Growth and pubertal development in HIV-infected adolescents

Growth Trajectories Over the First Year of Life Among Early-Treated Infants with Human Immunodeficiency Virus and Infants Who are Human Immunodeficiency Virus-Exposed Uninfected

OBJECTIVE

To investigate the role of early antiretroviral therapy (ART) on growth trajectories of infants with human immunodeficiency virus (IHIV) in the first year of life.

STUDY DESIGN

As part of a clinical trial of early ART in Johannesburg, South Africa (2015-2018), 116 IHIV diagnosed within 48 hours of birth were started on ART as soon as possible, and 80 uninfected infants born to mothers living with HIV (IHEU) were enrolled. Both groups were followed prospectively from birth through 48 weeks and growth parameters collected. The groups were compared and risk factors for poor growth investigated, in the full cohort and among IHIV separately.

RESULTS

IHIV had lower mean weight-for-age Z-scores (WAZ) than IHEU at 4 and 8 weeks (-1.17 [SE:0.14] vs -0.72 [0.14], P = .035 and -1.23 [0.15] vs -0.67 [0.14], P = .012). Although there was some closing of the gap over time, means remained lower in IHIV through 48 weeks. In length-for-age Z-scores (LAZ), differences widened over time and IHIV had lower Z-scores by 48 weeks (-1.41 [0.15] vs -0.80 [0.18], P = .011). Deficits in WAZ and LAZ in IHIV vs IHEU were most marked among girls. IHIV with pre-ART viral load ≥1000 copies/ml had significantly lower weight-for-length and mid-upper arm circumference Z-scores across all time points through 48 weeks.

CONCLUSIONS

IHIV on early ART had deficits in WAZ over the first 8 weeks of life and lower LAZ at 48 weeks than IHEU. Among IHIV, higher pre-ART viral load was associated with worse anthropometric indicators through 48 weeks.

Overview of the Epidemiology and Clinical Care Considerations for Adolescents and Young Adults Living with or at Risk of Human Immunodeficiency Virus

This article provides an updated examination of human immunodeficiency virus (HIV) epidemiologic trends among adolescents and young adults (AYAs) in the United States, highlighting the significant public health challenge posed by HIV within this demographic. Despite a notable decline in HIV diagnoses among AYAs, challenges remain, particularly due to 50% of AYAs living with HIV being unaware of their status. The article aims to evaluate current clinical recommendations, identify deficiencies, and propose evidence-based improvements for HIV prevention, diagnosis, and care, with the goal of enhancing health outcomes and reducing HIV prevalence among AYAs.

An interprofessional model of care for adolescents with perinatal HIV: A qualitative study

Background and Aims

The number of perinatally HIV-infected adolescents (PHIVA) is increasing however many health care systems are not prepared for this population and their health challenges, specifically a model of care (MoC) is lacking. Thus the objective of this study was to develop and propose a MoC for PHIVA.

Methods

Through a qualitative study design, a MoC was developed and ratified with two focus groups, consisting of PHIVA and healthcare professionals.

Results

Seven participants were included in each focus group and the following themes were developed: relatable attributes; missing components; implementation and suggestions. Changes were made to the drafts of the MoC in response to the focus group results, leading to the finalisation of a MoC for PHIVA. The MoC focused on the importance of interprofessional health care and addressed the physical sequelae that PHIVA are likely to encounter. A schematic of the MoC was created for the use in general public education.

Conclusion

It is important that healthcare facilities are equipped to handle the specific needs of PHIVA. The interprofessional MoC developed in this study helps to address the requirements of this population.

Effect of tuberculosis-HIV co-treatment on clinical and growth outcomes among hospitalized children newly initiating antiretroviral therapy

OBJECTIVE

Evaluate effects of tuberculosis (TB)-HIV co-treatment on clinical and growth outcomes in children with HIV (CHIV).

DESIGN

Longitudinal study among Kenyan hospitalized ART-naive CHIV in the PUSH trial (NCT02063880).

METHODS

CHIV started ART within 2 weeks of enrollment; Anti-TB therapy was initiated based on clinical and TB diagnostics. Children were followed for 6 months with serial viral load, CD4%, and growth assessments [weight-for-age z -score (WAZ), height-for-age z -score (HAZ), and weight-for-height z -score (WHZ)]. TB-ART treated and ART-only groups were compared at 6 months post-ART for undetectable viral load (<40 c/ml), CD4% change, and growth using generalized linear models, linear regression, and linear mixed-effects models, respectively.

RESULT

Among 152 CHIV, 40.8% (62) were TB-ART treated. Pre-ART, median age was 2.0 years and growth was significantly lower, and viral load significantly higher in the TB-ART versus ART-only group. After 6 months on ART, 37.2% of CHIV had undetectable viral load and median CD4% increased by 7.2% (IQR 2.0-11.6%) with no difference between groups. The TB-ART group had lower WAZ and HAZ over 6 month follow-up [WAZ -0.81 (95% CI: -1.23 to -0.38], P  < 0.001; HAZ -0.15 (95% CI: -0.29 to -0.01), P  = 0.030] and greater rate of WAZ increase in analyses unadjusted and adjusted for baseline WAZ [unadjusted 0.62 (95% CI: 0.18-1.07, P  = 0.006) or adjusted 0.58 (95% CI: 0.12-1.03, P  = 0.013)].

CONCLUSION

TB-HIV co-treatment did not adversely affect early viral suppression and CD4 + recovery post-ART. TB-ART-treated CHIV had more rapid growth reconstitution, but growth deficits persisted, suggesting need for continued growth monitoring.

Physical functioning in adolescents with perinatal HIV

Perinatal HIV impacts on growth and development in childhood, with physical impairments such as growth limitations, decreased physical activity, reduced exercise tolerance and cardiopulmonary dysfunction continuing into adolescence. There is limited data on other physical functioning domains in perinatally HIV-infected adolescents (PHIVA) thus the aim of this study was to establish the physical sequelae of perinatal HIV in adolescents. This South African cross-sectional study compared PHIVA with HIV-negative adolescents, assessing anthropometry, muscle strength, endurance and motor performance. All ethical considerations were adhered to. The study included 147 PHIVA and 102 HIV-negative adolescents, aged 10-16 years. The majority (87.1%) of PHIVA were virally suppressed however, they still showed significant deficits in height (p < 0.001), weight (p < 0.001) and BMI (p = 0.004). Both groups performed poorly in muscle strength and endurance but did not differ significantly. In motor performance, the PHIVA scored significantly lower for manual dexterity and balance, with significantly more PHIVA with motor difficulty. A regression analysis showed that viral suppression predicted muscle strength (p = 0.032) and age positively predicted endurance (p = 0.044) and negatively predicated aiming and catching (p = 0.009). In conclusion, PHIVA face growth deficits and challenges with motor performance, especially with manual dexterity and balance.

Growth Profiles of Children and Adolescents Living with and without Perinatal HIV Infection in Southern Africa: A Secondary Analysis of Cohort Data

Impaired linear growth and slower pubertal growth can be associated with perinatal HIV infection. We characterised growth relative to population norms, among the full adolescent period in southern Africa to better understand processes leading to morbidity in adulthood. We conducted a secondary analysis of 945 adolescents aged 8-20 years from urban Malawi and Zimbabwe; we included children with HIV (CWH), an uninfected comparison group from a cohort study, and CWH with co-morbid chronic lung disease (CLD) from a randomised controlled trial. We used latent class analysis of anthropometric Z-scores generated from British 1990 reference equations at two annual time-points, to identify growth trajectory profiles and used multinomial logistic regression to identify factors associated with growth profiles. Growth faltering (one or more of weight-for-age, height-for-age, or BMI-for-age Z-scores < -2) occurred in 38% (116/303) of CWH from the cohort study, 62% (209/336) of CWH with CLD, and 14% (44/306) of HIV-uninfected participants. We identified seven different growth profiles, defined, relatively, as (1) average growth, (2) tall not thin, (3) short not thin, (4) stunted not thin, (5) thin not stunted, (6) thin and stunted and (7) very thin and stunted. Females in profile 3 exhibited the highest body fat percentage, which increased over 1 year. Males at older age and CWH especially those with CLD were more likely to fall into growth profiles 4-7. Improvements in height-for-age Z-scores were observed in profiles 6-7 over 1 year. Interventions to target those with the worst growth faltering and longer-term follow-up to assess the impact on adult health are warranted.

Global variations in pubertal growth spurts in adolescents living with perinatal HIV

OBJECTIVE

To describe pubertal growth spurts among adolescents living with perinatally acquired HIV (ALWPHIV) on antiretroviral therapy (ART).

DESIGN

Observational data collected from 1994 to 2015 in the CIPHER global cohort collaboration.

METHODS

ALWPHIV who initiated ART age less than 10 years with at least four height measurements age at least 8 years were included. Super Imposition by Translation And Rotation (SITAR) models, with parameters representing timing and intensity of the growth spurt, were used to describe growth, separately by sex. Associations between region, ART regimen, age, height-for-age (HAZ), and BMI-for-age z -scores (BMIz) at ART initiation (baseline) and age 10 years, and SITAR parameters were explored.

RESULTS

Four thousand seven hundred and twenty-three ALWPHIV were included: 51% from East and Southern Africa (excluding Botswana and South Africa), 17% Botswana and South Africa, 6% West and Central Africa, 11% Europe and North America, 11% Asia-Pacific, and 4% Central, South America, and Caribbean. Growth spurts were later and least intense in sub-Saharan regions. In females, older baseline age and lower BMIz at baseline were associated with later and more intense growth spurts; lower HAZ was associated with later growth spurts. In males, older baseline age and lower HAZ were associated with later and less intense growth spurts; however, associations between baseline HAZ and timing varied by age. Lower HAZ and BMIz at 10 years were associated with later and less intense growth spurts in both sexes.

CONCLUSION

ALWPHIV who started ART at older ages or already stunted were more likely to have delayed pubertal growth spurts. Longer-term follow-up is important to understand the impact of delayed growth.

Growth, weight gain and BMI in virally suppressed children on antiretroviral therapy with specific reference to dolutegravir

BACKGROUND

Pediatric HIV infection cause retardation in height and weight. However, effective antiretroviral therapy (ART) result in desirable weight gain. Concerns have emerged regarding excessive weight gain related to the integrase inhibitor dolutegravir in adults but knowledge about the circumstances in children/adolescents is limited. We studied if dolutegravir containing ART or switch to dolutegravir affected body mass index (BMI) and described height development in the Stockholm pediatric/adolescent HIV cohort.

METHODS

A retrospective cohort study of height, weight and BMI in relation to ART in 94 children/adolescents living with HIV.

RESULTS

At last documented visit 60/94 children/adolescents were on dolutegravir, 50 had switched from a protease inhibitor or non-nucleoside reverse transcriptase inhibitor. Height standard deviation score (SDS) increased between first and last visit from mean height SDS -0.88 (16 had SDS < -2 and 6 SDS < -3) to -0.32 (four had SDS < -2). Mean BMI SDS increased from -0.15 to 0.62 in girls, but not (-0.20 to 0.09) in boys. The number of girls ≥ 12 years with BMI SDS ≥ 2 increased significantly from 0/38 to 8/38 and totally 9/50 (18%) girls and 4/44 (9%) boys had BMI SDS ≥ 2 at last visit. There was no difference in height or weight gain between different ART regimens. BMI SDS remained stable in 22/50 children switching to dolutegravir, decreased in 13 and increased in 15.

CONCLUSION

Adolescent girls gained weight to a greater extent than expected but independently of ART. We found no association between dolutegravir alone or combined with tenofovir alafenamide fumarate (TAF) and excessive weight gain. Height development was within normal range.

Prevalence and Factors Associated With Delayed Puberty Among Adolescents on Boosted Protease Inhibitor-based Second-line Antiretroviral Therapy: A Cross-sectional Study at a Pediatric Infectious Diseases Clinic in Uganda

BACKGROUND

Delayed puberty is a recognized phenomenon among children living with HIV type 1 infection but has not been widely reported among adolescents on second-line or newer treatments in high burden settings. The study aimed to determine the prevalence of, and factors associated with delayed puberty among adolescents on boosted protease inhibitor-based second-line antiretroviral therapy (ART) in Uganda.

METHODS

Between December 2017 and May 2018, we conducted a cross-sectional study among adolescents living with HIV (ALWHIV) 10-19 years of age on atazanavir- and lopinavir-based regimens at the Paediatric Infectious Diseases Clinic, Kampala. Participants were on ART for at least 3 months and had a recent viral load. Sociodemographics, clinical measurements: body mass index for age Z score, height for age Z score, Tanner staging were collected. ART history was extracted from medical records. The outcome was delayed puberty defined as absence of signs of breast development in a girl 13 years of age or a testicular volume of less than 4 mL in a boy 14 years of age by Tanner staging, or an age for Tanner staging which was at least 2 standard deviations above the expected mean.

RESULTS

Among 230 perinatally infected ALWHIV participants, 14.7 ± 3.1 years of age were included, 54.9% were female, 5.2% were wasted and the median duration on ART was 9.5 years (interquartile range 7.3-11.7). The prevalence of delayed puberty was 8.7% (10.4% females, 6.7% males). Overall mean age estimates at different Tanner stages by sex were significantly higher than reference populations. Age at ART initiation (adjusted odds ratio 1.37, 95% confidence interval: 1.06-1.77) and body mass index for age Z score (adjusted odds ratio: 7.63, 95% confidence interval: 1.80-32.38) were associated with delayed puberty.

CONCLUSIONS

Timely initiation of ART and nutritional monitoring could optimize body weight and consequently, normal puberty for ALWHIV. Longitudinal studies could establish biological diagnoses and guide treatment of delayed puberty in this population.

Fracture prevalence and its association with bone density among children living with HIV in Zimbabwe

OBJECTIVES

HIV infection impairs bone density in children living with HIV (CLWH). We aimed to determine the prevalence of self-reported fracture (past or current), associated risk factors and disability, by HIV status in Zimbabwean children.

DESIGN

Cross-sectional study.

METHODS

We recruited CLWH aged 8-16 years taking antiretroviral therapy (ART) for ≥2 years from HIV clinics, and HIV-uninfected children from schools in Harare. Interviewer-administered questionnaires collected data on fracture site and management, sociodemographics, dietary calcium and vitamin D, physical activity and HIV history. Dual-energy X-ray absorptiometry (DXA) measured size-adjusted bone density.

RESULTS

We recruited 303 CLWH [mean (SD) age 12.5 (2.5) years; 50% female] and 306 children without HIV [12.5 (2.5) years; 51% female]. Median age at HIV diagnosis in CLWH was 3.0 years [interquartile range (IQR) 1.2, 5.9], and median ART duration 8.1 years [IQR 6.2, 9.5]. 53.8% CLWH had self-reported disability and/or functional impairment, vs. 29.4% children without HIV. Fracture prevalence was 5.9% with no difference by HIV status [21/306 (6.9%) vs. 14/303 (4.6%), P  = 0.24]. Male sex was associated with fractures. Low size-adjusted bone density ( Z -score < -2) was associated with prevalent fractures in CLWH {risk ratio [RR] 1.14 (95% confidence interval (CI) -0.02, 2.29]}, but not in children without HIV [RR -0.04 (-2.00, 1.91)], P -interaction = 0.27. All sought medical attention for their fracture(s), but CLWH were less often admitted to hospital [2/14 (14.3%) vs. 7/21 (33.3%)].

CONCLUSION

Prevalent fractures may be associated with low lumbar spine bone density in CLWH. Fracture surveillance and strategies to reduce future fracture risk are warranted as CLWH enter adulthood.

Physical growth and sexual maturation of perinatally HIV-infected adolescent males in a southeast Nigerian tertiary hospital: a comparative cross-sectional study

Background

The advent of highly-active anti-retroviral therapy (HAART) has resulted in the survival of children with Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) into adolescence. Their prolonged survival has translated into co-morbidities like endocrine deficiencies which may manifest as growth and pubertal delay. This study aimed to determine the physical growth and sexual maturation of perinatally HIV-infected adolescent males and compare them with those of age-matched HIV-negative controls.

Methods

We conducted a comparative cross-sectional study of 104 perinatally HIV-infected males on HAART aged 10 to 19 years, and 104 age-matched HIV-negative males who served as controls. The subjects and controls were enrolled and assessed at a Nigerian tertiary hospital over six months. Anthropometric measurements such as weight, height, and BMI were obtained and Z scores for age were derived for weight, height, and BMI to determine physical growth using WHO AnthroPlus software. Sexual maturation was assessed using the method proposed by Marshall and Tanner. Data analysis and appropriate statistics were conducted with the Statistical Package for Social Sciences (SPSS) version 25 Chicago IL. A p-value < 0.05 was adopted as the level of statistical significance.

Results

The mean height, weight, and BMI Z scores of the subjects were all lower than those of the controls. The difference between the mean weight of the subjects (44.60 ± 13.32 kg) and the controls (49.97 ± 13.58 kg) was statistically significant (t = 2.88, p = 0.004). Similarly, the difference between the mean BMI Z-scores of the subjects (-0.96 ± 1.95) and the controls (-0.10 ± 0.86) was statistically significant (t = 4.10, p = < 0.001). The subjects showed a delay in pubic hair and testicular development for Stages 1, 2, and 3. Duration of HAART did not significantly affect the BMI of subjects who were in three groups: undernutrition, normal nutrition, and overnutrition (Kruskal-Wallis test, p = 0.30).

Conclusion

Perinatal HIV infection negatively affects physical growth and the onset of pubic-hair development (PH 2) despite the duration of HAART. We recommend that screening for weight deficit or pubertal delay should form part of the management protocol for HIV-infected male children on HAART.

Growth improvement following antiretroviral therapy initiation in children with perinatally-acquired HIV diagnosed in older childhood in Zimbabwe: a prospective cohort study

BACKGROUND

Children who initiate antiretroviral therapy (ART) before age 5 years can recover height and weight compared to uninfected peers, but growth outcomes are unknown for children initiating ART at older ages. We investigated factors associated with growth failure at ART initiation and modelled growth by age on ART.

METHODS

We conducted secondary analysis of cohort of children aged 6-15 years late-diagnosed with HIV in Harare, Zimbabwe, with entry at ART initiation in 2013-2015. Factors associated with height-for-age (HAZ), weight-for-age (WAZ) and BMI-for-age (BAZ) z-scores <- 2 (stunting, underweight and wasting respectively) at ART initiation were assessed using multivariable logistic regression. These outcomes were compared at ART initiation and 12 month follow-up using paired t-tests. HAZ and BAZ were modelled using restricted cubic splines.

RESULTS

Participants (N = 302; 51.6% female; median age 11 years) were followed for a median of 16.6 months (IQR 11.0-19.8). At ART initiation 34.8% were stunted, 34.5% underweight and 15.1% wasted. Stunting was associated with age ≥ 12 years, CD4 count < 200 cells/μl, tuberculosis (TB) history and history of hospitalisation. Underweight was associated with older age, male sex and TB history, and wasting was associated with older age, TB history and hospitalisation. One year post-initiation, t-tests showed increased WAZ (p = 0.007) and BAZ (p = 0.004), but no evidence of changed HAZ (p = 0.85). Modelling showed that HAZ and BAZ decreased in early adolescence for boys on ART, but not girls.

CONCLUSION

Stunting and underweight were prevalent at ART initiation among late-diagnosed children, and HAZ did not improve after 1 year. Adolescent boys with perinatally acquired HIV and late diagnosis are particularly at risk of growth failure in puberty.

A Challenging Knowledge Gap: Estimating Modes of HIV Acquisition Among Adolescents Entering HIV Care During Adolescence

Characterizing HIV acquisition modes among adolescents with HIV (AHIV) enrolling in care during adolescence is a challenging gap that impacts differential interventions. We explored whether primary data collection with targeted questionnaires may address this gap and improve understanding of risk factors and perceptions about adolescents’ HIV acquisition, in Kenyan AHIV entering care at ≥10 years, and their mothers with HIV (MHIV). Clinical data were derived through chart review. Among 1073 AHIV in care, only 26 (2%) met eligibility criteria of being ≥10 years at care enrollment, disclosed to, and with living MHIV. Among 18/26 AHIV-MHIV dyads enrolled (median age of AHIV 14 years), none had documented HIV acquisition modes. Data suggested perinatal infection in 17/18 AHIV, with 1 reported non-perinatal acquisition risk factor, and some discordance between adolescent-mother perceptions of HIV acquisition. In this difficult-to-enroll, vulnerable population of AHIV-MHIV dyads, primary data collection can enhance understanding of AHIV acquisition modes.

Growth and Pubertal Development Among HIV Infected and Uninfected Adolescent Girls in Lagos, Nigeria: A Comparative Cross-Sectional Study

This study aimed to compare growth and pubertal developmental parameters among HIV-infected and uninfected adolescent girls (11-19 years) in Lagos using a cross-sectional approach. Height, weight, BMI Z-scores, sexual maturity rating by Tanner stages and age at menarche, were compared in the 2 groups. The mean age was similar in both groups (13.2 [±2.3] years and 13.6 [±1.6] years for HIV positive and negative respectively [ P = .13]). Majority (66.2%) were in Junior Secondary classes and the mean socioeconomic class was 2.5 (±0.9). HIV-infected girls had significantly lower height, weight, and BMI Z scores compared to their uninfected counterparts. The proportion that had attained Tanner stages 3 to 5 were significantly lower among the HIV-positive participants. The study identified lower growth parameters and pubertal delay among HIV-infected adolescent females compared to HIV uninfected girls. Growth and sexual maturation assessment should form part of routine care of adolescents living with HIV.

Growth and CD4 patterns of adolescents living with perinatally acquired HIV worldwide, a CIPHER cohort collaboration analysis

INTRODUCTION

Adolescents living with HIV are subject to multiple co-morbidities, including growth retardation and immunodeficiency. We describe growth and CD4 evolution during adolescence using data from the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) global project.

METHODS

Data were collected between 1994 and 2015 from 11 CIPHER networks worldwide. Adolescents with perinatally acquired HIV infection (APH) who initiated antiretroviral therapy (ART) before age 10 years, with at least one height or CD4 count measurement while aged 10-17 years, were included. Growth was measured using height-for-age Z-scores (HAZ, stunting if <-2 SD, WHO growth charts). Linear mixed-effects models were used to study the evolution of each outcome between ages 10 and 17. For growth, sex-specific models with fractional polynomials were used to model non-linear relationships for age at ART initiation, HAZ at age 10 and time, defined as current age from 10 to 17 years of age.

RESULTS

A total of 20,939 and 19,557 APH were included for the growth and CD4 analyses, respectively. Half were females, two-thirds lived in East and Southern Africa, and median age at ART initiation ranged from <3 years in North America and Europe to >7 years in sub-Saharan African regions. At age 10, stunting ranged from 6% in North America and Europe to 39% in the Asia-Pacific; 19% overall had CD4 counts <500 cells/mm3 . Across adolescence, higher HAZ was observed in females and among those in high-income countries. APH with stunting at age 10 and those with late ART initiation (after age 5) had the largest HAZ gains during adolescence, but these gains were insufficient to catch-up with non-stunted, early ART-treated adolescents. From age 10 to 16 years, mean CD4 counts declined from 768 to 607 cells/mm3 . This decline was observed across all regions, in males and females.

CONCLUSIONS

Growth patterns during adolescence differed substantially by sex and region, while CD4 patterns were similar, with an observed CD4 decline that needs further investigation. Early diagnosis and timely initiation of treatment in early childhood to prevent growth retardation and immunodeficiency are critical to improving APH growth and CD4 outcomes by the time they reach adulthood.

Growth and the pubertal growth spurt in South African adolescents living with perinatally-acquired HIV infection

BACKGROUND

The majority children living with HIV infection now survive into adulthood because of effective antiretroviral therapy (ART), but few data exist on their growth during adolescent years. This study investigated growth patterns and evaluated factors associated with suboptimal growth in adolescents with perinatally-acquired HIV infection.

METHODS

This retrospective cohort study included HIV-infected adolescents, aged 13 to 18 years, with at least 5 years of ART follow-up at a large HIV clinic in the Gauteng Province, South Africa. Weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ) and body mass index (BMI)-for-age Z-scores were calculated using World Health Organization (WHO) growth standards. Growth velocity graphs were generated utilising the mean height change calculated at 6-monthly intervals, using all available data after ART initiation, to calculate the annual change. Other collected data included WHO HIV disease staging, CD4%, HIV viral loads (VLs), ART regimens and tuberculosis co-infection.

RESULTS

Included were 288 children with a median age of 6.5 years (IQR 4.2;8.6 years) at ART initiation, and 51.7% were male. At baseline the majority of children had severe disease (92% WHO stages 3&4) and were started on non-nucleoside reverse transcriptase inhibitor-based regimens (79.2%). The median CD4% was 13.5% (IQR 7.9;18.9) and median HIV viral load log 5.0 (IQR 4.4;5.5). Baseline stunting (HAZ <-2) was prevalent (55.9%), with a median HAZ of -2.2 (IQR -3.1;-1.3). The median WAZ was -1.5 (IQR -2.5;-0.8), with 29.2% being underweight-for-age (WAZ <-2). The peak height velocity (PHV) in adolescents with baseline stage 3 disease was higher than for those with stage 4 disease. Being older at ART start (p<0.001) and baseline stunting (p<0.001) were associated with poorer growth, resulting in a lower HAZ at study exit, with boys more significantly affected than girls (p<0.001).

CONCLUSIONS

Suboptimal growth in adolescents with perinatally-acquired HIV infection is a significant health concern, especially in children who started ART later in terms of age and who had baseline stunting and is more pronounced in boys than in girls.

Surveillance of Pretreatment Drug Resistance Among HIV-Infected Children in Ibadan, Nigeria

There are about 2.1 million children infected with HIV globally and about 120,000 deaths annually. Nigeria has one of the highest rates of pediatric HIV infection globally. Pretreatment HIV drug resistance data inform the choice of first- and second-line antiretroviral therapy (ART) regimens. This study investigated the prevalence of HIV drug-resistant strains among ART-naive children in Ibadan, Nigeria. A total of 20 children aged <15 years were enrolled. Demographic, clinical, and laboratory data were documented. Total nucleic acid was extracted from blood samples after which amplification of HIV-1 pol gene was done using polymerase chain reaction. Amplified gene was sequenced using big dye sequencing method. The sequenced HIV-1 pol gene was typed and analyzed for identification of mutations indicative of drug resistance across the different classes of ART. HIV-1 RNA pol gene was successfully amplified in 12/20 (60%) children. All were identified as HIV-1 and the subtypes were G and CRF 02AG, recombinant of 02_AG/G and recombinant of 02_AG/A1. Drug-resistant mutations (DRMs) were identified in 4/12 (33%). Three out of the four mutations were identified as non-nucleoside reverse transcriptase inhibitors DRM (K103N), whereas the fourth had nucleoside reverse transcriptase inhibitors DRM (M184V). Results from this preliminary study show that drug resistance among ART-naive children is a problem in Ibadan. Pretreatment drug resistance testing is desirable in children before initiation of ART to guide effective treatment.

Physical sequelae of growing into adolescence with perinatally acquired HIV: a scoping review protocol

OBJECTIVE

This scoping review aims to identify and describe the physical sequelae experienced by adolescents with perinatally acquired HIV.

INTRODUCTION

Perinatally acquired HIV is a prevalent condition affecting adolescents. It results in neurocognitive dysfunction and mental health challenges. Data show that some of the physical challenges facing this population include stunted growth and delayed puberty; however, other physical challenges remain largely unknown.

INCLUSION CRITERIA

This review will consider studies that include adolescents aged 10 to 19 years, with perinatally (vertically) acquired HIV. Adolescents from any geographic area, of any ethnicity or socioeconomic background will be considered. The concepts included will be all physical sequelae of perinatally acquired HIV. Studies of any research design, including quantitative, qualitative, and mixed methods, as well as systematic reviews, will be considered.

METHODS

This review will utilize a three-step search strategy. There will be an initial search of MEDLINE (PubMed), followed by a full search of MEDLINE (PubMed), PEDro, CINAHL (EBSCO), Scopus (Elsevier), ScienceDirect (Elsevier), and Google Scholar. Gray literature will be searched using CDC Stacks and OpenGrey. Lastly, the reference lists of all articles will be checked for additional studies. Titles and abstracts will be screened by two independent reviewers against the inclusion criteria, and a third reviewer will resolve any discrepancies. Results will be charted on a data extraction tool and presented with a table, diagrammatic representation, and a descriptive narrative.

Fixed-dose combination bictegravir, emtricitabine, and tenofovir alafenamide in adolescents and children with HIV: week 48 results of a single-arm, open-label, multicentre, phase 2/3 trial

BACKGROUND

Bictegravir is a potent integrase strand-transfer inhibitor (INSTI) with a high genetic barrier to resistance. Bictegravir, coformulated with emtricitabine and tenofovir alafenamide, is recommended by key European and US HIV treatment guidelines as the preferred single-tablet regimen for adults and adolescents. The aim of this study was to assess the pharmacokinetics, safety, and efficacy of switching to this regimen in virologically suppressed children and adolescents with HIV.

METHODS

In this single-arm, open-label trial, we enrolled virologically suppressed children and adolescents (aged 6 to <18 years) with HIV at 22 hospital clinics in South Africa, Thailand, Uganda, and the USA. Eligible participants had a bodyweight of at least 25 kg, were virologically suppressed (HIV-1 RNA <50 copies per mL) on a stable ART regimen for at least 6 months before screening, had a CD4 count of at least 200 cells per μL, and an estimated glomerular filtration rate of at least 90 mL/min per 1·73 m² by the Schwartz formula at screening. All participants received the fixed-dose regimen of coformulated bictegravir 50 mg, emtricitabine 200 mg, and tenofovir alafenamide 25 mg once daily. Pharmacokinetic analysis was used for dosing confirmation, and results compared with adult values. The primary outcomes were area under the curve at the end of the dosing interval (AUC_tau) and concentration at the end of the dosing interval (C_tau) of bictegravir, and incidence of treatment-emergent adverse events and laboratory abnormalities at week 24. Efficacy and safety analyses included all participants who received at least one dose of study drug. We report the 48-week results. This study is registered with ClinicalTrials.gov, NCT02881320.

FINDINGS

Between Sept 29, 2016 and Feb 16, 2018, we enrolled 102 participants. 100 participants received bictegravir, emtricitabine, and tenofovir alafenamide (cohort 1 [adolescents aged 12 to <18 years], n=50; cohort 2 [children aged 6 to <12 years], n=50). The mean bictegravir AUC_tau was 89 100 ng × h/mL (coefficient of variation 31·0%) in adolescents (cohort 1) and 128 000 ng × h/mL (27·8%) in children (cohort 2). Compared with adults, bictegravir C_tau was 35% lower in adolescents and 11% lower in children. The 90% CIs of both parameters were within the predefined pharmacokinetic equivalence boundary and within overall range of exposures observed in adults and deemed to be safe and efficacious (geometric least-squares mean ratio [GLSM] 86·3% [90% CI 80·0-93·0] for AUC_tau and 65·4% [58·3-73·3] for C_tau in adolescents; GLSM 125% [90% CI 117-134] for AUC_tau and 88·9% [80·6-98·0] for C_tau for children). Bictegravir, emtricitabine, and tenofovir alafenamide was well tolerated; most adverse events were grade 2 or less in severity and no study drug-related serious adverse events were reported. One participant discontinued study drug due to adverse events (grade 2 insomnia and anxiety). Virological suppression (HIV-1 RNA <50 copies per mL) was maintained by all 100 participants at week 24 and by 98 (98%) of 100 at week 48; no participants had treatment-emergent resistance.

INTERPRETATION

In adolescents and children with HIV, the bictegravir, emtricitabine, and tenofovir alafenamide single-tablet regimen was well tolerated and maintained virological suppression. Our data support the treatment of HIV in adolescents and children with this single-tablet regimen. At present, the single-tablet regimen is recommended as first-line treatment in the USA for adolescents and as an alternative regimen in children and has the potential to represent an important regimen in the paediatric population.

FUNDING

Gilead Sciences.

Effect of HIV infection on growth and bone density in peripubertal children in the era of antiretroviral therapy: a cross-sectional study in Zimbabwe

Background

Faltered linear growth and pubertal delay, which are both common in children with HIV in sub-Saharan Africa, might affect adolescent bone accrual and future fragility fracture risk. We investigated the association of HIV with bone density adjusted for skeletal size in peripubertal children in Zimbabwe.

Methods

We did a cross-sectional study of baseline data from the IMVASK cohort, which enrolled children aged 8–16 years with HIV who had been taking antiretroviral therapy (ART) for at least 2 years, and children of the same age without HIV. Children with HIV were recruited from public sector HIV clinics at Parirenyatwa General Hospital and Harare Central Hospital (Harare, Zimbabwe), and children without HIV were recruited from six schools in the same suburbs that the hospitals serve. Sociodemographic, clinical, and anthropometric data were collected. Dual-energy X-ray absorptiometry (DXA) was used to measure the bone outcomes of total-body less-head bone mineral content for lean mass adjusted for height (TBLH-BMC^LBM), and lumbar spine bone mineral apparent density (LS-BMAD), and we assessed the prevalence of low TBLH-BMC^LBM and low LS-BMAD (defined by Z-scores of less than −2·0). Size adjustment techniques were used to overcome the size dependence of DXA measurement. We used linear regression models, with multiple imputation for missing data, to assess relationships between risk factors and TBLH-BMC^LBM and LS-BMAD Z-scores in children with and without HIV.

Findings

We recruited 303 children with HIV (mean age 12·4 years [SD 2·5]; 151 [50%] girls) and 306 children without HIV (mean age 12·5 years [SD 2·5]; 155 [51%] girls). In children with HIV, median age of HIV diagnosis was 3·0 years (IQR 1·2–5·8), and median ART duration was 8·1 years (6·2–9·5); for 102 (34%) children, ART included tenofovir disoproxil fumarate (TDF). Children with HIV had a higher prevalence of low TBLH-BMC^LBM Z-score than children without HIV (29 [10%] of 279 children with available data vs 18 [6%] of 292 with available data; p=0·066) and a higher prevalence of low LS-BMAD Z-score (40 [14%] of 279 vs 17 [6%] of 293 with available data; p=0·0007). HIV and male sex were associated with earlier pubertal (Tanner) stage. The negative associations between HIV and Z-scores for TBLH-BMC^LBM and LS-BMAD were more pronounced with pubertal maturation, particularly in girls. Among children with HIV, TDF exposure and orphanhood were associated with lower TBLH-BMC^LBM Z-score in confounder-adjusted analysis. Current TDF use (vs non-TDF-based ART) was associated with a reduction in TBLH-BMC^LBM Z-score of 0·41 (95% CI 0·08–0·74; p=0·015) and in LS-BMAD Z-score of 0·31 (0·08–0·69; p=0·12).

Interpretation

Despite ART, HIV is associated with substantial skeletal deficits towards the end of puberty. The extent of bone deficits associated with TDF and its widespread use in children in sub-Saharan Africa are a concern for future adult fracture risk.

Funding

Wellcome Trust.

Comparison of Muscle Strength, Aerobic Capacity and Body Composition between Healthy Adolescents and Those Living with HIV: A Systematic Review and Meta-Analysis

Background: The adverse effects of antiretroviral therapy associated with complications generated by human immunodeficiency virus (HIV) promote impairments in physical fitness in adolescents. Objective: To analyze the aerobic capacity, muscle strength, and body composition of adolescents living with HIV compared with a healthy population of the same age. Methods: Searches were performed in the MEDLINE, Embase, Web of Science, Scopus and SportDiscus databases until September 2019 and updated in April 2020. Eligibility Criteria: adolescents of both sexes in the age group from 10 to 19 years; living with HIV; cross-sectional, case–control, cohort studies; comparing with a healthy population. Mean differences and 95% Confidence intervals (CIs) were calculated using RevMan (software for systematic reviews). Results: Five articles were included, involving 197 adolescents living with HIV (16 to 18 years) and 185 without infection (13 to 18 years), with the sample in each study ranging from 15 to 65 adolescents. Aerobic capacity and muscle strength were reduced in adolescents with HIV, and body mass index was also significantly lower in this group. Conclusion: Adolescents living with HIV have impaired cardiorespiratory fitness, muscle strength, and body composition when compared to their uninfected peers. However, this systematic review provides limited evidence on the differences between the physical fitness outcomes of adolescents living with HIV compared to healthy adolescents.

Stunting and growth velocity of adolescents with perinatally acquired HIV: differential evolution for males and females. A multiregional analysis from the IeDEA global paediatric collaboration

INTRODUCTION

Stunting is a key issue for adolescents with perinatally acquired HIV (APH) that needs to be better understood. As part of the IeDEA multiregional consortium, we described growth evolution during adolescence for APH on antiretroviral therapy (ART).

METHODS

We included data from sub-Saharan Africa, the Asia-Pacific, and the Caribbean, Central and South America regions collected between 2003 and 2016. Adolescents on ART, reporting perinatally acquired infection or entering HIV care before 10 years of age, with at least one height measurement between 10 and 16 years of age, and followed in care until at least 14 years of age were included. Characteristics at ART initiation and at 10 years of age were compared by sex. Correlates of growth defined by height-for-age z-scores (HAZ) between ages 10 and 19 years were studied separately for males and females, using linear mixed models.

RESULTS

Overall, 8737 APH were included, with 46% from Southern Africa. Median age at ART initiation was 8.1 years (interquartile range (IQR) 6.1 to 9.6), 50% were females, and 41% were stunted (HAZ<-2 SD) at ART initiation. Males and females did not differ by age and stunting at ART initiation, CD4 count over time or retention in care. At 10 years of age, 34% of males were stunted versus 39% of females (p < 0.001). Females had better subsequent growth, resulting in a higher prevalence of stunting for males compared to females by age 15 (48% vs. 25%) and 18 years (31% vs. 15%). In linear mixed models, older age at ART initiation and low CD4 count were associated with poor growth over time (p < 0.001). Those stunted at 10 years of age or at ART initiation had the greatest growth improvement during adolescence.

CONCLUSIONS

Prevalence of stunting is high among APH worldwide. Substantial sex-based differences in growth evolution during adolescence were observed in this global cohort, which were not explained by differences in age of access to HIV care, degree of immunosuppression or region. Other factors influencing growth differences in APH, such as differences in pubertal development, should be better documented, to guide further research and inform interventions to optimize growth and health outcomes among APH.

Height and timing of growth spurt during puberty in young people living with vertically acquired HIV in Europe and Thailand

The aim of this study was to describe growth during puberty in young people with vertically acquired HIV.

Impact of antiretroviral treatment on height evolution of HIV infected children

BACKGROUND

Antiretroviral treatment (ART) has been shown to have a beneficial effect on the weight evolution but its effect on height remains unclear. We described patterns of height evolution and identified predictors of catch-up growth in HIV-infected children on ART.

METHODS

To describe the height evolution from birth to adulthood, we developed a nonlinear mixed effect model using data from perinatally HIV-infected children who initiated ART from 1999 to 2013 in a prospective cohort study in Thailand. The main covariates of interest were: sex, ART regimen (dual nucleoside reverse-transcriptase inhibitor, non-nucleoside reverse transcriptase inhibitor (NNRTI)-, or protease inhibitor (PI)-based), baseline CD4 percentage, HIV-RNA load and CDC HIV Classification stage and occurrence of AIDS-defining events.

RESULTS

A total 477 children (43% boys) contributed 18,596 height measurements over a median duration of 6.3 years on ART (interquartile range, 3.0 to 8.3). At ART initiation, median age was 6.2 years (1.8 to 9.6), 16% of children were underweight (weight-for-age z-score < - 2), 49% presented stunting (height-for-age z-score < - 2), and 7% wasting (weight-for-height z-score < - 2). The most frequent regimen at ART initiation was NNRTI-based (79%). A model with 4 components, birth length and 3 exponential functions of age accounting for the 3 growth phases was developed and show that the height-growth velocity was inversely associated with the age at ART initiation, the adult height was significantly lower in those who had experienced at least one AIDS-defining event while, as expected, the model found that adult height in females was lower than in males. Age at ART initiation, type of ART regimen, CDC stage, CD4 percentages, and HIV-RNA load were not associated with the final height.

CONCLUSIONS

The younger the children at ART initiation, the greater the effect on height-growth velocity, supporting the World Health Organization's recommendation to start ART as early as possible. However, final adult height was not linked to the age at ART initiation.

Growth in the first 5 years after antiretroviral therapy initiation among HIV-infected children in the IeDEA West African Pediatric Cohort

OBJECTIVE

To describe growth evolution and its correlates in the first 5 years of antiretroviral therapy (ART) initiation among HIV-infected children followed up in West Africa.

METHODS

All HIV-infected children younger than 10 years followed in the IeDEA pWADA cohort while initiating ART, with at least one anthropometric measurement within the first 5 years of treatment were included in the study. Growth was described according to the WHO child growth standards, using Weight-for-age Z-score (WAZ), Height-for-age Z-score (HAZ) and Weight-for-Height/BMI-for-age Z-score (WHZ/BAZ). Growth evolution and its correlates, measured at ART initiation, were modelled in individual linear mixed models for each anthropometric indicator, with a spline term added at the 12-, 24- and 9-month time point for WAZ, HAZ and WHZ/BAZ, respectively.

RESULTS

Among the 4156 children selected (45% girls, median age at ART initiation 3.9 years [IQR interquartile range 1.9-6.6], and overall 68% malnourished at ART initiation), important gains were observed in the first 12, 24 and 9 months on ART for WAZ, HAZ and WHZ/BAZ, respectively. Correlates at ART initiation of a better growth evolution overtime were early age (<2 years of age), severe immunodeficiency for age, and severity of malnutrition.

CONCLUSIONS

Growth evolution is particularly strong within the first 2 years on ART but slows down after this period. Weight and height gains help to recover from pre-ART growth deficiency but are insufficient for the most severely malnourished. The first year on ART could be the best period for nutritional interventions to optimize growth among HIV-infected children in the long-term.

Influence of the antiretroviral therapy on the growth pattern of children and adolescents living with HIV/AIDS

OBJECTIVE

Weight and height growth impairment is one of the most frequent manifestations in HIV-infected children and may be the first sign of disease, being considered a marker of disease progression and an independent risk factor for death. The aim of this review is to evaluate the influence of antiretroviral therapy on the growth pattern of children and adolescents living with HIV/AIDS.

SOURCE OF DATA

A non-systematic review was carried out in the PubMed database, with the terms "HIV", "Weight and height growth", "ART" and "children". The most relevant publications were selected.

DATA SYNTHESIS

Antiretroviral therapy has significantly reduced morbidity and mortality in HIV-infected children and is clearly associated with recovery of weight and height-for-age Z-scores, especially when started early, in the asymptomatic child still without weight-height impairment. Therapeutic strategies involving the GH/IGF-1 axis, especially for children with growth impairment, are still being studied.

CONCLUSIONS

HIV-infected children show early weight-height impairment; antiretroviral therapy improves the anthropometric profile of these children.