Trends in hospitalizations among children and young adults with perinatally acquired HIV

Hospitalisation rates for youth living with perinatally acquired HIV in England

INTRODUCTION

Complex challenges amongst ageing cohorts of adolescents and adults living with perinatally acquired HIV (PaHIV) may impact on hospitalisation. We report hospitalisation rates and explored predictive factors for hospitalisation in adolescents and adults (10-35 years) living with PaHIV in England.

METHOD

Retrospective observational cohort study over a three-year period 2016-2019. Data collected included cause and duration of hospitalisation, HIV viral load and CD4 lymphocyte count. The primary outcome was overnight hospitalisation. Patients exited at study end/ transfer of care (TOC)/ loss to follow up (LTFU) or death. Maternity/hospital admissions at other centres were excluded. Admission rates per 100 person-years (95% CI) were calculated by age group. Negative binomial regression with generalized estimating equations was performed.

RESULTS

255 patients contributed 689 person-years of follow up. 56% were female and 83% were of a Black, Black British, Caribbean or African ethnicity. At baseline, the median age was 19 years (IQR 16-22). 36 individuals experienced a total of 62 admissions which resulted in 558 overnight stays (median stay was 5 nights). One person died (lymphoma), six had TOC and one was LTFU by the end of the three-year study period. Crude incidence of admission for the whole cohort was 9.0 per 100 PY (6.9-11.6). The respective crude incidence rates were 1.5 PY (0.0-8.2) in those aged 10-14 years and 3.5 PY (1.5-7.0) in the 15-19-year-olds. In those aged 20-24 years it was 14.5 PY (10.1-20.2) and in those >25 years the crude incidence rate was 11.7 PY (6.9-18.5). Factors significantly associated with admission were a CD4 lymphocyte count <200 cells/uL, adjusted IRR 4.0 (1.8-8.8) and a history of a CDC-C diagnosis, adjusted IRR 2.9 (1.6-5.3). 89% admissions were HIV-related: 45% new/current CDC-C diagnoses, 76% due to infection.

CONCLUSIONS

Hospitalisation rates were four-fold higher in adults (>20 years of age) compared to adolescents (10-19-year-olds). The continuing challenges experienced by PaHIV youth require enhanced multidisciplinary support throughout adulthood.

Factors Associated with Morbidity and Mortality Among Sexually Active Asian Adolescents and Young Adults with Perinatally Acquired HIV

We assessed morbidity and mortality among Thai and Vietnamese adolescents and young adults with perinatally acquired human immunodeficiency virus (PHIV) compared with matched HIV-negative peers, 12-24 years of age. Data on serious adverse events (SAEs) were prospectively collected between 2013 and 2018 according to U.S. NIH Division of AIDS criteria. Of 288 youth, 142 had PHIV and 146 were HIV negative. At enrollment, the overall median age was 19 (interquartile range [IQR] 17-20) years, 67% were female, and 95% were Thai. Almost all PHIV youth (99%) were receiving antiretroviral therapy; 50% self-reported adherence ≥95%. Median CD4 was 579 (IQR 404-800) cells/mm3, and 24% had HIV-RNA ≥1,000 copies/mL. During follow-up, 31 (22%) PHIV youth and 9 (6%) HIV-negative youth had at least one SAE. The overall crude SAE rate was 4.66 (3.42-6.35) per 100 person-years (PY); 7.22 (5.08-10.26) per 100 PY among youth with PHIV and 2.10 (1.09-4.03) per 100 PY in HIV-negative youth (p < .001). All seven deaths that occurred were among those with PHIV and primarily due to opportunistic infections (e.g., pneumocystis pneumonia, tuberculous meningitis). In multivariate analyses, having PHIV, being <20 years of age, and having anogenital high-risk human papillomavirus (HPV) infection with types 16 and/or 18 increased risk of SAEs. Among PHIV youth, CD4 count <350 cells/mm3, HIV-RNA ≥1,000 copies/mL, advanced WHO stages, and having anogenital HPV 16 and/or 18 infection predicted higher incidence of SAEs; no prior use of alcohol was protective. These data emphasize the need for tailored interventions for adolescents with PHIV to prevent long-term morbidity and mortality.

Hospitalization among infants who initiate antiretroviral therapy before 3 months of age

INTRODUCTION

Studies examining hospitalization among infants with HIV in resource-limited settings, in the context of early infant diagnosis and early antiretroviral therapy (ART) initiation, are limited.

METHODS

We used routinely collected data on infants who initiated ART aged <3 months (Western Cape province, South Africa; 2013-2017) to describe hospitalization from birth until 12 months post-ART initiation. Record reviews were additionally performed at three tertiary-level facilities. We used mixed-effects Poisson regression to examine factors associated with hospitalization.

RESULTS

Among 840 infants, 579 (69%) were hospitalized; 36% had >1 hospitalization. Median age at ART initiation decreased from 57 days (interquartile range [IQR] 22-74; 2013-2015) to 19 days (IQR 5-54; 2016-2017). Early neonatal hospitalization (age <7 days) occurred in 271 infants (32%) and represented 24% of hospitalizations (272/1131). Overall, 443 infants (53%) were hospitalized at age ≥7 days, including 13% with hospitalizations pre-ART initiation, 15% pre and post-ART initiation and 25% post-ART initiation. Excluding early neonatal hospitalizations, initiating ART at older age vs. age <1 week was associated with higher hospitalization rates: adjusted incidence rate ratios (95% confidence interval) were 1.86 (1.31-2.64); 2.31 (1.62-3.29) and 2.47 (1.76-3.46) if ART initiation age was 1-4 weeks; 5-8 weeks and 9-12 weeks respectively. Among infants whose hospital records were reviewed, reasons for early neonatal hospitalizations mostly related to prematurity or low birthweight (n = 46/60; 77%) whereas hospitalizations at age ≥7 days were mostly due to infections (n = 206/243; 85%).

CONCLUSIONS

Earlier ART initiation is associated with lower hospitalization rates. High hospitalization rates, despite initiation age <3 months, is concerning.

Independent Risk Factors for Deaths due to AIDS in Chongqing, China: Does Age Matter?

Background: People living with HIV (PLWH) are aging worldwide, and different management strategies may be required for older and younger PLWH. However, demographic characteristics, illness distribution, mortality, and independent risk factors in the PLWH population in China are not yet fully understood, especially in patients aged 50 years or older.

Methods: We conducted a retrospective analysis of 4445 HIV-positive Chinese inpatients in Chongqing, China.

Results: The mortality rate in patients 50 years or older (the older group) was significantly higher than that in those under 50 years (the younger group) (p < 0.001). In the younger group, independent risk factors for death included: nadir CD4+ T-cell counts <200 cells/μL, not owning medical healthcare insurance, not being on cART, injection drug use, and having one of the following comorbidities: Pneumocystis pneumonia, cryptococcal meningitis, AIDS malignancy, non-AIDS malignancy, and kidney disease. In the older group, independent predictors of death included: being urban residents, nadir CD4+ T-cell counts <200 cells/μL, not being on cART, and having comorbidities such as Pneumocystis pneumonia, hepatitis C, talaromycosis, non-AIDS malignancy, and kidney disease.

Conclusions: Demographic characteristics, illness distribution, mortality, and independent risk factors for death in HIV-positive patients differ between the older group and the younger group, indicating that a changing suite of medical and allied support services may be required the for management of older PLWH.

Recruitment of Youth Living With HIV to Optimize Adherence and Virologic Suppression: Testing the Design of Technology-Based Community Health Nursing to Improve Antiretroviral Therapy (ART) Clinical Trials

Background

Despite advances in HIV diagnosis and treatment, adolescents and young adults 12-25 years old have high HIV incidence, poor engagement and retention in treatment, and low rates of adherence and virologic suppression when compared to their older counterparts. HIV has emerged as a chronic disease for which antiretroviral therapy (ART) adherence is critical for virologic suppression and long-term survival. Virologic suppression has been elusive for many youth with HIV (YHIV). Novel strategies designed to facilitate health care systems’ support for YHIV between medical visits are essential for improving ART adherence, virologic suppression, and long-term survival.

Objective

The aim of this study is to compare the effectiveness of a technology-enhanced community health nursing intervention (TECH2CHECK) to a standard of care (SOC) control group for improving ART adherence and subsequent viral suppression using a randomized trial design. The objectives are to assess the feasibility, acceptability, and cost-effectiveness of TECH2CHECK as compared to SOC for management of HIV in the outpatient setting and to examine the sustainability of self-care behavior, adherence, and virologic suppression among youth following the intervention period.

Methods

We will recruit 120 adherence-challenged YHIV being followed at clinics specializing in HIV care in the Baltimore-Washington metropolitan area and in Jacksonville. Eligible participants complete an audio, computer-assisted self-interview and are randomized to either TECH2CHECK intervention or the SOC (60 participants in each arm). The primary outcome of interest is virologic suppression (viral load <20 copies/mL) and improved treatment adherence. Participants in the intervention arm receive community health nursing visits at 2 weeks, 6 weeks, 10 weeks, 14 weeks, and 26 weeks. The intervention arm also receives SMS messaging comprising daily adherence and appointment reminders and positive reinforcement for medication adherence daily for 2 weeks, on alternate days for 2 weeks, thrice weekly for 1 month, weekly for 3 months, and every 2 weeks for the rest of the study duration. The control group receives appointment reminders and SOC per clinic protocol. Exploratory analysis will be conducted to determine differences in medication adherence and virologic suppression in the 2 arms and to assess cost-effectiveness and study feasibility and acceptability.

Results

In the first 23 months of the study (July 2018-April 2020), 56 (55%) of 102 eligible patients were enrolled and randomized. At present, participating youths are primarily African American (53/56, 95%), male (37/56, 66%), and ≥18 years old (53/56, 95%). Follow-up study visits, as required per the protocol, have been completed by 77% (43/56), 94% (45/48), 95% (37/39), 96% (24/25), and 100% (10/10) of participants at the 1-month, 3-month, 6-month, 12-month, and 18-month follow-ups, respectively.

Conclusions

Preliminary accrual and retention data suggest that TECH2CHECK is feasible and acceptable.

Trial Registration

ClinicalTrials.gov NCT03600103 https://clinicaltrials.gov/ct2/show/NCT03600103

International Registered Report Identifier (IRRID)

DERR1-10.2196/23480

Higher Acuity Resource Utilization With Older Age and Poorer HIV Control in Adolescents and Young Adults in the HIV Research Network

BACKGROUND

Adolescents and young adults (AYA) with HIV experience poorer health outcomes compared with adults. To improve care for AYA with HIV, information about patterns of costly health care resource utilization is needed.

METHODS

Among 13-30 year olds in the US HIV Research Network, we stratified outpatient visits, emergency department (ED) visits, and inpatient days/person-year (PY) by HIV acquisition model [perinatal (PHIVY) and nonperinatal (NPHIVY)], age (13-17, 18-23, and 24-30 years), CD4 strata (<200, 200-499, and ≥500 cells/µL), and viral load (VL) suppression (<, ≥400 copies/mL [c/mL]) combined with antiretroviral (ARV) use.

RESULTS

Among 4540 AYA (PHIVY: 15%; NPHIVY: 85%), mean follow-up was 2.8 years. Among PHIVY, most person-time (PT) was spent between ages 13 and 23 years (13-17 years: 43%; 18-23 years: 45%), CD4 ≥500/µL (61%), and VL <400 c/mL (69%). Among NPHIVY, most PT was spent between ages 24 and 30 years (56%), with CD4 ≥500/µL (54%), and with VL <400 c/mL (67%). PT spent while prescribed ARVs and with VL ≥400 c/mL was 29% (PHIVY) and 24% (NPHIVY). For PHIVY and NPHIVY, outpatient visit rates were higher at younger ages (13-17 years and 18-23 years), lower CD4 (<200 and 200-499/µL), and among those prescribed ARVs. Rates of ED visits and inpatient days were higher during PT spent at older ages (18-23 years and 24-30 years), lower CD4 (<200 and 200-499/µL), and VL ≥400 c/mL. Utilization was higher among PHIVY than NPHIVY (outpatient: 12.1 vs. 6.0/PY; ED: 0.4 vs. 0.3/PY; inpatient: 1.5 vs. 0.8/PY).

CONCLUSIONS

More ED visits and inpatient days were observed during time spent at older ages, lower CD4 count, and VL ≥400 c/mL. Interventions to improve virologic suppression and immune response may improve outcomes, and thus decrease costly resource utilization, for AYA with HIV.

Long-term outcomes in perinatally HIV-infected adolescents and young adults on antiretroviral therapy: a review of South African and global literature

Paediatric antiretroviral programmes have been implemented globally for more than a decade, yet information on long-term treatment outcomes in perinatally HIV-infected adolescents is limited. Published literature on long-term treatment outcomes was reviewed, including virologic, immunologic and growth outcomes, as well as drug resistance and factors associated with drug resistance. Outcomes were compared between high-income countries and low- and middle-income countries (LMIC), with additional focus on South Africa, the country with the biggest HIV epidemic in the world and the largest treatment programme. Treatment outcomes varied but viral suppression results globally were generally concerning. No studies from LMIC have reported on outcomes after >10 years follow-up, demonstrating that further studies are needed.

Disease- and Treatment-related Morbidity in Adolescents With Perinatal HIV Infection in Asia

BACKGROUND

Perinatally HIV-infected adolescents (PHIVA) are exposed to a chronic systemic infection and long-term antiretroviral therapy (ART), leaving them susceptible to morbidities associated with inflammation, immunodeficiency and drug toxicity.

METHODS

Data collected 2001 to 2016 from PHIVA 10-19 years of age within a regional Asian cohort were analyzed using competing risk time-to-event and Poisson regression analyses to describe the nature and incidence of morbidity events and hospitalizations and identify factors associated with disease-related, treatment-related and overall morbidity. Morbidity was defined according to World Health Organization clinical staging criteria and U.S. National Institutes of Health Division of AIDS criteria.

RESULTS

A total 3,448 PHIVA contributed 17,778 person-years. Median age at HIV diagnosis was 5.5 years, and ART initiation was 6.9 years. There were 2,562 morbidity events and 307 hospitalizations. Cumulative incidence for any morbidity was 51.7%, and hospitalization was 10.0%. Early adolescence was dominated by disease-related infectious morbidity, with a trend toward noninfectious and treatment-related morbidity in later adolescence. Higher overall morbidity rates were associated with a CD4 count <350 cells/µL, HIV viral load ≥10,000 copies/mL and experiencing prior morbidity at age <10 years. Lower overall morbidity rates were found for those 15-19 years of age compared with 10-14 years and those who initiated ART at age 5-9 years compared with <5 or ≥10 years.

CONCLUSIONS

Half of our PHIVA cohort experienced a morbidity event, with a trend from disease-related infectious events to treatment-related and noninfectious events as PHIVA age. ART initiation to prevent immune system damage, optimize virologic control and minimize childhood morbidity are key to limiting adolescent morbidity.

Trends in Diagnoses Among Hospitalizations of HIV-infected Children and Adolescents in the United States: 2003-2012

OBJECTIVE

Using data from 2003-2012, we updated a previous analysis of trends in hospitalizations of HIV-infected children and adolescents in the United States.

METHODS

We used data from the Kids´ Inpatient Database of the Healthcare Cost and Utilization Project to derive nationally representative estimates of the number of hospitalizations and the rates per 1000 hospitalizations of select discharge diagnoses and procedures in 2003, 2006, 2009 and 2012 among HIV-infected and HIV-uninfected children and adolescents ≤18 years, excluding hospitalizations for conditions related to pregnancy/delivery and neonatal diagnoses. We also examined trends in the prevalence of select discharge diagnoses and procedures using multivariable logistic regression models.

RESULTS

During 2003-2012, the number of hospitalizations for HIV-infected children declined 58% versus 17% for uninfected, but the odds of having discharge codes for most of the diagnoses and procedures studied, including death during hospitalization, remained higher among HIV-infected compared with uninfected children. Among HIV-infected children, the prevalence of discharge diagnoses for pneumonia, pneumococcal disease and varicella/herpes zoster infections and odds of death during hospitalization decreased over time, while bacterial infections/sepsis and methicillin-resistant Staphylococcus aureus increased. Among HIV-uninfected children, there was no increase in diagnoses of bacterial infection/sepsis, but otherwise trends were similar.

CONCLUSIONS

The number of hospitalizations for HIV-infected children declined from 2003 to 2012. The decreased prevalence of several discharge diagnoses and lower risk of death during hospitalization likely reflect improvements in HIV therapies and increased uptake of other preventive strategies. However, the increasing prevalence of discharge diagnoses for bacterial infections/sepsis warrants further attention and monitoring.

Association of Risk of Viremia, Immunosuppression, Serious Clinical Events, and Mortality With Increasing Age in Perinatally Human Immunodeficiency Virus-Infected Youth

IMPORTANCE

As perinatally human immunodeficiency virus-infected youth (PHIVY) in the United States grow older and more treatment experienced, clinicians need updated information about the association of age, CD4 cell count, viral load (VL), and antiretroviral (ARV) drug use with risk of opportunistic infections, key clinical events, and mortality to understand patient risks and improve care.

OBJECTIVE

To examine the incidence or first occurrence during follow-up of key clinical events (including Centers for Disease Control and Prevention stage B [CDC-B] and stage C [CDC-C] events) and mortality among PHIVY stratified by age, CD4 cell count, and VL and ARV status.

DESIGN, SETTING, AND PARTICIPANTS

Combining data from the Pediatric HIV/AIDS Cohort Study (PHACS) Adolescent Master Protocol and International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1074 multicenter cohort studies (March 2007 through April 2015), we estimated event rates during person-time spent in key strata of age (7-12, 13-17, and 18-30 years), CD4 cell count (<200, 200-499, and ≥500/μL), and a combined measure of VL and ARV status (VL <400 or ≥400 copies/mL; ARV therapy or no ARV therapy). A total of 1562 participants in the PHACS Adolescent Master Protocol and IMPAACT P1074 were eligible, and 1446 PHIVY from 41 ambulatory sites in the 12 US states, including Puerto Rico were enrolled. The dates of analysis were March 2015 through January 2017.

MAIN OUTCOMES AND MEASURES

Clinical event rates stratified by person-time in age, CD4 cell count, and VL and ARV categories.

RESULTS

A total of 1446 PHIVY participated in the study (mean [SD] age, 14.6 [4.6] years; 759 female [52.5%]; 953 black [65.9%]). During a mean (SD) follow-up of 4.9 (1.3) years, higher incidences of CDC-B events, CDC-C events, and mortality were observed as participants aged. Older PHIVY (aged 13-17 and 18-30 years) spent more time with a VL of 400 copies/mL or more and with a CD4 cell count of less than 200/µL compared with 7- to 12-year-old participants (30% and 44% vs 22% of person-time with a VL≥400 copies/mL; 5% and 18% vs 2% of person-time with CD4 cell count <200/µL; P < .001 for each comparison). We observed higher rates of CDC-B events, CDC-C events, bacterial infections, and mortality at lower CD4 cell counts, as expected. The mortality rate among older PHIVY was 6 to 12 times that among the general US population. Higher rates of sexually transmitted infections were also observed at lower CD4 cell counts after adjusting for age.

CONCLUSIONS AND RELEVANCE

Older PHIVY were at increased risk of viremia, immunosuppression, CDC-B events, CDC-C events, and mortality. Interventions to improve ARV therapy adherence and optimize models of care for PHIVY as they age are urgently needed to improve long-term outcomes among PHIVY.

Predictors of Hospitalization among Children on ART in Ethiopia: a Cohort study

BACKGROUND

Substantial progress has been made in the management of pediatric HIV infection in Ethiopia with the implementation of mother-to-child-prevention programs. Since the introduction of HAART in 2005, mortality among HIV-infected children has reduced while the rate of hospitalization was expected to rise. The purpose of this study, therefore, was to assess predictors of hospitalization in children on ART in seven university referral hospitals in Ethiopia.

METHODS

A prospective cohort study design was employed on children age 0-18 years as part of a multisite observational study. ART-experienced eligible and ART-naïve children with HIV/AIDS were enrolled into the Advanced Clinical Monitoring (ACM) till December 31, 2012 were included. From the database, information on hospitalization and other independent variables were extracted. Analysis was done using both SPSS for Windows version 16.0 and STATA. Descriptive analyses and modeling was done using logistic regression.

RESULTS

Of the 405 children on ART (174 experienced, 231 naive), 86 (20.7%) were hospitalized for various reasons; two children were excluded since they were hospitalized for unrelated conditions (appendicitis and burn). Fifty one (60.7%) of the eighty four admitted children were hospitalized in the first six months of ART initiation. Of the independent variables, only the presence of opportunistic infections and duration on ART were significantly associated with hospitalization both on bi-variable and multivariable analyses (P-value <0.05). As the duration on ART increased by one month, the risk of hospitalization decreased by 5.4%, which is statistically significant (P < 0.001). Whereas the incidence (number) of OI's increased by one, the risk of being hospitalized increased by 35.2% (P = 0.002). Of the individual opportunistic infections, pneumonia was found to be the only predictor of hospitalization (P-value = 0.002).

CONCLUSION

This study showed that nearly two-third of the hospitalization was within 6 months of initiation of ART; and presence of OI and duration on ART were the only predictors of hospitalization.

The Challenge of and Opportunities for Transitioning and Maintaining a Continuum of Care Among Adolescents and Young Adults Living with HIV in Resource Limited Settings

An unprecedented number of youth living with HIV (YLHIV) are aging into adolescence and young adulthood, increasing concerns about the possibility of these youth being lost in the transition from supported care (sometimes in pediatric settings) to more independent healthcare settings and perhaps furthering the emerging disparities in outcomes (e.g., higher nonadherence to treatment, increased morbidity and mortality). In resource-rich settings where there is likely greater recognition of adolescent cognitive and developmental challenges, transitioning YLHIV to adult healthcare has emerged as a major challenge. In resource limited settings (RLS), where the burden of HIV is significant and healthcare resources often stretched, the challenge to move toward healthcare independence and maintain a fluid continuum of care for YLHIV may be the greatest. We review key issues in transitioning YLHIV in RLS, highlighting steps in the transition process, examining evidence where available, and discussing challenges and opportunities to understanding and optimizing outcomes.