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Bossacoma Busquets F, Sánchez E, Noguera-Julián A, Villaronga Flaqué M, Fortuny C. Weight-adapted fixed-dose combined adult antiretroviral tablets for HIV-infected children. J Clin Pharm Ther 2021; 46:867-871. [PMID: 33393094 DOI: 10.1111/jcpt.13341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/05/2020] [Accepted: 12/16/2020] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Therapeutic alternatives to simplify antiretroviral therapy (ART) in HIV-infected children are needed. We report our experience with abacavir(ABC)/lamivudine(3TC) individualized dose compounded capsules (IDCC). COMMENT We present a prospective case series of HIV-infected children who did not weigh enough to receive the adult fixed-dose combination including ABC/3TC 600mg/300mg, and were treated with weight-adapted ABC/3TC IDCC in Barcelona, Spain. Thirteen patients (12 girls) received ABC/3TC IDCC for a median(IQR) time of 30(17-54) months. No significant changes were observed in CD4 cell counts, weight or height z-scores over time. Suppression of viral replication was maintained in 7 patients with undetectable viremia at baseline. Another 5 patients achieved viral suppression with ABC/3TC IDCC-based ART, while one non-adherent girl did not. No adverse events related to ABC/3TC IDCC were observed. WHAT IS NEW AND CONCLUSION Despite small numbers, the long-term use of ABC/3TC IDCC was feasible, safe, and effective in the treatment of HIV-infected children.
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Affiliation(s)
| | - Emilia Sánchez
- Blanquerna Ramon Llull University Faculty of Health Sciences, Barcelona, Spain
| | - Antoni Noguera-Julián
- Hospital Sant Joan de Déu, Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Universitat de Barcelona, Pediatria, CIBER, Red de Investigación Translacional en Infectología Pediatrica, RITIP, Barcelona, Spain
| | | | - Clàudia Fortuny
- Hospital Sant Joan de Deu, Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Universitat de Barcelona, Pediatria, Red de Investigación Translacional en Infectología Pediátrica, RITIP, Barcelona, Spain
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2
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Jackson C, Hsia Y, Bielicki JA, Ellis S, Stephens P, Wong ICK, Sharland M. Estimating global trends in total and childhood antibiotic consumption, 2011-2015. BMJ Glob Health 2019; 4:e001241. [PMID: 30899565 PMCID: PMC6407570 DOI: 10.1136/bmjgh-2018-001241] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 12/17/2018] [Accepted: 12/23/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Understanding patterns of antibiotic consumption is essential to ensure access to appropriate antibiotics when needed and to minimise overuse, which can lead to antibiotic resistance. We aimed to describe changes in global antibiotic consumption between 2011 and 2015. METHODS We analysed wholesale data on total antibiotic sales and antibiotics sold as child-appropriate formulations (CAFs), stratified by country income level (low/middle-income and high-income countries (LMICs and HICs)). The volume of antibiotics sold per year was recorded for 36 LMICs and 39 HICs, measured in standard units (SU: 1 SU is equivalent to a single tablet, capsule or 5 mL ampoule/vial/oral suspension) and SU per person, overall and as CAFs. Changes over time were quantified as percentage changes and compound annual growth rates in consumption per person. Analyses were conducted separately for total sales, sales of antibiotics in the Access and Watch groups of the WHO's Essential Medicines List for children 2017, for amoxicillin and amoxicillin with clavulanic acid. RESULTS Antibiotic consumption increased slightly between 2011 and 2015, from 6.85×1010 SU to 7.44×1010 SU overall and from 1.66×1010 SU to 1.78×1010 SU for CAFs. However, trends differed between countries and for specific antibiotics; for example, consumption of amoxicillin as CAFs changed little in LMICs and HICs, but that of amoxicillin with clavulanic acid increased by 6.8% per year in LMICs and decreased by 1.0% per year in HICs. CONCLUSIONS As measured in standard units in sales data, the rate of increase in global antibiotic consumption may be slowing. However, the trends appear to differ between countries and drugs. In the absence of routine surveillance of antibiotic use in many countries, these data provide important indicators of trends in consumption which should be confirmed in national and local studies of prescribing.
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Affiliation(s)
- Charlotte Jackson
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George’s, University of London, London, UK
| | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George’s, University of London, London, UK
| | - Julia A Bielicki
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George’s, University of London, London, UK
- Paediatric Pharmacology and Paediatric Infectious Diseases, University Children's Hospital Basel, Basel, Switzerland
| | - Sally Ellis
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | | | - Ian C K Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- Department of Pharmacology and Pharmacy, University of Hong Kong, Pokfulam, Hong Kong
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George’s, University of London, London, UK
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3
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Dakshina S, Olaru ID, Khan P, Raman L, McHugh G, Bwakura-Dangarembizi M, Nathoo K, Munyati S, Mujuru H, Ferrand RA. Evaluation of weight-based prescription of antiretroviral therapy in children. HIV Med 2019; 20:248-253. [PMID: 30632659 PMCID: PMC6590156 DOI: 10.1111/hiv.12702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2018] [Indexed: 11/30/2022]
Abstract
Objectives The aim of the study was to investigate the extent of and factors associated with incorrect dosing of antiretroviral therapy (ART) in HIV‐infected children in Harare, Zimbabwe. Methods All children aged 0–10 years and children aged 11–17 years who weighed < 35 kg and taking ART were recruited from the paediatric HIV clinic at Harare Hospital. Their current doses of ART drugs were compared against doses recommended by the national guidelines. Results Among 309 children recruited [55% male; median age 7 years (interquartile range (IQR) 5–10 years)], the median CD4 count was 899 cells/μL and the median duration of their current ART regimen was 11.2 months (IQR 4.9–17.1 months). Overall, 110 (35.6%) children were prescribed incorrect doses of at least one drug component within their ART regimen; 64 (20.7%) under‐dosed and 49 (15.9%) over‐dosed on at least one drug. Children receiving a higher than recommended dose of at least one drug were younger compared with correctly dosed children (median 6 versus 7 years, respectively; P = 0.001), had been on their current ART regimen for a shorter time (median 7.2 versus 13 months, respectively; P = 0.003) and were less likely to be receiving a three‐drug fixed‐dose combination (FDC; 42.9 versus 63.3%, respectively; P = 0.009). Those who were under‐dosed were also less likely to be on a three‐drug FDC (25 versus 63.3%, respectively; P < 0.001). Conclusions Over a third of children were prescribed incorrect doses of ART. Children taking triple‐drug FDCs were likely to be correctly dosed. Our study highlights the importance of weight monitoring at each clinical contact, training of health care providers on paediatric drug dosing and the need for wider availability of FDCs for children.
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Affiliation(s)
- S Dakshina
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - I D Olaru
- Biomedical Research and Training Institute, Harare, Zimbabwe.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - P Khan
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,Interactive Research and Development, Karachi, Pakistan
| | - L Raman
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - G McHugh
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - M Bwakura-Dangarembizi
- Department of Paediatrics and Child Health College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - K Nathoo
- Department of Paediatrics and Child Health College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - S Munyati
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - H Mujuru
- Department of Paediatrics and Child Health College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - R A Ferrand
- Biomedical Research and Training Institute, Harare, Zimbabwe.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
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Tadesse BT, Kinloch NN, Baraki B, Lapointe HR, Cobarrubias KD, Brockman MA, Brumme CJ, Foster BA, Jerene D, Makonnen E, Aklillu E, Brumme ZL. High Levels of Dual-Class Drug Resistance in HIV-Infected Children Failing First-Line Antiretroviral Therapy in Southern Ethiopia. Viruses 2018; 10:E60. [PMID: 29389912 PMCID: PMC5850367 DOI: 10.3390/v10020060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 01/30/2018] [Accepted: 01/30/2018] [Indexed: 11/29/2022] Open
Abstract
Clinical monitoring of pediatric HIV treatment remains a major challenge in settings where drug resistance genotyping is not routinely available. As a result, our understanding of drug resistance, and its impact on subsequent therapeutic regimens available in these settings, remains limited. We investigate the prevalence and correlates of HIV-1 drug resistance among 94 participants of the Ethiopia Pediatric HIV Cohort failing first-line combination antiretroviral therapy (cART) using dried blood spot-based genotyping. Overall, 81% (73/90) of successfully genotyped participants harbored resistance mutations, including 69% (62/90) who harbored resistance to both Nucleoside Reverse Transcriptase Inhibitors (NRTIs) and Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs). Strikingly, 42% of resistant participants harbored resistance to all four NRTIs recommended for second-line use in this setting, meaning that there are effectively no remaining cART options for these children. Longer cART duration and prior regimen changes were significantly associated with detection of drug resistance mutations. Replicate genotyping increased the breadth of drug resistance detected in 34% of cases, and thus is recommended for consideration when typing from blood spots. Implementation of timely drug resistance testing and access to newer antiretrovirals and drug classes are urgently needed to guide clinical decision-making and improve outcomes for HIV-infected children on first-line cART in Ethiopia.
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Affiliation(s)
| | - Natalie N Kinloch
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada.
| | - Bemuluyigza Baraki
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada.
| | - Hope R Lapointe
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC V6Z 1Y6, Canada.
| | - Kyle D Cobarrubias
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada.
| | - Mark A Brockman
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada.
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC V6Z 1Y6, Canada.
| | - Chanson J Brumme
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC V6Z 1Y6, Canada.
| | - Byron A Foster
- Departments of Dermatology and Pediatrics, Oregon Health Sciences University, Portland, OR 97239, USA.
| | - Degu Jerene
- Management Sciences for Health, Addis Ababa 1250, Ethiopia.
| | - Eyasu Makonnen
- Department of Pharmacology, College of Health Sciences, Addis Ababa University, Addis Ababa 9086, Ethiopia.
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital Huddinge C1:68, Stockholm 141 86, Sweden.
| | - Zabrina L Brumme
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada.
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC V6Z 1Y6, Canada.
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Abstract
BACKGROUND Growth failure is common among HIV-infected infants, but there are limited data on the effects of HIV exposure or timing of HIV acquisition on growth. METHODS Fourteen thousand one hundred ten infants were enrolled in the Zimbabwe Vitamin A for Mothers and Babies trial in Zimbabwe before the availability of antiretroviral therapy or co-trimoxazole. Anthropometric measurements were taken from birth through 12-24 months of age. Growth outcomes were compared between 5 groups of children: HIV-infected in utero (IU), intrapartum (IP) or postnatally (PN); HIV-exposed uninfected (HEU); and HIV unexposed. RESULTS Growth failure was common across all groups of children. Compared with HIV-unexposed children, IU-, IP- and PN-infected children had significantly lower length-for-age and weight-for-length Z scores throughout the first 2 years of life. At 12 months, odds ratios for stunting were higher in IU [6.25, 95% confidence interval (CI): 4.20-9.31] and IP infants (4.76, 95% CI: 3.58-6.33) than in PN infants (1.70, 95% CI: 1.16-2.47). Compared with HIV-unexposed infants, HEU infants at 12 months had odds ratios for stunting of 1.23 (95% CI: 1.08-1.39) and wasting of 1.56 (95% CI: 1.22-2.00). CONCLUSIONS HIV-infected infants had very high rates of growth failure during the first 2 years of life, particularly if IU or IP infected, highlighting the importance of early infant diagnosis and antiretroviral therapy. HEU infants had poorer growth than HIV-unexposed infants in the first 12 months of life.
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Schlatter AF, Deathe AR, Vreeman RC. The Need for Pediatric Formulations to Treat Children with HIV. AIDS Res Treat 2016; 2016:1654938. [PMID: 27413548 PMCID: PMC4927993 DOI: 10.1155/2016/1654938] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/25/2016] [Indexed: 11/17/2022] Open
Abstract
Over 3.2 million children worldwide are infected with HIV, but only 24% of these children receive antiretroviral therapy (ART). ART adherence among children is a crucial part of managing human-immunodeficiency virus (HIV) infection and extending the life and health of infected children. Important causes of poor adherence are formulation- and regimen-specific properties, including poor palatability, large pill burden, short dosing intervals, and the complex storage and transportation of drugs. This review aims to summarize the various regimen- and formulation-based barriers to ART adherence among children to support the need for new and innovative pediatric formulations for antiretroviral therapy (ART). Detailing the arguments both for and against investing in the development of pediatric HIV medications, as well as highlighting recent advances in pediatric ART formulation research, provides a synopsis of the current data related to pediatric ART formulations and adherence.
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Affiliation(s)
- Adrienne F. Schlatter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret 30100, Kenya
| | - Andrew R. Deathe
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret 30100, Kenya
| | - Rachel C. Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret 30100, Kenya
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7
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Missed opportunities of inclusion in a cohort of HIV-infected children to initiate antiretroviral treatment before the age of two in West Africa, 2011 to 2013. J Int AIDS Soc 2016; 19:20601. [PMID: 27015798 PMCID: PMC4808141 DOI: 10.7448/ias.19.1.20601] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 01/22/2016] [Accepted: 02/22/2016] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The World Health Organization (WHO) 2010 guidelines recommended to treat all HIV-infected children less than two years of age. We described the inclusion process and its correlates of HIV-infected children initiated on early antiretroviral therapy (EART) at less than two years of age in Abidjan, Côte d'Ivoire, and Ouagadougou, Burkina Faso. METHODS All children with HIV-1 infection confirmed with a DNA PCR test of a blood sample, aged less than two years, living at a distance less than two hours from the centres and whose parents (or mother if she was the only legal guardian or the legal caregiver if parents were not alive) agreed to participate in the MONOD ANRS 12206 project were included in a cohort to receive EART based on lopinavir/r. We used logistic regression to identify correlates of inclusion. RESULTS Among the 217 children screened and referred to the MONOD centres, 161 (74%) were included and initiated on EART. The main reasons of non-inclusion were fear of father's refusal (48%), mortality (24%), false-positive HIV infection test (16%) and other ineligibility reasons (12%). Having previously disclosed the child's and mother's HIV status to the father (adjusted odds ratio (aOR): 3.20; 95% confidence interval (95% CI): 1.55 to 6.69) and being older than 12 months (aOR: 2.05; 95% CI: 1.02 to 4.12) were correlates of EART initiation. At EART initiation, the median age was 13.5 months, 70% had reached WHO Stage 3/4 and 57% had a severe immune deficiency. CONCLUSIONS Fear of stigmatization by the father and early competing mortality were the major reasons for missed opportunities of EART initiation. There is an urgent need to involve fathers in the care of their HIV-exposed children and to promote early infant diagnosis to improve their future access to EART and survival.
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Lee JSF, Sagaon Teyssier L, Dongmo Nguimfack B, Collins IJ, Lallemant M, Perriens J, Moatti JP. An analysis of volumes, prices and pricing trends of the pediatric antiretroviral market in developing countries from 2004 to 2012. BMC Pediatr 2016; 16:41. [PMID: 26979974 PMCID: PMC4793558 DOI: 10.1186/s12887-016-0578-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The pediatric antiretroviral (ARV) market is poorly described in the literature, resulting in gaps in understanding treatment access. We analyzed the pediatric ARV market from 2004 to 2012 and assessed pricing trends and associated factors. METHODS Data on donor funded procurements of pediatric ARV formulations reported to the Global Price Reporting Mechanism database from 2004 to 2012 were analyzed. Outcomes of interest were the volume and mean price per patient-year ARV formulation based on WHO ARV dosing recommendations for a 10 kg child. Factors associated with the price of formulations were assessed using linear regression; potential predictors included: country income classification, geographical region, market segment (originator versus generic ARVs), and number of manufacturers per formulation. All analyses were adjusted for type of formulations (single, dual or triple fixed-dose combinations (FDCs)) RESULTS Data from 111 countries from 2004 to 2012 were included, with procurement of 33 formulations at a total value of USD 204 million. Use of dual and triple FDC formulations increased substantially over time, but with limited changes in price. Upon multivariate analysis, prices of originator formulations were found to be on average 72 % higher than generics (p < 0.001). A 10 % increase in procurement volume was associated with a 1 % decrease (p < 0.001) in both originator and generic prices. The entry of one additional manufacturer producing a formulation was associated with a decrease in prices of 2 % (p < 0.001) and 8 % (p < 0.001) for originator and generic formulations, respectively. The mean generic ARV price did not differ by country income level. Prices of originator ARVs were 48 % (p < 0.001) and 14 % (p < 0.001) higher in upper-middle income and lower-middle income countries compared to low income countries respectively, with the exception of South Africa, which had lower prices despite being an upper-middle income country. CONCLUSIONS The donor funded pediatric ARV market as represented by the GPRM database is small, and lacks price competition. It is dominated by generic drugs due to the lower prices offered and the practicality of FDC formulations. This market requires continued donor support and the current initiatives to protect it are important to ensure market viability, especially if new formulations are to be introduced in the future.
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Affiliation(s)
- Janice Soo Fern Lee
- Drugs for Neglected Diseases initiative (DNDi), 15 Chemin Louis Dunant, 1202, Geneva, Switzerland.
| | - Luis Sagaon Teyssier
- INSERM, UMR912 "Economics and Social Sciences Applied to Health & Analysis of Medical Information" (SESSTIM), 13006, Marseille, France.,Aix Marseille University, UMR_S912, IRD, 13006, Marseille, France.,ORS PACA, Southeastern Health Regional Observatory, 13006, Marseille, France
| | | | - Intira Jeannie Collins
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Marc Lallemant
- Drugs for Neglected Diseases initiative (DNDi), 15 Chemin Louis Dunant, 1202, Geneva, Switzerland
| | - Joseph Perriens
- HIV Department, World Health Organization, Geneva, Switzerland
| | - Jean-Paul Moatti
- INSERM, UMR912 "Economics and Social Sciences Applied to Health & Analysis of Medical Information" (SESSTIM), 13006, Marseille, France.,Aix Marseille University, UMR_S912, IRD, 13006, Marseille, France.,ORS PACA, Southeastern Health Regional Observatory, 13006, Marseille, France
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Aurpibul L, Puthanakit T, Sudjaritruk T, Oberdorfer P, Chotecharoentanan T, Taejaroenkul S, Wongnum N, Sirisanthana V. The 10-year effectiveness of combination antiretroviral treatment in perinatally HIV-infected children participating in Thailand's National Access Program. Antivir Ther 2015; 21:261-5. [PMID: 26158783 DOI: 10.3851/imp2978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The National Access to Antiretroviral Program for People Living with HIV/AIDS was launched in Thailand in 2002. HIV-infected, antiretroviral-naive, severely immunosuppressed children were initiated on highly active combination antiretroviral treatment (cART). This study aimed to determine the long-term effectiveness of cART. METHODS Data were extracted from medical records. Primary end points were mortality rate, proportion of children who remained on first-line cART regimen and children with plasma HIV RNA level (pVL) <50 copies/ml at week 520. RESULTS From August 2002 to July 2003, 107 children were enrolled. The baseline median age was 7.6 years (IQR 5.7-10.0), the median CD4(+) T-cell count was 60 cells/mm(3) (IQR 21-272) and the median pVL was 5.37 log10 copies/ml (IQR 5.01-5.76). The mortality rate during and after the first year was 3.7 and 0.006 deaths/100 person-years, respectively. At week 520, 90 (84%) continued to be actively followed. Their median age was 17.8 years (IQR 15.8-19.8). 73 (81% as-treated) remained on the first-line regimen, while 18 (20%) had switched to a second-line cART regimen, at the median time of 272 weeks (IQR 256-363) after the first-line cART initiation. 69 (77%) had pVL<50 copies/ml and the median CD4(+) T-cell count was 636 cells/mm(3) (IQR 466-804). 83 (92%) and 64 (71%) had CD4(+) T-cell counts ≥200 and >500 cells/mm(3), respectively. CONCLUSIONS Long-term virological control, favourable immunological outcomes and healthy survival was achieved in severely immunosuppressed, perinatally HIV-infected children who started first-line NNRTI-based cART. Continuing surveillance for long-term complications is warranted.
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Affiliation(s)
- Linda Aurpibul
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand.
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10
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Abstract
Millions of children die every year before they reach the age of 5 years, of conditions largely treatable with existing medicines. The WHO Model List of Essential Medicines was launched in 1977 to make the most necessary drugs available to populations whose basic health needs could not be met by the existing supply system. During the first 30 years of the Model List of Essential Medicines, children's needs were not systematically considered. After adoption of the 'Better medicines for children' resolution by the World Health Assembly, things changed. The first WHO Model List of Essential Medicines for Children was drawn up by a Paediatric Expert Subcommittee and adopted in October 2007. The most recent, 4th Model List of Essential Medicines for Children was adopted in 2013. Data from country surveys show that access to essential medicines for children is still generally poor; much more work is needed.
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Affiliation(s)
- Kalle Hoppu
- Hospital for Children and Adolescents and Department of Clinical Pharmacology, University of Helsinki and Poison Information Centre, Helsinki University Central Hospital, Helsinki, Finland
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11
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Ditekemena J, Luhata C, Bonane W, Kiumbu M, Tshefu A, Colebunders R, Koole O. Antiretroviral treatment program retention among HIV-infected children in the Democratic Republic of Congo. PLoS One 2014; 9:e113877. [PMID: 25541707 PMCID: PMC4277274 DOI: 10.1371/journal.pone.0113877] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 10/31/2014] [Indexed: 11/19/2022] Open
Abstract
Background Retaining patients with HIV infection in care is still a major challenge in sub- Saharan Africa, particularly in the Democratic Republic of Congo (DRC) where the antiretroviral treatment (ART) coverage is low. Monitoring retention is an important tool for evaluating the quality of care. Methods and Findings A review of medical records of HIV -infected children was performed in three health facilities in the DRC: the Amo-Congo Health center, the Monkole Clinic in Kinshasa, and the HEAL Africa Clinic in Goma. Medical records of 720 children were included. Kaplan Meier curves were constructed with the probability of retention at 6 months, 1 year, 2 years and 3 years. Retention rates were: 88.2% (95% CI: 85.1%–90.8%) at 6 months; 85% (95% CI: 81.5%–87.6%) at one year; 79.4% (95%CI: 75.5%–82.8%) at two years and 74.7% (95% CI: 70.5%–78.5%) at 3 years. The retention varied across study sites: 88.2%, 66.6% and 92.5% at 6 months; 84%, 59% and 90% at 12 months and 75.7%, 56.3% and 85.8% at 24 months respectively for Amo-Congo/Kasavubu, Monkole facility and HEAL Africa. After multivariable Cox regression four variables remained independently associated with attrition: study site, CD4 cell count <350 cells/µL, children younger than 2 years and children whose caregivers were member of an independent church. Conclusions Attrition remains a challenge for pediatric HIV positive patients in ART programs in DRC. In addition, the low coverage of pediatric treatment exacerbates the situation of pediatric HIV/AIDS.
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Affiliation(s)
- John Ditekemena
- Elizabeth Glaser Paediatric AIDS Foundation, Kinshasa, Democratic Republic of Congo
- * E-mail:
| | - Christophe Luhata
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | | | - Modeste Kiumbu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | | | - Olivier Koole
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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12
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Vermund SH, Blevins M, Moon TD, José E, Moiane L, Tique JA, Sidat M, Ciampa PJ, Shepherd BE, Vaz LME. Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement. PLoS One 2014; 9:e110116. [PMID: 25330113 PMCID: PMC4203761 DOI: 10.1371/journal.pone.0110116] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 09/16/2014] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Residents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15-49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting. METHODS We studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006-July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk. RESULTS Of 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3-8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001). CONCLUSIONS We found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.
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Affiliation(s)
- Sten H. Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Troy D. Moon
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Eurico José
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Linda Moiane
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - José A. Tique
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Mohsin Sidat
- School of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Philip J. Ciampa
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Bryan E. Shepherd
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Lara M. E. Vaz
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
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Pham HV, Ishizaki A, Nguyen LV, Phan CTT, Phung TTB, Takemoto K, Pham AN, Bi X, Khu DTK, Ichimura H. Two-year outcome of first-line antiretroviral therapy among HIV-1 vertically-infected children in Hanoi, Vietnam. Int J STD AIDS 2014; 26:821-30. [PMID: 25332224 DOI: 10.1177/0956462414556328] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 09/08/2013] [Indexed: 11/15/2022]
Abstract
A retrospective analysis of 86 HIV-1 vertically-infected Vietnamese children with a follow-up period >24 months after initiating antiretroviral therapy (ART) was performed from 2008 to 2012, to assess the outcome of first-line ART in resource-limited settings. Of the 86 children, 68 (79.1%) were treated successfully (plasma HIV-1 viral load [VL] <1000 copies/ml), and 63 (73.3%) had full viral suppression (VL <400 copies/ml) after 24 months of ART. No significant difference between successfully treated patients and failure groups was observed in VL, CD4(+) T-cell count or clinical stage at baseline; age at ART start; or ART regimen. All 14 children with VL >5000 copies/ml, one of four children with VL 1000-5000 copies/ml and none with VL <1000 copies/ml developed reverse transcriptase inhibitor (RTI)-resistance mutations by 24 months of ART. Y181C and M184V/I were the most dominant non-nucleoside and nucleoside RTI-resistance mutations, respectively (13/15, 86.7%). These findings suggest that VL testing after 24 months of ART can be used to efficiently differentiate ART failures among HIV-1 vertically-infected children in resource-limited settings.
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Affiliation(s)
- H V Pham
- Department of Viral Infection and International Health, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan National Hospital of Pediatrics, Hanoi, Vietnam
| | - A Ishizaki
- Department of Viral Infection and International Health, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - L V Nguyen
- National Hospital of Pediatrics, Hanoi, Vietnam
| | - C T T Phan
- Department of Viral Infection and International Health, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan National Hospital of Pediatrics, Hanoi, Vietnam
| | - T T B Phung
- National Hospital of Pediatrics, Hanoi, Vietnam
| | - K Takemoto
- Department of Clinical Laboratory, Kanazawa University Hospital, Kanazawa, Japan
| | - A N Pham
- National Hospital of Pediatrics, Hanoi, Vietnam
| | - X Bi
- Department of Viral Infection and International Health, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - D T K Khu
- National Hospital of Pediatrics, Hanoi, Vietnam
| | - H Ichimura
- Department of Viral Infection and International Health, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan Kanazawa University Innovative Preventive Medicine Joint Education and Research Center, Kanazawa University, Kanazawa, Japan
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Zheng J, Zhao D. Clinical, immunological, and virological outcomes of pediatric antiretroviral therapy in central China. BMC Res Notes 2014; 7:419. [PMID: 24994004 PMCID: PMC4086285 DOI: 10.1186/1756-0500-7-419] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 06/30/2014] [Indexed: 11/26/2022] Open
Abstract
Background Antiretroviral therapy (ART) reduces HIV-related mortality and morbidity substantially in children. The clinical characteristics, immunological and virological outcomes were evaluated in HIV-infected children receiving ART. Methods Twenty-six HIV-1-infected children receiving ART in Hubei province, China, were enrolled retrospectively in this study. During the period of ART, plasma viral load, lymphocyte phenotype of CD4 and CD8 cells and clinical events were assessed. Results The median duration of ART was 41 months (18–72.3 months). In children showing clinical improvement, high viral suppression rate below log10 (2.7) copies/ml by the third months of ART was observed. The median CD4 cell counts reached to 820.5/μl by 12 months and the median ratio of CD4/CD8 increased to 0.6 by 21 months. The counts of peripheral white blood cells and red blood cells decreased in the first 12 months, while Hb concentration, MCV and MCH increased (P < 0.001). Conclusions Despite the limited small sample size, ART is an effective strategy for inhibiting HIV replication and reconstructing the immunological response in children with AIDS.
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Affiliation(s)
| | - Dongchi Zhao
- Department of Pediatrics, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
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Doherty K, Essajee S, Penazzato M, Holmes C, Resch S, Ciaranello A. Estimating age-based antiretroviral therapy costs for HIV-infected children in resource-limited settings based on World Health Organization weight-based dosing recommendations. BMC Health Serv Res 2014; 14:201. [PMID: 24885453 PMCID: PMC4021070 DOI: 10.1186/1472-6963-14-201] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 04/02/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pediatric antiretroviral therapy (ART) has been shown to substantially reduce morbidity and mortality in HIV-infected infants and children. To accurately project program costs, analysts need accurate estimations of antiretroviral drug (ARV) costs for children. However, the costing of pediatric antiretroviral therapy is complicated by weight-based dosing recommendations which change as children grow. METHODS We developed a step-by-step methodology for estimating the cost of pediatric ARV regimens for children ages 0-13 years old. The costing approach incorporates weight-based dosing recommendations to provide estimated ARV doses throughout childhood development. Published unit drug costs are then used to calculate average monthly drug costs. We compared our derived monthly ARV costs to published estimates to assess the accuracy of our methodology. RESULTS The estimates of monthly ARV costs are provided for six commonly used first-line pediatric ARV regimens, considering three possible care scenarios. The costs derived in our analysis for children were fairly comparable to or slightly higher than available published ARV drug or regimen estimates. CONCLUSIONS The methodology described here can be used to provide an accurate estimation of pediatric ARV regimen costs for cost-effectiveness analysts to project the optimum packages of care for HIV-infected children, as well as for program administrators and budget analysts who wish to assess the feasibility of increasing pediatric ART availability in constrained budget environments.
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Affiliation(s)
- Kathleen Doherty
- Medical Practice Evaluation Center, Divisions of General Medicine, Massachusetts General Hospital, Boston, MA, USA.
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Callens SFJ, McKellar MS, Colebunders R. HIV care and treatment for children in resource-limited settings. Expert Rev Anti Infect Ther 2014; 6:181-90. [DOI: 10.1586/14787210.6.2.181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sivapalasingam S, Mendillo M, Ahmed A, Mwamzuka M, Said S, Marshed F, Luhar Abdulaziz F, Fajans M, Holzman R. The importance of caregivers in the outcome of pediatric HIV management, Mombasa, Kenya. AIDS Care 2013; 26:425-33. [PMID: 24090313 DOI: 10.1080/09540121.2013.841829] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We assessed programmatic gaps that prevent the optimal treatment of pediatric HIV infection despite free antiretroviral care in Kenya. Of 626 HIV-infected Kenyan children, the median age was five years, 54% were male and the mortality rate was 3.2 per 100 person-years. A total of 380 (61%) children initiated antiretroviral therapy (ART) during the study period. Among the 246 children who never started ART, 129 (52%) met the criteria for ART initiation. Immunologic failure occurred in 20% of children who received ART for >24 weeks. In multivariate analysis, immunological failure was associated with having nonimmediate relative or unrelated caregivers accompanying the child to clinic (AOR = 69.16, p = 0.008). Having ≥ 3 types of accompanying caregivers was also associated with virologic failure in multivariate analysis (AOR = 3.84, p = 0.03). The lost to follow-up rate was 8.7/100 persons-years for the entire cohort, and significantly higher (17.7/100 persons-years) among children not on ART (p < 0.001). Among children who do initiate ART, those with the best treatment outcomes were those who had a limited number of close relatives as caregivers and good adherence to ART. Focus on early ART initiation and education of the right caregiver will likely improve retention and quality of pediatric HIV care in Kenya.
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Effectiveness of first-line antiretroviral therapy and acquired drug resistance among HIV-1-infected children in India. Pediatr Infect Dis J 2013; 32:e227-9. [PMID: 23249907 DOI: 10.1097/inf.0b013e31827fb2d1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Analysis of treatment response among HIV-infected children in India on first-line antiretroviral treatment for >2 years revealed that 85% were virologically suppressed. Of those with virologic failure, only 17% manifested immunologic failure, whereas majority had resistance-associated mutations. The presence of resistance highlights the need for virologic monitoring of children receiving antiretroviral treatment to optimize treatment success and preserve future treatment options.
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Bhattacharya M, Saxena R. Outcome of anti-retroviral treatment in HIV-infected orphans and non-orphans at an ART centre in North India. Paediatr Int Child Health 2013; 32:228-32. [PMID: 23164297 DOI: 10.1179/2046905512y.0000000035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Few Indian studies have reported the long-term efficacy of anti-retroviral treatment (ART) in children and in orphaned, HIV-infected children in particular. AIM To study differences in outcome of ART in HIV-infected orphans compared with non-orphans. METHODS A retrospective study of 87 HIV-infected children who commenced ART in the period January 2006 to August 2007. The main measures were orphan status, absolute CD4 count and weight-for-height (WHZ) and height-for-age (HAZ) Z-scores. RESULTS Median follow-up was 33 months. Forty (45·9%) children were orphaned. Orphans and non-orphans had similar baseline median WHZ and HAZ (-2·48 vs -2·63, P = 0·65 and -2·78 vs -2·91, P = 0·77, respectively). The two groups were similar in terms of WHO clinical stage and frequency of severe immunosuppression at presentation (P = 0·88 and 0·25, respectively). After ART initiation, the median absolute CD4 count increased progressively in both groups. Median WHZ and HAZ increased throughout the study period in the orphans and reached -1 at 27 and 39 months of ART, respectively. In the non-orphans, WHZ remained below that of the orphan group, the difference becoming statistically significant from 18 months of ART. The increment in HAZ in the non-orphan group was at par with the orphan group until 12 months of follow-up, after which it fell between 18 and 30 months. Subsequently, HAZ rose but remained below that of the orphan group. Both WHZ and HAZ failed to reach -1 in the non-orphan group. In both groups, 85% reported 100% adherence to ART. CONCLUSION The outcome of ART is not affected by orphan status with the extended family adequately supporting orphaned children. Growth of children whose parents are HIV-infected may be constrained despite ART if there is inadequate family support.
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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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Outcomes of antiretroviral therapy in children in Asia and Africa: a comparative analysis of the IeDEA pediatric multiregional collaboration. J Acquir Immune Defic Syndr 2013; 62:208-19. [PMID: 23187940 PMCID: PMC3556242 DOI: 10.1097/qai.0b013e31827b70bf] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We investigated 18-month incidence and determinants of death and loss to follow-up of children after antiretroviral therapy (ART) initiation in a multiregional collaboration in lower-income countries. METHODS HIV-infected children (positive polymerase chain reaction <18 months or positive serology ≥18 months) from International Epidemiologic Databases to Evaluate AIDS cohorts, <16 years, initiating ART were eligible. A competing risk regression model was used to analyze the independent risk of 2 failure types: death and loss to follow-up (>6 months). FINDINGS Data on 13,611 children, from Asia (N = 1454), East Africa (N = 3114), Southern Africa (N = 6212), and West Africa (N = 2881) contributed 20,417 person-years of follow-up. At 18 months, the adjusted risk of death was 4.3% in East Africa, 5.4% in Asia, 5.7% in Southern Africa, and 7.4% in West Africa (P = 0.01). Age < 24 months, World Health Organization stage 4, CD4 < 10%, attending a private sector clinic, larger cohort size, and living in West Africa were independently associated with poorer survival. The adjusted risk of loss to follow-up was 4.1% in Asia, 9.0% in Southern Africa, 14.0% in East Africa, and 21.8% in West Africa (P < 0.01). Age < 12 months, nonnucleoside reverse transcriptase inhibitor I-based ART regimen, World Health Organization stage 4 at ART start, ART initiation after 2005, attending a public sector or a nonurban clinic, having to pay for laboratory tests or antiretroviral drugs, larger cohort size, and living in East Africa or West Africa were significantly associated with higher loss to follow-up. CONCLUSIONS Findings differed substantially across regions but raise overall concerns about delayed ART start, low access to free HIV services for children, and increased workload on program retention in lower-income countries. Universal free access to ART services and innovative approaches are urgently needed to improve pediatric outcomes at the program level.
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The pattern of attrition from an antiretroviral treatment program in Nigeria. PLoS One 2012; 7:e51254. [PMID: 23272094 PMCID: PMC3521762 DOI: 10.1371/journal.pone.0051254] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 10/30/2012] [Indexed: 11/19/2022] Open
Abstract
Objective To evaluate the rate and factors associated with attrition of patients receiving ART in tertiary and secondary hospitals in Nigeria. Methods and Findings We reviewed patient level data collected between 2007 and 2010 from 11 hospitals across Nigeria. Kaplan-Meier product-limit and Cox regression were used to determine probability of retention in care and risk factors for attrition respectively. Of 6,408 patients in the cohort, 3,839 (59.9%) were females, median age of study population was 33years (IQR: 27–40) and 4,415 (69%) were from secondary health facilities. The NRTI backbone was Stavudine (D4T) in 3708 (57.9%) and Zidovudine (ZDV) in 2613 (40.8%) of patients. Patients lost to follow up accounted for 62.7% of all attrition followed by treatment stops (25.3%) and deaths (12.0%). Attrition was 14.1 (N = 624) and 15.1% (N = 300) in secondary and tertiary hospitals respectively (p = 0.169) in the first 12 months on follow up. During the 13 to 24 months follow up period, attrition was 10.7% (N = 407) and 19.6% (N = 332) in secondary and tertiary facilities respectively (p<0.001). Median time to lost to follow up was 11.1 (IQR: 6.1 to 18.5) months in secondary compared with 13.6 (IQR: 9.9 to 17.0) months in tertiary sites (p = 0.002). At 24 months follow up, male gender [AHR 1.18, 95% CI: 1.01–1.37, P = 0.038]; WHO clinical stage III [AHR 1.30, 95%CI: 1.03–1.66, P = 0.03] and clinical stage IV [AHR 1.90, 95%CI: 1.20–3.02, p = 0.007] and care in a tertiary hospital [AHR 2.21, 95% CI: 1.83–2.67, p<0.001], were associated with attrition. Conclusion Attrition could potentially be reduced by decentralizing patients on ART after the first 12 months on therapy to lower level facilities, earlier initiation on treatment and strengthening adherence counseling amongst males.
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The needs for HIV treatment and care of children, adolescents, pregnant women and older people in low-income and middle-income countries. AIDS 2012; 26 Suppl 2:S105-16. [PMID: 23303433 DOI: 10.1097/qad.0b013e32835bddfc] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Success in diagnosing and treating HIV-infected adults has, where HIV care and treatment is available, turned HIV into a chronic, rather than life-limiting disease. Progress meeting the needs of HIV-infected children, perinatally and horizontally infected adolescents, pregnant women and older people has lagged behind. We review the special needs and barriers to scaling up care and antiretroviral therapy (ART) coverage in these populations. DESIGN AND METHODS A literature review combined with personal views and operational experience specifically from countries covered by the Evidence for Action programme. RESULTS Challenges include logistics of diagnosis and treatment in pregnancy, difficulties in early infant diagnosis, availability of appropriate paediatric formulations, management of adolescents, and comorbidities in older people. CONCLUSION Priorities for development need to focus upon the simplification of HIV care to allow provision for all ages at the primary healthcare level. Specific priorities include focused use of virological testing in infants, ongoing development of dispersible and scored fixed-dose ART combinations suitable for use across ages, development of 'adolescent-friendly' HIV services catering for perinatally and horizontally infected adolescents to improve adherence and reduce onward transmissions, simplification of referral pathways to ensure all pregnant women are tested for HIV and commenced on ART, and education of healthcare workers on the specific needs of HIV care in older patients. Each priority will be reviewed and potential solutions discussed.
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Quantification of CD4 responses to combined antiretroviral therapy over 5 years among HIV-infected children in Kinshasa, Democratic Republic of Congo. J Acquir Immune Defic Syndr 2012; 61:90-8. [PMID: 22732464 DOI: 10.1097/qai.0b013e31825bd9b7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The long-term effects of combined antiretroviral therapy (cART) on CD4 percentage in HIV-infected children are incompletely understood, with evidence from resource-deprived areas particularly scarce even though most children with HIV live in such settings. We sought to describe this relationship. METHODS Observational longitudinal data from cART-naive children enrolled between December 2004 and May 2010 into an HIV care and treatment program in Kinshasa, Democratic Republic of Congo were analyzed. To estimate the effect of cART on CD4 percentage while accounting for time-dependent confounders affected by prior exposure to cART, a marginal structural linear mean model was used. RESULTS Seven hundred ninety children were active for 2090 person-years and a median of 31 months; 619 (78%) initiated cART. At baseline, 405 children (51%) were in HIV clinical stage 3 or 4; 528 (67%) had advanced or severe immunodeficiency. Compared with no cART, the estimated absolute rise in CD4 percentage was 6.8% [95% confidence interval (CI), 4.7% to 8.9%] after 6 months of cART, 8.6% (95% CI, 7.0% to 10.2%) after 12 months, and 20.5% (95% CI, 16.1% to 24.9%) after 60 months. cART-mediated CD4 percentage gains were slowest but greatest among children with baseline CD4 percentage <15. The cumulative incidence of recovery to "not significant" World Health Organization age-specific immunodeficiency was lower if cART was started when immunodeficiency was severe rather than mild or advanced. CONCLUSIONS cART increased CD4 percentages among HIV-infected children in a resource-deprived setting, as previously noted among children in the United States. More gradual and protracted recovery in children with lower baseline CD4 percentages supports earlier initiation of pediatric cART.
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Successful clinical outcomes following decentralization of tertiary paediatric HIV care to a community-based paediatric antiretroviral treatment network, Chiangrai, Thailand, 2002 to 2008. J Int AIDS Soc 2012; 15:17358. [PMID: 23078768 PMCID: PMC3494174 DOI: 10.7448/ias.15.2.17358] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 08/30/2012] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Most paediatric antiretroviral treatments (ARTs) in Thailand are limited to tertiary care hospitals. To decentralize paediatric HIV treatment and care, Chiangrai Prachanukroh Hospital (CRH) strengthened a provincial paediatric HIV care network by training community hospital (CH) care teams to receive referrals of children for community follow-up. In this study, we assessed factors associated with death and clinical outcomes of HIV-infected children who received care at CRH and CHs after implementation of a community-based paediatric HIV care network. METHODS Clinical records were abstracted for all children who initiated ART at CRH. Paired Wilcoxon signed rank tests were used to assess CD4% and virological change among all children. Cox proportional hazard models were used to assess factors associated with death. Treatment outcomes (CD4%, viral load (VL) and weight-for-age Z-score (WAZ)) were compared between CRH and CH children who met the criteria for analysis. RESULTS Between February 2002 and April 2008, 423 HIV-infected children initiated ART and 410 included in the cohort analysis. Median follow-up for the cohort was 28 months (interquartile range (IQR)=12 to 42); 169 (41%) children were referred for follow-up at CH. As of 31 March 2008, 42 (10%) children had died. Baseline WAZ (< -2 (p=0.001)) and baseline CD4% (<5% (p=0.015)) were independently associated with death. At 48 months, 86% of ART-naïve children in follow-up had VL<400 copies/ml. For sub-group analysis, 133 children at CRH and 154 at CHs were included for comparison. Median baseline WAZ was lower in CH children than in CRH children (p=0.001); in both groups, WAZ, CD4% and VL improved after ART with no difference in rate of WAZ and CD4% gain (p=0.421 and 0.207, respectively). CONCLUSIONS Children at CHs had more severe immunological suppression and low WAZ at baseline. Community- and tertiary care-based paediatric ART follow-ups result in equally beneficial outcomes with the strengthening of a provincial referral network between tertiary and community care. Nutrition interventions may benefit children in community-based HIV treatment and care.
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The unanswered question: when to initiate antiretroviral therapy in children with HIV infection. Curr Opin HIV AIDS 2012; 2:416-25. [PMID: 19372921 DOI: 10.1097/coh.0b013e3282cef1ee] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW The question of when to initiate antiretroviral treatment for children is perhaps the most critical unanswered question in pediatric HIV therapeutics. With large numbers of children throughout the world acquiring HIV infection and with improved global access to HIV treatment it is particularly timely to consider the optimal time to initiate antiretroviral therapy in infants, children and adolescents. RECENT FINDINGS Early treatment can result in suppression of HIV viremia, immune preservation and prevention of disease progression. This must be balanced by the challenges of maintaining adherence to multidrug regimens, the risks of selecting drug-resistant virus, and long and short-term toxicities of medications. SUMMARY This review provides a framework within which to consider when to initiate children on antiretroviral treatment. A child's age and developmental status, where they live, and the goals and expectations for treatment provide a context for balancing the risks of disease progression with the risks of drug-related toxicities and viral resistance.
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Abstract
PURPOSE OF REVIEW The aim of this article is to present approaches towards simplifying pediatric antiretroviral therapy in order to improve access to care, coverage of HIV-positive children, and support adherence to treatment. RECENT FINDINGS Barriers to rapid and effective global scale-up of pediatric antiretroviral therapy include the narrow range of available pediatric antiretrovirals, complicated dosing schedules, and social and economic instability of the family caused by poverty, stigma, and death. Healthcare providers can simplify antiretroviral therapy delivery by promoting the development and use of pediatric fixed dose combinations and scored adult antiretrovirals, using weight-band dosing tables to prescribe antiretrovirals, and identifying less complex regimens. Caretakers would benefit from active counseling to facilitate more open communication with their children about adherence and disclosure. Children can develop long-term coping strategies through learning life skills that build confidence and improve decision-making. Whenever possible, antiretroviral therapy programs should provide access to free antiretrovirals, identify funds to cover transportation costs, and refer families to available community support programs. SUMMARY Interventions to simplify the administration of antiretroviral therapy need to address not only how antiretrovirals are prescribed and formulated, but the relationships of HIV-positive children with their families and communities as well.
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Kabue MM, Buck WC, Wanless SR, Cox CM, McCollum ED, Caviness AC, Ahmed S, Kim MH, Thahane L, Devlin A, Kochelani D, Kazembe PN, Calles NR, Mizwa MB, Schutze GE, Kline MW. Mortality and clinical outcomes in HIV-infected children on antiretroviral therapy in Malawi, Lesotho, and Swaziland. Pediatrics 2012; 130:e591-9. [PMID: 22891234 PMCID: PMC3962849 DOI: 10.1542/peds.2011-1187] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine mortality and immune status improvement in HIV-infected pediatric patients on antiretroviral treatment (ART) in Malawi, Lesotho, and Swaziland. METHODS We conducted a retrospective cohort study of patients aged <12 years at ART initiation at 3 sites in sub-Saharan Africa between 2004 and 2009. Twelve-month and overall mortality were estimated, and factors associated with mortality and immune status improvement were evaluated. RESULTS Included in the study were 2306 patients with an average follow-up time on ART of 2.3 years (interquartile range 1.5-3.1 years). One hundred four patients (4.5%) died, 9.0% were lost to follow-up, and 1.3% discontinued ART. Of the 104 deaths, 77.9% occurred in the first year of treatment with a 12-month mortality rate of 3.5%. The overall mortality rate was 2.25 deaths/100 person-years (95% confidence interval [CI] 1.84-2.71). Increased 12-month mortality was associated with younger age; <6 months (hazard ratio [HR] = 8.11, CI 4.51-14.58), 6 to <12 months (HR = 3.43, CI 1.96-6.02), and 12 to <36 months (HR = 1.92, CI 1.16-3.19), and World Health Organization stage IV (HR = 4.35, CI 2.19-8.67). Immune status improvement at 12 months was less likely in patients with advanced disease and age <12 months. CONCLUSIONS Despite challenges associated with pediatric ART in developing countries, low mortality and good treatment outcomes can be achieved. However, outcomes are worse in younger patients and those with advanced disease at the time of ART initiation, highlighting the importance of early diagnosis and treatment.
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Affiliation(s)
- Mark M. Kabue
- Baylor College of Medicine Abbott Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi
| | - W. Chris Buck
- Baylor College of Medicine Abbott Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi;,Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, and
| | - Sebastian R. Wanless
- Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, and
| | - Carrie M. Cox
- Baylor College of Medicine Abbott Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi;,Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, and
| | - Eric D. McCollum
- Baylor College of Medicine Abbott Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi;,Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, and
| | - A. Chantal Caviness
- Baylor College of Medicine, Department of Pediatrics and Texas Children’s Hospital, Houston, Texas
| | - Saeed Ahmed
- Baylor College of Medicine Abbott Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi;,Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, and
| | - Maria H. Kim
- Baylor College of Medicine Abbott Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi;,Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, and
| | - Lineo Thahane
- Baylor College of Medicine Bristol-Myers Squibb Children’s Clinical Centre of Excellence, Maseru, Lesotho; and
| | - Andrew Devlin
- Baylor College of Medicine Bristol-Myers Squibb Children’s Clinical Centre of Excellence, Maseru, Lesotho; and
| | - Duncan Kochelani
- Baylor College of Medicine Bristol-Myers Squibb Children’s Clinical Centre of Excellence, Mbabane, Swaziland
| | - Peter N. Kazembe
- Baylor College of Medicine Abbott Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi
| | - Nancy R. Calles
- Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, and,Baylor College of Medicine, Department of Pediatrics and Texas Children’s Hospital, Houston, Texas
| | - Michael B. Mizwa
- Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, and
| | - Gordon E. Schutze
- Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, and,Baylor College of Medicine, Department of Pediatrics and Texas Children’s Hospital, Houston, Texas
| | - Mark W. Kline
- Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, and,Baylor College of Medicine, Department of Pediatrics and Texas Children’s Hospital, Houston, Texas
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Barlow-Mosha LN, Bagenda DS, Mudiope PK, Mubiru MC, Butler LM, Fowler MG, Musoke PM. The long-term effectiveness of generic adult fixed-dose combination antiretroviral therapy for HIV-infected Ugandan children. Afr Health Sci 2012; 12:249-58. [PMID: 23382737 PMCID: PMC3557678 DOI: 10.4314/ahs.v12i3.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Access to pediatric antiretroviral formulations is increasing in resource-limited countries, however adult FDCs are still commonly used by antiretroviral therapy (ART) programs. OBJECTIVE To describe long-term effectiveness of using adult FDC of d4T+3TC+NVP (Triomune) in children for HIV treatment. METHODS Clinical, immunologic, and virologic outcomes of HIV-infected ART-naïve children aged six months to 12 years, were evaluated up to 96 weeks post-ART initiation. RESULTS From March 2004 to June 2006, 104 children were followed with a median age of 5.4 years, median CD4 cell percent and HIV-1 RNA were 11.0% (IQR 6.7-13.9) and 348,846copies/mL (IQR 160,941-681,313) respectively at baseline. Using Kaplan-Meir estimates, 75% of children had undetectable viral loads (<400copies/mL) at 96 weeks of ART. Children with a baseline CD4 cell percent >15% were 3 times more likely to achieve viral load <400copies/mL than those with baseline CD4 cell percent <5% after adjusting for baseline age {aHR = 3.03 (1.10-8.32), p=0.03}; no difference was found among those with CD4 cell percent >5-14.9% and <5%. CONCLUSION Treatment with generic adult FDC for HIV-infected Ugandan children led to sustained clinical, immunologic and virologic response during 96 weeks of ART. Early initiation of ART is key to achieving virological success.
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Affiliation(s)
- L N Barlow-Mosha
- Makerere University-Johns Hopkins University Research Collaboration (MU-JHU), Uganda.
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Okomo U, Togun T, Oko F, Peterson K, Townend J, Peterson I, Jaye A. Treatment outcomes among HIV-1 and HIV-2 infected children initiating antiretroviral therapy in a concentrated low prevalence setting in West Africa. BMC Pediatr 2012; 12:95. [PMID: 22770231 PMCID: PMC3407729 DOI: 10.1186/1471-2431-12-95] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 07/08/2012] [Indexed: 12/04/2022] Open
Abstract
Background There is little data on responses to combination antiretroviral therapy (cART) among HIV-infected children in the West African region. We describe treatment outcomes among HIV-1 and HIV-2 infected children initiating cART in a research clinic in The Gambia, West Africa. Methods All treatment naive HIV-infected children who initiated cART according to the WHO ART guidelines for children between October 2004 and December 2009 were included in the analysis. Kaplan-Meir estimates and sign-rank test were used to investigate the responses to treatment. Results 65 HIV-1 and five HIV-2 infected children aged < 15 years were initiated on cART over this time period. HIV-1 infected children were treated with a combination of Zidovudine or Stavudine + Lamivudine + Nevirapine or Efavirenz while children with HIV-2 were treated with Zidovudine + Lamivudine + ritonavir-boosted Lopinavir. HIV-1 infected children were followed-up for a median (IQR) duration of 20.1 months (6.9 – 34.3), with their median (IQR) age at treatment initiation, CD4% and plasma viral load at baseline found to be 4.9 years (2.1 – 9.1), 13.0% (7.0 – 16.0) and 5.4 log10 copies/ml (4.4 – 6.0) respectively. The median age at treatment initiation of the five HIV-2 infected children was 12 years (range: 4.6 – 14.0) while their median baseline CD4+ T cell count and HIV-2 viral load were 140 cells/mm3 (Range: 40 – 570 cells/mm3) and 4.5 log10copies/mL (Range: 3.1 - 4.9 log10copies/mL) respectively. Among HIV-1 infected children <5 years of age at ART initiation, the median (IQR) increases in CD4% from baseline to 12, 24 and 36 months were 14% (8 – 19; P = 0.0004), 21% (15 – 22; P = 0.005) and 15% (15 – 25; P = 0.0422) respectively, while the median (IQR) increase in absolute CD4 T cell count from baseline to 12, 24 and 36 months for those ≥5 years at ART initiation were 470 cells/mm3 (270 – 650; P = 0.0005), 230 cells/mm3 (30 – 610; P = 0.0196) and 615 cells/mm3 (250 – 1060; P = 0.0180) respectively. The proportions of children achieving undetectable HIV-1 viral load at 6-, 12-, 24- and 36 months of treatment were 24/38 (63.2%), 20/36 (55.6%), 8/22 (36.4%) and 7/12 (58.3%) respectively. The probability of survival among HIV-1 infected children after 12 months on ART was 89.9% (95% CI 78.8 – 95.3). CD4 T cell recovery was sub-optimal in all the HIV-2 infected children and none achieved virologic suppression. Two of the HIV-2 infected children died within 6 months of starting treatment while the remaining three were lost to follow-up. Conclusions The beneficial effects of cART among HIV-1 infected children in our setting are sustained in the first 24 months of treatment with a significant improvement in survival experience up to 36 months; however the outcome was poor in the few HIV-2 infected children initiated on cART.
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Affiliation(s)
- Uduak Okomo
- Medical Research Council (UK) Laboratories, Fajara, Banjul, The Gambia.
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Is operational research delivering the goods? The journey to success in low-income countries. THE LANCET. INFECTIOUS DISEASES 2012; 12:415-21. [PMID: 22326018 DOI: 10.1016/s1473-3099(11)70309-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Operational research in low-income countries has a key role in filling the gap between what we know from research and what we do with that knowledge-the so-called know-do gap, or implementation gap. Planned research that does not tangibly affect policies and practices is ineffective and wasteful, especially in settings where resources are scarce and disease burden is high. Clear parameters are urgently needed to measure and judge the success of operational research. We define operational research and its relation with policy and practice, identify why operational research might fail to affect policy and practice, and offer possible solutions to address these shortcomings. We also propose measures of success for operational research. Adoption and use of these measures could help to ensure that operational research better changes policy and practice and improves health-care delivery and disease programmes.
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Best BM, Capparelli EV, Diep H, Rossi SS, Farrell MJ, Williams E, Lee G, van den Anker JN, Rakhmanina N. Pharmacokinetics of lopinavir/ritonavir crushed versus whole tablets in children. J Acquir Immune Defic Syndr 2011; 58:385-91. [PMID: 21876444 PMCID: PMC3205189 DOI: 10.1097/qai.0b013e318232b057] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Lopinavir/ritonavir (Kaletra) is first-line therapy for pediatric HIV infection. In clinical practice, Kaletra tablets are occasionally crushed for pediatric administration. This study compared lopinavir/ritonavir exposure between whole and crushed tablets in HIV-infected children. DESIGN This was a randomized, open-label, cross-over study of pediatric patients taking lopinavir/ritonavir as part of their antiretroviral regimen. Each subject had 2 separate (within 30 days) steady-state 12-hour pharmacokinetic (PK) studies with crushed and whole 200/50 mg lopinavir/ritonavir tablets. METHODS PK blood samples were drawn at 0 (predose), 1, 2, 4, 6, 8, and 12 hours postdose. Lopinavir and ritonavir plasma concentrations measured by high-performance liquid chromatography were used to calculate non-compartmental area under the concentration versus time curve (AUC) and clearance. Wilcoxon signed-rank tests compared PK values between crushed and whole tablets. RESULTS Twelve children, median age of 13 years (10-16 years), took 550/138 mg·m(-2) per day lopinavir/ritonavir divided every 12 hours. The median lopinavir AUC after crushed and whole tablets were 92 mg·hr·L(-1) and 144 mg·hr·L(-1), respectively, with an AUC ratio of 0.55 (P = 0.003). Median ritonavir AUC of crushed and whole tablets were 7 mg·hr·L(-1) and 13.3 mg·hr·L(-1), respectively, with an AUC ratio of 0.53 (P = 0.006). CONCLUSIONS Administration of crushed 200/50 mg lopinavir/ritonavir tablets to children significantly reduced lopinavir and ritonavir exposure with a decrease in AUC by 45% and 47%, respectively. The administration of crushed tablets would require higher doses and therapeutic drug monitoring to ensure adequate lopinavir exposure in patients requiring this practice. The use of crushed lopinavir/ritonavir tablets should be avoided, if possible.
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Affiliation(s)
- Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA 92093-0719, USA.
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Lihana RW, Lwembe RM, Bi X, Ochieng W, Panikulam A, Palakudy T, Musoke R, Owens M, Ishizaki A, Okoth FA, Songok EM, Ichimura H. Efficient monitoring of HIV-1 vertically infected children in Kenya on first-line antiretroviral therapy. J Clin Virol 2011; 52:123-8. [PMID: 21798798 DOI: 10.1016/j.jcv.2011.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 06/11/2011] [Accepted: 06/28/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Worldwide access to antiretroviral therapy (ART) in low- and middle-income countries has significantly increased. Although this presents better treatment options for HIV-infected individuals, the challenge of monitoring ART in these settings still remains. OBJECTIVE To investigate efficient and cost-effective criteria for assessing ART failure among HIV-1-infected children on first-line ART in resource-limited settings. STUDY DESIGN Retrospective analysis of 75 HIV-1 vertically infected Kenyan children with a follow-up period of 24 months after initiating ART. Plasma viral load, peripheral CD4(+)T-cell counts and HIV-1 drug-resistance mutations were monitored biannually. RESULTS Plasma viral load (VL) was suppressed to undetectable level or more than 1.5 log(10) from baseline levels in 53 (70.7%) children within 24 months. VL in the remaining 22 (29.3%) children was not suppressed significantly. Of the 22 children, 21 were infected with HIV-1 strains that developed drug-resistance mutations; 9 within 12 months and 12 between 12 and 24 months. Among the 53 who were successfully treated, VL was suppressed in 33 within 12 months and in 20 between 12 and 24 months. There was no significant difference in VL at baseline and the change of CD4(+)T-cell counts after initiating ART between those treated successfully and the failure groups. CONCLUSION After initiating ART, children may require longer times to achieve complete viral suppression. Plasma viral load testing 24 months after initiating ART could be used to differentiate ART failures among HIV-1 vertically infected children in resource-limited settings. Additionally, drug resistance testing, if affordable, would be helpful in identifying those failing therapy and in choosing second-line regimens.
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Affiliation(s)
- Raphael W Lihana
- Department of Viral Infection and International Health, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Ishikawa, Kanazawa 920-8640, Japan
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Ahoua L, Guenther G, Rouzioux C, Pinoges L, Anguzu P, Taburet AM, Balkan S, Olson DM, Olaro C, Pujades-Rodríguez M. Immunovirological response to combined antiretroviral therapy and drug resistance patterns in children: 1- and 2-year outcomes in rural Uganda. BMC Pediatr 2011; 11:67. [PMID: 21791095 PMCID: PMC3176156 DOI: 10.1186/1471-2431-11-67] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 07/26/2011] [Indexed: 02/05/2023] Open
Abstract
Background Children living with HIV continue to be in urgent need of combined antiretroviral therapy (ART). Strategies to scale up and improve pediatric HIV care in resource-poor regions, especially in sub-Saharan Africa, require further research from these settings. We describe treatment outcomes in children treated in rural Uganda after 1 and 2 years of ART start. Methods Cross-sectional assessment of all children treated with ART for 12 (M12) and 24 (M24) months was performed. CD4 counts, HIV RNA levels, antiretroviral resistance patterns, and non-nucleoside reverse transcriptase inhibitor (NNRTI) plasma concentrations were determined. Patient adherence and antiretroviral-related toxicity were assessed. Results Cohort probabilities of retention in care were 0.86 at both M12 and M24. At survey, 71 (83%, M12) and 32 (78%, M24) children remained on therapy, and 84% participated in the survey. At ART start, 39 (45%) were female; median age was 5 years. Median initial CD4 percent was 11% [IQR 9-15] in children < 5 years old (n = 12); CD4 count was 151 cells/mm3 [IQR 38-188] in those ≥ 5 years old (n = 26). At M12, median CD4 gains were 11% [IQR 10-14] in patients < 5 years old, and 206 cells/mm3 [IQR 98-348] in ≥ 5 years old. At M24, median CD4 gains were 11% [IQR 5-17] and 132 cells/mm3 [IQR 87-443], respectively. Viral suppression (< 400 copies/mL) was achieved in 59% (M12) and 33% (M24) of children. Antiretroviral resistance was found in 25% (M12) and 62% (M24) of children. Overall, 29% of patients had subtherapeutic NNRTI plasma concentrations. Conclusions After one year of therapy, satisfactory survival and immunological responses were observed, but nearly 1 in 4 children developed viral resistance and/or subtherapeutic plasma antiretroviral drug levels. Regular weight-adjustment dosing and strategies to reinforce and maintain ART adherence are essential to maximize duration of first-line therapy in children in resource-limited countries.
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Hoppu K, Anabwani G, Garcia-Bournissen F, Gazarian M, Kearns GL, Nakamura H, Peterson RG, Sri Ranganathan S, de Wildt SN. The status of paediatric medicines initiatives around the world--What has happened and what has not? Eur J Clin Pharmacol 2011; 68:1-10. [PMID: 21732178 DOI: 10.1007/s00228-011-1089-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 06/09/2011] [Indexed: 01/07/2023]
Abstract
PURPOSE This review was conducted to examine the current status of paediatric medicines initiatives across the globe. METHODS The authors made a non-systematic descriptive review of current world situation. RESULTS Two regions, the United States (US) and the European Union (EU), and the World Health Organization (WHO) have introduced strong paediatric initiatives to improve children's health through improving access to better paediatric medicines. The experience from the US initiative indicates that it is possible to stimulate development and study of paediatric medicines and provide important new information for improvement of paediatric therapy. The early results from the EU initiative are similarly encouraging. In Canada, Japan, Australia and other developed countries, specific paediatric medicines initiatives have been less extensive and weaker, with modest results. Disappointingly, current evidence suggests that results from clinical trials outside the US often do not benefit children in the country in which the trials were largely conducted. Pharmaceutical companies that have derived a financial benefit commensurate with the cost of doing the paediatric trials in one country do not seem to be making the results of these trials available to all countries if there is no financial incentive to the company. The WHO campaign 'make medicines child size' has produced substantive accomplishments in building improved foundations to improve mechanisms that will enhance children's access to critical medicines in resource-limited settings. However, practically all of this work has been performed using an amalgamation of short-term funding from a variety of sources as opposed to a sustained, programmatic commitment. CONCLUSIONS Although much still needs to be done, it's clear that with concerted efforts and appropriate resources, change is possible but slow. Retaining and fostering public and political interest in paediatric medicines is challenging, but pivotal for success.
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Affiliation(s)
- Kalle Hoppu
- Hospital for Children and Adolescents and Dept. of Clinical Pharmacology, University of Helsinki and Poison Information Centre, Helsinki University Central Hospital, P.O. Box 790, 00029, Helsinki, Finland.
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Ndondoki C, Dabis F, Namale L, Becquet R, Ekouevi D, Bosse-Amani C, Arrivé E, Leroy V. Survie et évolution clinique et biologique des enfants infectés par le VIH traités par les antiretroviraux en Afrique : revue de littérature, 2004–2009. Presse Med 2011. [DOI: 10.1016/j.lpm.2010.11.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Phelps BR, Rakhmanina N. Antiretroviral drugs in pediatric HIV-infected patients: pharmacokinetic and practical challenges. Paediatr Drugs 2011; 13:175-92. [PMID: 21500872 DOI: 10.2165/11587300-000000000-00000] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Antiretroviral (ARV) therapy has been shown to achieve high therapeutic efficacy in treating pediatric HIV disease. The delivery of affordable, child friendly, and easy to store and administer ARV drugs is key to the successful management of HIV in children. In recent years, significant progress has been made in scaling up the access to pediatric ARV therapy among children worldwide. Despite the improved ARV drug access, multiple challenges remain concerning palatability and efficient delivery of ARV drugs to children from infancy into adolescence. Data are limited regarding developmental changes in pharmacokinetics of individual ARV drugs, and pediatric and adult fixed-dose combinations. This review provides a practical discussion regarding the pharmacokinetics of ARV agents in pediatric HIV-infected patients, as well as the practical challenges of currently available formulations, such as palatability of liquid formulations, challenges of crushing tablets, and using adult and pediatric fixed-dose combinations.
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Affiliation(s)
- B Ryan Phelps
- Division of Infectious Disease, Childrens National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Peacock-Villada E, Richardson BA, John-Stewart GC. Post-HAART outcomes in pediatric populations: comparison of resource-limited and developed countries. Pediatrics 2011; 127:e423-41. [PMID: 21262891 PMCID: PMC3025421 DOI: 10.1542/peds.2009-2701] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2010] [Indexed: 11/24/2022] Open
Abstract
CONTEXT No formal comparison has been made between the pediatric post-highly active antiretroviral therapy (HAART) outcomes of resource-limited and developed countries. OBJECTIVE To systematically quantify and compare major baseline characteristics and clinical end points after HAART between resource-limited and developed settings. METHODS Published articles and abstracts (International AIDS Society 2009, Conference on Retroviruses and Opportunistic Infections 2010) were examined from inception (first available publication for each search engine) to March 2010. Publications that contained data on post-HAART mortality, weight-for-age z score (WAZ), CD4 count, or viral load (VL) changes in pediatric populations were reviewed. Selected studies met the following criteria: (1) patients were younger than 21 years; (2) HAART was given (≥ 3 antiretroviral medications); and (3) there were >20 patients. Data were extracted for baseline age, CD4 count, VL, WAZ, and mortality, CD4 and virologic suppression over time. Studies were categorized as having been performed in a resource-limited country (RLC) or developed country (DC) on the basis of the United Nations designation. Mean percentage of deaths per cohort and deaths per 100 child-years, baseline CD4 count, VL, WAZ, and age were calculated for RLCs and DCs and compared by using independent samples t tests. RESULTS Forty RLC and 28 DC publications were selected (N = 17 875 RLCs; N = 1835 DC). Mean percentage of deaths per cohort and mean deaths per 100 child-years after HAART were significantly higher in RLCs than DCs (7.6 vs 1.6, P < .001, and 8.0 vs 0.9, P < .001, respectively). Mean baseline CD4% was 12% in RLCs and 23% in DCs (P = .01). Mean baseline VLs were 5.5 vs 4.7 log(10) copies per mL in RLCs versus DCs (P < .001). CONCLUSIONS Baseline CD4% and VL differ markedly between DCs and RLCs, as does mortality after pediatric HAART. Earlier diagnosis and treatment of pediatric HIV in RLCs would be expected to result in better HAART outcomes.
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Monitoring Antiretroviral Therapy in HIV-Infected Children in Resource-Limited Countries: A Tale of Two Epidemics. AIDS Res Treat 2010; 2011:280901. [PMID: 21490777 PMCID: PMC3066553 DOI: 10.1155/2011/280901] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 10/30/2010] [Indexed: 11/30/2022] Open
Abstract
Twenty-nine years into the HIV epidemic, several advances have been made; however, there remain several challenges particularly with pediatric HIV in resource-limited countries. The obstacles facing pediatric antiretroviral therapy (ART) delivery in resource-limited countries are multifaceted: lack of health care infrastructure, limited availability of pediatric drug formulations, lack of early HIV diagnostic and monitoring techniques, limited manpower with expertise in pediatric HIV care, limited donor funding, and competing public health priorities with limited health care budget. In this paper, the challenges with various ART monitoring tools in resource-limited countries are discussed. Noninvasive (e.g., patient, clinical events outcome, and adherence) and invasive (e.g., immunologic and virologic) monitoring tools are discussed. Several cheap and technically less complex laboratory tests for monitoring are becoming available. Funding agencies and country programs should invest in validating the use of current technologies to optimize pediatric HIV care in resource-limited countries.
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Hansudewechakul R, Sirisanthana V, Kurniati N, Puthanakit T, Lumbiganon P, Yusoff NKN, Fong SM, Nallusamy R, Srasuebkul P, Law M, Sohn AH, Chokephaibulkit K. Antiretroviral therapy outcomes of HIV-infected children in the TREAT Asia pediatric HIV observational database. J Acquir Immune Defic Syndr 2010; 55:503-9. [PMID: 20842043 PMCID: PMC2975064 DOI: 10.1097/qai.0b013e3181f5379a] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We report responses to combination antiretroviral therapy (cART) in the Therapeutics Research, Education, and AIDS Training in Asia Pediatric HIV Observational Database. METHODS Children included were those who had received cART (ie, ≥3 antiretrovirals) at <18 years. The analysis was intention-to-treat by the first cART regimen. Median values are provided with interquartile ranges; hazard ratios (HRs) with 95% confidence intervals. RESULTS Of the 1655 children included, 50.4% were male, with a median age at cART of 7.0 (3.9-9.8) years and CD4 of 8% (2.0%-15%); 92.5% were started on an NNRTI; median duration of follow-up was 2.9 (1.4-4.6) years. Loss-to-follow-up and death rates were 4.2 (3.7-4.8) and 2.1 (1.7-2.5) per 100 person-years, respectively. At 36 months, median CD4 was 26% (21%-31%); 81% of those with viral load (n = 302) were <400 copies per milliliter. Children who reached CD4 ≥25% within 5 years were more likely to be females (HR: 1.4; 1.2-1.7), start before 18 months old (HR: 3.8; 2.4-6.2), lack a history of monotherapy/dual therapy (HR: 1.7; 1.4-2.5), and have a higher baseline CD4 (per 10% increase: HR: 2; 1.9-2.2). CONCLUSIONS These data underscore the need for early diagnosis and cART initiation to preserve immune function.
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Affiliation(s)
| | | | - Nia Kurniati
- Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | | | | | | | | | - Preeyaporn Srasuebkul
- National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, Australia
| | - Matthew Law
- National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, Australia
| | - Annette H. Sohn
- TREAT Asia/amfAR – The Foundation for AIDS Research, Bangkok, Thailand
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A chewable pediatric fixed-dose combination tablet of stavudine, lamivudine, and nevirapine: pharmacokinetics and safety compared with the individual liquid formulations in human immunodeficiency virus-infected children in Thailand. Pediatr Infect Dis J 2010; 29:940-4. [PMID: 20453709 PMCID: PMC2981099 DOI: 10.1097/inf.0b013e3181e2189d] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric fixed-dose combinations (FDCs) are needed to facilitate antiretroviral therapy in children. We evaluated the relative bioavailability, safety, and therapeutic adequacy of a novel chewable pediatric FDC tablet of stavudine (7 mg), lamivudine (30 mg), and nevirapine (50 mg), referred to as GPO-VIR S7, and compared it with the individual original brand-name liquid formulations in human immunodeficiency virus-infected Thai children. METHODS The International Maternal Pediatric Adolescent AIDS Clinical Trials group (IMPAACT) P1056 study was a phase I/II, 2-arm, randomized, open-label, multidose pharmacokinetic cross-over study. Children ≥6 to ≤30 kg receiving nevirapine-based HAART for at least 4 weeks were randomized to receive GPO-VIR S7 chewable tablets or the equivalent liquid formulations. Children were stratified by weight and dosing was weight-based. Intensive 12-hour blood sampling was performed on day 28, and subjects then crossed-over to the alternate formulation at equal doses with identical 12-hour sampling on day 56. Pharmacokinetic indices were determined by noncompartmental analysis. RESULTS Thirty-four children completed the study. While taking Government Pharmaceutical Organization (GPO)-VIR S7 the geometric mean (90% CI) area under the curve was 1.54 μg·hr/mL (1.42-1.67) for stavudine, 6.39 (5.82-7.00) for lamivudine, and 74.06 (65.62-83.60) for nevirapine. Nevirapine drug exposure for GPO-VIR S7 was therapeutically adequate. Geometric mean area under the curve ratios (90% CI) of GPO-VIR S7/liquid formulation for stavudine, lamivudine, and nevirapine were 0.97 (0.92-1.02), 1.41 (1.30-1.53), and 1.08 (1.04-1.13), respectively. No serious drug-related toxicity was reported. CONCLUSIONS The chewable FDC was safe and provided therapeutically adequate plasma drug exposures in human immunodeficiency virus-infected children. Substituting the FDC for liquid formulations can simplify antiretroviral therapy.
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National Program Scale-Up and Patient Outcomes in a Pediatric Antiretroviral Treatment Program, Thailand, 2000-2007. J Acquir Immune Defic Syndr 2010; 54:423-9. [DOI: 10.1097/qai.0b013e3181dc5eb0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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O'Brien DP, Venis S, Greig J, Shanks L, Ellman T, Sabapathy K, Frigati L, Mills C. Provision of antiretroviral treatment in conflict settings: the experience of Médecins Sans Frontières. Confl Health 2010; 4:12. [PMID: 20553624 PMCID: PMC2911421 DOI: 10.1186/1752-1505-4-12] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 06/17/2010] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Many countries ravaged by conflict have substantial morbidity and mortality attributed to HIV/AIDS yet HIV treatment is uncommonly available. Universal access to HIV care cannot be achieved unless the needs of populations in conflict-affected areas are addressed. METHODS From 2003 Médecins Sans Frontières introduced HIV care, including antiretroviral therapy, into 24 programmes in conflict or post-conflict settings, mainly in sub-Saharan Africa. HIV care and treatment activities were usually integrated within other medical activities. Project data collected in the Fuchia software system were analysed and outcomes compared with ART-LINC data. Programme reports and other relevant documents and interviews with local and headquarters staff were used to develop lessons learned. RESULTS In the 22 programmes where ART was initiated, more than 10,500 people were diagnosed with HIV and received medical care, and 4555 commenced antiretroviral therapy, including 348 children. Complete data were available for adults in 20 programmes (n = 4145). At analysis, 2645 (64%) remained on ART, 422 (10%) had died, 466 (11%) lost to follow-up, 417 (10%) transferred to another programme, and 195 (5%) had an unclear outcome. Median 12-month mortality and loss to follow-up were 9% and 11% respectively, and median 6-month CD4 gain was 129 cells/mm 3.Patient outcomes on treatment were comparable to those in stable resource-limited settings, and individuals and communities obtained significant benefits from access to HIV treatment. Programme disruption through instability was uncommon with only one program experiencing interruption to services, and programs were adapted to allow for disruption and population movements. Integration of HIV activities strengthened other health activities contributing to health benefits for all victims of conflict and increasing the potential sustainability for implemented activities. CONCLUSIONS With commitment, simplified treatment and monitoring, and adaptations for potential instability, HIV treatment can be feasibly and effectively provided in conflict or post-conflict settings.
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Affiliation(s)
- Daniel P O'Brien
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
- Department of Infectious Diseases, Geelong Hospital, Geelong, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
| | - Sarah Venis
- Manson Unit, Médecins Sans Frontières, London, UK
| | - Jane Greig
- Manson Unit, Médecins Sans Frontières, London, UK
| | - Leslie Shanks
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
| | - Tom Ellman
- Manson Unit, Médecins Sans Frontières, London, UK
| | - Kalpana Sabapathy
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
| | - Lisa Frigati
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
- School of Child and Adolescent Health, Red Cross Childrens' Hospital, Capetown, South Africa
| | - Clair Mills
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
- Te Kupenga Hauora Maori, Faculty of Medical and Health Sciences,University of Auckland, Auckland, New Zealand
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Janssen N, Ndirangu J, Newell ML, Bland RM. Successful paediatric HIV treatment in rural primary care in Africa. Arch Dis Child 2010; 95:414-21. [PMID: 19880392 PMCID: PMC3181433 DOI: 10.1136/adc.2009.169367] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2009] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Clinical outcomes of HIV-infected children on antiretroviral treatment (ART) in a decentralised, nurse/counsellor-led programme. DESIGN Clinical cohort. SETTING KwaZulu-Natal, South Africa. PATIENTS HIV-infected children aged MAIN OUTCOME MEASURES Survival according to baseline characteristics including age, WHO clinical stage, haemoglobin and CD4%, was assessed in Kaplan-Meier analyses. Hazard ratios for mortality were estimated using Cox proportional hazards regression and changes in laboratory parameters and weight-for-age z scores after 6-12 months' treatment were calculated. RESULTS 477 HIV-infected children began ART at a median age of 74 months (range 4-180), median CD4 count (CD4%) of 433 cells/mm(3) (17%) and median HIV viral load of log 4.2 copies/ml; 105 (22%) were on treatment for tuberculosis and 317 (76.6%) were WHO stage 3/4. There were significant increases after ART initiation in CD4% (17% vs 22%; p<0.001), haemoglobin (9.9 vs 11.7 g/l; p60 months (adjusted HR 3.2; 95% CI 1.2 to 9.1). CONCLUSIONS Good clinical outcomes in HIV-infected children on ART are possible in a rural, decentralised service. Few young children are on ART, highlighting the urgent need to identify HIV-exposed infants.
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Affiliation(s)
- N Janssen
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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Sauvageot D, Schaefer M, Olson D, Pujades-Rodriguez M, O'Brien DP. Antiretroviral therapy outcomes in resource-limited settings for HIV-infected children <5 years of age. Pediatrics 2010; 125:e1039-47. [PMID: 20385636 DOI: 10.1542/peds.2009-1062] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We describe medium-term outcomes for young children receiving antiretroviral therapy (ART) in resource-limited countries. METHODS Analyses were conducted on surveillance data for children <5 years of age receiving ART (initiated April 2002 to January 2008) in 48 HIV/AIDS treatment programs in Africa and Asia. Primary outcome measures were probability of remaining in care, probability of developing World Health Organization stage 4 clinical events, rate of switching to second-line ART, and drug toxicity, compared at 6, 12, 24, and 36 months of ART. RESULTS Of 3936 children (90% in Africa) initiating ART, 9% were <12 months, 50% were 12 to 35 months, and 41% were 36 to 59 months of age. The median time of ART was 10.5 months. Probabilities of remaining in care after 12, 24, and 36 months of ART were 0.85, 0.80, and 0.75, respectively. Compared with children 36 to 59 months of age at ART initiation, probabilities of remaining in care were significantly lower for children <12 months of age. Overall, 55% and 69% of deaths and losses to follow-up occurred in the first 3 and 6 months of ART, respectively. Probabilities of developing stage 4 clinical events after 12, 24, and 36 months of ART were 0.03, 0.06, and 0.09, respectively. Only 33 subjects (0.8%) switched to second-line regimens, and 151 (3.8%) experienced severe drug toxicities. CONCLUSIONS Large-scale ART for children <5 years of age in resource-limited settings is feasible, with encouraging clinical outcomes, but efforts should be increased to improve early HIV diagnosis and treatment.
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Early clinical outcomes in children enrolled in human immunodeficiency virus infection care and treatment in lesotho. Pediatr Infect Dis J 2010; 29:340-5. [PMID: 20019645 DOI: 10.1097/inf.0b013e3181bf8ecb] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children are largely underrepresented among those accessing treatment of HIV infection in Africa. Reported outcomes of children enrolled in national care and treatment programs are needed to inform the widespread scale-up of pediatric HIV care in resource-limited settings. METHODS The objective of this article is to report on the early outcomes of a pediatric HIV infection care and treatment program in Lesotho during its first 14 months of operation. Clinical protocols are described, and characteristics and outcomes of the first cohort of children enrolled in care are reported, derived from a retrospective review of medical records. RESULTS In the program's first 14 months, 1566 children and adolescents aged between 0 and 16 years were evaluated for HIV, with 567 (36%) confirmed to be infected. Of infected patients, 61% presented with advanced or severe symptoms of HIV disease and 65% presented with CD4 profiles consistent with advanced or severe immunodeficiency, based on World Health Organization 2006 guidelines. Two hundred and eighty four children received highly active antiretroviral therapy. The mortality rate was 18.6 deaths per 100 patient years of follow-up. Ninety-nine percent of deaths occurred within 90 days of enrollment. Deceased patients were significantly younger, had higher rates of stunting and wasting, and were more likely to present with low CD4 cell counts. CONCLUSION Highly active antiretroviral therapy was well tolerated, but the early mortality rate was high despite concurrent management of HIV and comorbidities. Given that hundreds of thousands of children remain without access to HIV care, renewed efforts are needed to reach this underserved population.
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Isaakidis P, Raguenaud ME, Te V, Tray CS, Akao K, Kumar V, Ngin S, Nerrienet E, Zachariah R. High survival and treatment success sustained after two and three years of first-line ART for children in Cambodia. J Int AIDS Soc 2010; 13:11. [PMID: 20302672 PMCID: PMC2851581 DOI: 10.1186/1758-2652-13-11] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 03/21/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-term outcomes of antiretroviral therapy (ART) in children remain poorly documented in resource-limited settings. The objective of this study was to assess two-and three-year survival, CD4 evolution and virological response among children on ART in a programmatic setting in Cambodia. METHODS Children treated with first-line ART for at least 24 months were assessed with viral load testing and genotyping. We used Kaplan-Meier analysis for survival and Cox regression to identify risk factors associated with treatment failure. RESULTS Of 1168 registered HIV-positive children, 670 (57%) started ART between January 2003 and December 2007. Survival probability was 0.93 (95% CI: 0.91-0.95) and 0.91 (95% CI: 0.88-0.93) at 24 and 36 months after ART initiation, respectively. Median CD4 gain for children aged over five years was 704 cells/mm3 at 24 months and 737 at 36 months. Median CD4 percentage gain for children under five years old was 15.2% at 24 months and 15% at 36 months. One hundred and thirty children completed at least 24 months of ART, and 138 completed 36 months: 128 out of 268 (48%) were female. Median age at ART initiation was six years.Overall, 22 children had viral loads of >1000 copies/ml (success ratio = 86% on intention-to-treat-analysis) and 21 of 21 presented mutations conferring resistance mostly to lamivudine and non-nucleoside reverse transcriptase inhibitors. Risk factors for failure after 24 and 36 months were CD4 counts below the threshold for severe immunosupression at those months respectively. Only two out of 22 children with viral loads of >1000 copies/ml met the World Health Organization immunological criteria for failure (sensitivity = 0.1). CONCLUSIONS Good survival, immunological restoration and viral suppression can be sustained after two to three years of ART among children in resource-constrained settings. Increased access to routine virological measurements is needed for timely diagnosis of treatment failure.
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Affiliation(s)
| | | | - Vantha Te
- Pediatrics Department, Donkeo Referral Hospital, Ministry of Health, Takeo, Cambodia
| | | | - Kazumi Akao
- Angkor Hospital for Children, Siem Reap, Cambodia
| | - Varun Kumar
- Angkor Hospital for Children, Siem Reap, Cambodia
| | - Sopheak Ngin
- HIV/Hepatitis Laboratory, Pasteur Institute of Cambodia
| | | | - Rony Zachariah
- Médecins Sans Frontières, Operational Research Unit, Brussels, Belgium
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Germanaud D, Derache A, Traore M, Madec Y, Toure S, Dicko F, Coulibaly H, Traore M, Sylla M, Calvez V, Marcelin AG. Level of viral load and antiretroviral resistance after 6 months of non-nucleoside reverse transcriptase inhibitor first-line treatment in HIV-1-infected children in Mali. J Antimicrob Chemother 2010; 65:118-24. [PMID: 19933171 DOI: 10.1093/jac/dkp412] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate the virological response and to describe the resistance profiles in the case of failure after 6 months of first-line highly active antiretroviral therapy (HAART) in HIV-1-infected children living in resource-limited settings. PATIENTS AND METHODS Ninety-seven HIV-1-infected children who started two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) (mainly zidovudine/lamivudine/nevirapine) in Mali were prospectively studied. Virological failure (VF) was defined as loss to follow-up, death or HIV-1 RNA viral load (VL) of >400 copies/mL at 6 months. When VL was >50 copies/mL, a genotypic resistance test was performed. RESULTS Among the 97 children, median age at antiretroviral initiation was 31 months and the majority were in WHO clinical (77.3%) and immunological (70.1%) stage III or IV. At month 6, 44% of children had VL > 400 copies/mL (61% VF). Among the children with detectable VL, 30/37 genotypic resistance tests were available, 8 with wild-type viruses and 22 with resistance mutations (73%): 19 M184V/I, 21 NNRTI mutations and only 3 thymidine analogue mutations (TAMs) (K70R, D67N and L210W in three distinct viruses). At failure, 6/8 children with wild-type viruses had a VL of <1000 copies/mL whereas 21/22 with resistant viruses had a VL of >1000 copies/mL. CONCLUSIONS Under NNRTI-based regimens, early detection of VF could allow the reinforcement of adherence when VL was <1000 copies/mL, because in most of these cases no resistance mutations were detected, or a change to a protease inhibitor-based regimen if VL was >1000 copies/mL. The low frequency of TAMs suggests that most NRTIs can be used in a second-line regimen after early failure.
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Kwara A, Ramachandran G, Swaminathan S. Dose adjustment of the non-nucleoside reverse transcriptase inhibitors during concurrent rifampicin-containing tuberculosis therapy: one size does not fit all. Expert Opin Drug Metab Toxicol 2010; 6:55-68. [PMID: 19968575 DOI: 10.1517/17425250903393752] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE OF THE FIELD HIV/tuberculosis (TB) co-infection is common and associated with high mortality. Simultaneous highly active antiretroviral therapy during TB treatment is associated with substantial survival benefit but drug-drug interactions complicate NNRTI dosing. AREAS COVERED IN THIS REVIEW We reviewed the impact of rifampicin-containing TB therapy on the NNRTIs pharmacokinetics and clinical outcome. PubMed database was searched from 1966 to July 2009 using the terms efavirenz, rifampicin, nevirapine, pharmacokinetics, pharmacogenetics, HIV, TB, CYP2B6, CYP3A4 and metabolism. References from identified articles and abstracts from meetings were also reviewed. WHAT THE READER WILL GAIN A comprehensive review of the literature on this subject including pharmacokinetic and clinical studies. Most studies were small, observational or underpowered to detect the true effect of rifampicin on NNRTI-based therapy. None of the studies were controlled for genetic factors and there were limited data on children. TAKE HOME MESSAGE There were insufficient data to make definitive recommendations about dose adjustment of the NNRTIs during rifampin-containing therapy. Current data suggest that the standard dose of efavirenz or nevirapine is adequate in most HIV/TB co-infected adults. However, more research is needed in pediatric populations as well as to define role of drug-gene interactions.
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Affiliation(s)
- Awewura Kwara
- Warren Alpert Medical School of Brown University and The Miriam Hospital, Providence, Rhode Island 02906, USA.
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Ciaranello AL, Chang Y, Margulis AV, Bernstein A, Bassett IV, Losina E, Walensky RP. Effectiveness of pediatric antiretroviral therapy in resource-limited settings: a systematic review and meta-analysis. Clin Infect Dis 2010; 49:1915-27. [PMID: 19916798 DOI: 10.1086/648079] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Responses to antiretroviral therapy (ART) among human immunodeficiency virus (HIV)-infected children in resource-limited settings have recently been reported, but outcomes vary. We sought to derive pooled estimates of the 12-month rate of virologic suppression (HIV RNA, <400 copies/mL) and gain in CD4 cell percentage (DeltaCD4%) for children initiating ART in resource-limited settings. METHODS We conducted a systematic review and meta-analysis of published reports of HIV RNA and CD4 outcomes for treatment-naive children aged 0-17 years old by means of the Medline, EMBASE (Excerpta Medica Database), and LILACS (Latin American and Caribbean Health Sciences Literature) electronic databases and the Cochrane Clinical Trials Register. Pooled estimates of the reported proportion with HIV RNA <400 copies/mL and DeltaCD4% after 12 months of ART were derived using patient-level estimates and fixed- and random-effects models. To approximate intention-to-treat analyses, in sensitivity analyses children with missing 12-month data were assumed to have HIV RNA>400 copies/mL or DeltaCD4% of zero. RESULTS In patient-level estimates after 12 months of ART, the pooled proportion with virologic suppression was 70% (95% confidence interval [CI], 67%-73%); the pooled DeltaCD4% was 13.7% (95% CI, 11.8%-15.7%). Results from the fixed- and random-effects models were similar. In approximated intention-to-treat analyses, the pooled estimates decreased to 53% with virologic suppression (95% CI, 50%-55%) and to a DeltaCD4% of 8.5% (95% CI, 5.5%-11.4%). CONCLUSIONS Pooled estimates of reported virologic and immunologic benefits after 12 months of ART among HIV-infected children in resource-limited settings are comparable with those observed among children in developed settings. Consistency in reporting on reasons for missing data will aid in the evaluation of ART outcomes in resource-limited settings.
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Affiliation(s)
- Andrea L Ciaranello
- The Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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