

Drug Resistance Mutations Among South African Children Living With HIV on WHO-recommended ART Regimens

BACKGROUND

Children living with human immunodeficiency virus (HIV) (CLHIV) receiving antiretroviral therapy (ART) in resource-limited settings are susceptible to high rates of acquired HIV drug resistance (HIVDR), but few studies include children initiating age-appropriate World Health Organization (WHO)-recommended first-line regimens. We report data from a cohort of ART-naive South African children who initiated first-line ART.

METHODS

ART-eligible CLHIV aged 0-12 years were enrolled from 2012 to 2014 at 5 public South African facilities and were followed for up to 24 months. Enrolled CLHIV received standard-of-care WHO-recommended first-line ART. At the final study visit, a dried blood spot sample was obtained for viral load and genotypic resistance testing.

RESULTS

Among 72 successfully genotyped CLHIV, 49 (68.1%) received ABC/3TC/LPV/r, and 23 (31.9%) received ABC/3TC/EFV. All but 2 children on ABC/3TC/LPV/r were <3 years, and all CLHIV on ABC/3TC/EFV were ≥3 years. Overall, 80.6% (58/72) had at least one drug resistance mutation (DRM). DRMs to nonnucleoside reverse transcriptase inhibitors (NNRTIs) and nucleoside reverse transcriptase inhibitors (NRTIs) were found among 65% and 51% of all CLHIV, respectively, with no statistical difference by ART regimen. More CLHIV on ABC/3TC/EFV, 47.8% (11/23), were found to have 0 or only 1 effective antiretroviral drug remaining in their current regimen compared to 8.2% (4/49) on ABC/3TC/LPV/r.

CONCLUSIONS

High levels of NNRTI and NRTI DRMs among CLHIV receiving ABC/3TC/LPV/r suggests a lasting impact of failed mother-to-child transmission interventions on DRMs. However, drug susceptibility analysis reveals that CLHIV with detectable viremia on ABC/3TC/LPV/r are more likely to have maintained at least 2 effective agents on their current HIV regimen than those on ABC/3TC/EFV.

Outcomes After Second-Line Antiretroviral Therapy in Children Living With HIV in Latin America

BACKGROUND

Little is known about the long-term outcomes of children living with HIV in Latin America. Few studies have examined antiretroviral therapy (ART) regimen switches in the years after the introduction of ART in this population. This study aimed to assess clinical outcomes among children who started second-line ART in the Caribbean, Central and South America network for HIV epidemiology.

METHODS

Children (<18 years old) with HIV who switched to second-line ART at sites within Caribbean, Central and South America network for HIV epidemiology were included. The cumulative incidence and relative hazards of virologic failure while on second-line ART, loss to follow-up, additional major ART regimen changes, and all-cause mortality were evaluated using competing risks methods and Cox models.

RESULTS

A total of 672 children starting second-line ART were included. Three years after starting second-line ART, the cumulative incidence of death was 0.10 [95% confidence interval (CI) 0.08 to 0.13], loss to follow-up was 0.14 (95% CI: 0.11 to 0.17), and major regimen change was 0.19 (95% CI: 0.15 to 0.22). Of those changing regimens, 35% were due to failure and 11% due to toxicities/side effects. Among the 312 children with viral load data, the cumulative incidence of virologic failure at 3 years was 0.62 (95% CI: 0.56 to 0.68); time to virologic failure and regimen change were uncorrelated (rank correlation -0.001; 95% CI -0.18 to 0.17).

CONCLUSIONS

Poor outcomes after starting second-line ART in Latin America were common. The high incidence of virologic failure and its poor correlation with changing regimens was particularly worrisome. Additional efforts are needed to ensure children receive optimal ART regimens.

Clinical, immunologic and virologic outcomes of children and adolescents receiving second line anti-retroviral therapy in two referral hospitals in Addis Ababa, Ethiopia

BACKGROUND

Ethiopia launched free access for antiretroviral therapy in 2005. The number of patients on second line antiretroviral treatment has increased with each passing year. The objectives of this study were to describe the clinical, immunological and virologic outcomes of children and adolescents receiving second line anti-retroviral therapy in two referral hospitals, Yekatit 12 and Zewditu Memorial Hospitals, in Addis Ababa, Ethiopia.

METHODS

This was a hospital based retrospective cohort study conducted among children and adolescents aged 18 years and less and receiving a second line antiretroviral drugs. Data was collected using structured questionnaires. Means and percentages were used for nominal variables. Statistical analysis was made using statistical software-SPSS 23.0. Kaplan Meier analysis, long rank test and multivariate Cox proportion model were used to identify factors affecting survival.

RESULTS

A total of 75 children and adolescents were studied with a mean age of 13.28 years (SD: 4) with a mean treatment period on second line regimens of 35.2 months (SD: 21.8 months). Forty-eight participants were experiencing successful measures (in all three parameters) for their second line anti-retroviral treatment. Ten had virologic treatment failure while seven had died. Both treatment failure and death rates were higher within the first two years of treatment. Poor treatment adherence (Adjusted hazard ratio: 5.1 (95% CI: 1.1-23.2; p-value = 0.02)) and advanced World Health Organization clinical stage at start of the second line antiretrovirals (Adjusted hazard ratio: 7.51 (95% CI: 1.35-18.02; p-value = 0.002)) correlated significantly with survival of children and adolescents receiving treatment.

CONCLUSIONS

The study describes clinical, immunological and virologic outcomes of second line antiretroviral treatment in a pediatric cohort under care in two hospitals in Addis Ababa, Ethiopia. Poor adherence and pre-treatment advanced clinical stages were predictors of survival.

Virologic response of treatment experienced HIV-infected Ugandan children and adolescents on NNRTI based first-line regimen, previously monitored without viral load

Background

Many HIV-infected African children gained access to antiretroviral treatment (ART) through expansion of PEPFAR programs since 2004 and introduction of “Test and Treat” WHO guidelines in 2015. As ART access increases and children transition from adolescence to adulthood, treatment failure is inevitable. Viral load (VL) monitoring in Uganda was introduced in 2016 replacing clinical monitoring. However, there’s limited data on the comparative effectiveness of these two strategies among HIV-infected children in resource-limited settings (RLS).

Methods

HIV-infected Ugandan children aged 1–12 years from HIV-care programs with > 1 year of first-line ART using only immunologic and clinical criteria to monitor response to treatment were screened in 2010. Eligible children were stratified by VL ≤ 400 and > 400 copies/ml randomized to clinical and immunological (control) versus clinical, immunological and VL monitoring to determine treatment failure with follow-up at 12, 24, 36, and 48 weeks. Plasma VL was analyzed retrospectively for controls. Mixed-effects logistic regression models were used to compare the prevalence of viral suppression between study arms and identify factors associated with viral suppression.

Results

At baseline all children (n = 142) were on NNRTI based ART (75% Nevirapine, 25% efavirenz). One third of ART-experienced children had detectable VL at baseline despite high CD4%. Median age was 6 years (interquartile range [IQR]: 5–9) and 43% were female. Overall, the odds of viral suppression were not different between study arms: (arm by week interaction, p = 0.63), adjusted odds ratio [aOR]: 1.07; 95%CI: 0.53, 2.17, p = 0.57) and did not change over time (aOR: 0 vs 24 week: 1.15; 95% CI: 0.91, 1.46, p = 0.24 and 0 vs 48 weeks: 1.26; 95%CI: 0.92, 1.74, p = 0.15). Longer duration of a child’s ART exposure was associated with lower odds of viral suppression (aOR: 0.61; 95% CI: 0.42, 0.87, p < .01). Only 13% (9/71) of children with virologic failure were switched to second-line ART, in spite of access to real-time VL.

Conclusion

With increasing ART exposure, viral load monitoring is critical for early detection of treatment failure in RLS. Clinicians need to make timely informed decisions to switch failing children to second-line ART.

Trial registration

ClinicalTrials.gov NCT04489953, 28 Jul 2020. Retrospectively registered. (https://register.clinicaltrials.gov).

Addressing Pediatric HIV Pretreatment Drug Resistance and Virologic Failure in Sub-Saharan Africa: A Cost-Effectiveness Analysis of Diagnostic-Based Strategies in Children ≥3 Years Old

Improvement of antiretroviral therapy (ART) regimen switching practices and implementation of pretreatment drug resistance (PDR) testing are two potential approaches to improve health outcomes for children living with HIV. We developed a microsimulation model of disease progression and treatment focused on children with perinatally acquired HIV in sub-Saharan Africa who initiate ART at 3 years of age. We evaluated the cost-effectiveness of diagnostic-based strategies (improved switching and PDR testing), over a 10-year time horizon, in settings without and with pediatric dolutegravir (DTG) availability as first-line ART. The improved switching strategy increases the probability of switching to second-line ART when virologic failure is diagnosed through viral load testing. The PDR testing strategy involves a one-time PDR test prior to ART initiation to guide choice of initial regimen. When DTG is not available, PDR testing is dominated by the improved switching strategy, which has an incremental cost-effectiveness ratio (ICER) of USD 579/life-year gained (LY), relative to the status quo. If DTG is available, improved switching has a similar ICER (USD 591/LY) relative to the DTGstatus quo. Even when substantial financial investment is needed to achieve improved regimen switching practices, the improved switching strategy still has the potential to be cost-effective in a wide range of sub-Saharan African countries. Our analysis highlights the importance of strengthening existing laboratory monitoring systems to improve the health of children living with HIV.

International epidemiology databases to evaluate AIDS (IeDEA) in sub-Saharan Africa, 2012-2019

PURPOSE

The objectives of the International epidemiology databases to evaluate AIDS (IeDEA) are to (i) evaluate the delivery of combination antiretroviral therapy (ART) in children, adolescents and adults in sub-Saharan Africa, (ii) to describe ART regimen effectiveness, durability and tolerability, (iii) to examine HIV-related comorbidities and coinfections and (iv) to examine the pregnancy-related and HIV-related outcomes of women on ART and their infants exposed to HIV or ART in utero or via breast milk.

PARTICIPANTS

IeDEA is organised in four regions (Central, East, Southern and West Africa), with 240 treatment and care sites, six data centres at African, European and US universities, and almost 1.4 million children, adolescents and adult people living with HIV (PLWHIV) enrolled.

FINDINGS TO DATE

The data include socio-demographic characteristics, clinical outcomes, opportunistic events, treatment regimens, clinic visits and laboratory measurements. They have been used to analyse outcomes in PLWHIV-1 or PLWHIV-2 who initiate ART, including determinants of mortality, of switching to second-line and third-line ART, drug resistance, loss to follow-up and the immunological and virological response to different ART regimens. Programme-level estimates of mortality have been corrected for loss to follow-up. We examined the impact of coinfection with hepatitis B and C, and the epidemiology of different cancers and of (multidrug resistant) tuberculosis, renal disease and of mental illness. The adoption of 'Treat All', making ART available to all PLWHIV regardless of CD4+ cell count or clinical stage was another important research topic.

FUTURE PLANS

IeDEA has formulated several research priorities for the 'Treat All' era in sub-Saharan Africa. It recently obtained funding to set up sentinel sites where additional data are prospectively collected on cardiometabolic risks factors as well as mental health and liver diseases, and is planning to create a drug resistance database.

Outcomes of second-line antiretroviral therapy among children living with HIV: a global cohort analysis

INTRODUCTION

Limited data describe outcomes on second-line antiretroviral therapy (ART) among children globally. Our objective was to contribute data on outcomes among children living with HIV after initiation of second-line ART in the context of routine care within a large global cohort collaboration.

METHODS

Patient-level data from 1993 through 2015 from 11 paediatric HIV cohorts were pooled. Characteristics at switch and through two years of follow-up were summarized for children who switched to second-line ART after starting a standard first-line regimen in North America, Latin America, Europe, Asia, Southern Africa (South Africa & Botswana) and the rest of sub-Saharan Africa (SSA). Cumulative incidences of mortality and loss to follow-up (LTFU) were estimated using a competing risks framework.

RESULTS

Of the 85,389 children on first-line ART, 3,555 (4%) switched to second-line after a median of 2.8 years on ART (IQR: 1.6, 4.7); 69% were from Southern Africa or SSA and 86% of second-line regimens were protease inhibitor-based. At switch, median age was 8.4 years and 50% had a prior AIDS diagnosis. Median follow-up after switch to second-line ranged from 1.8 years in SSA to 5.3 years in North America. Median CD4 counts at switch to second-line ranged from 235 cells/mm3 in SSA to 828 cells/mm3 in North America. Improvements in CD4 counts were observed over two years of follow-up, particularly in regions with lower CD4 counts at second-line switch. Improvements in weight-for-age z-scores were not observed during follow-up. Cumulative incidence of LTFU at two years was <5% in all regions except SSA (7.1%) and Southern Africa (7.4%). Risk of mortality was <3% at two years of follow-up in all regions, except Latin America (4.9%) and SSA (5.5%).

CONCLUSIONS

Children switched to second-line ART experience CD4 count increases as well as low to moderate rates of LTFU and mortality within two years after switch. Severe immune deficiency at time of switch in some settings suggests need for improved recognition and management of treatment failure in children.

Association of Antiretroviral Drug Regimen With Viral Suppression in HIV-positive Children on Antiretroviral Therapy in Eswatini

BACKGROUND

Global pediatric treatment goals are for 90% of known children living with HIV to be on antiretroviral therapy (ART), with 90% having viral suppression. We used enrollment data from a study evaluating a family-centered HIV care program in Eswatini to describe the ART histories and virologic outcomes of enrolled children living with HIV and identify factors associated with viral suppression (<1000 RNA copies/mL) and undetectability (<400 RNA copies/mL).

METHODS

Factors associated with viral suppression and undetectability were identified using Pearson χ for categorical variables and Wilcoxon rank sum tests for continuous variables.

RESULTS

Three hundred seventy-seven children were enrolled, median age 8.5 years. Median age at HIV diagnosis was 2.1 years; at ART initiation, 2.6 years; and ART duration at enrollment, 4.1 years. Ninety-nine percent were receiving ART; 95.2% were on first-line ART and 4.8% on second-line ART. Most children (43.1%) were receiving nevirapine-based ART (median age 9.2 years), with 31.3% on lopinavir-ritonavir-based (median age 5.4 years) and 25.5%, efavirenz-based ART (median age 10.3 years). Viral suppression (<1000 copies/mL) was observed in 77.9% and undetectability (<400 copies/mL) in 73.5% of children. The only factor significantly associated with viral suppression was ART regimen, with 72.1% of children on nevirapine-based ART versus 86.7% on efavirenz-based ART virally suppressed.

CONCLUSIONS

Although 99% of children enrolled in the study were receiving ART, viral suppression was observed in only 77.9%, with lowest rates among children receiving nevirapine-based ART. These findings highlight the critical importance of monitoring treatment regimen for optimizing treatment outcomes for pediatric HIV.