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Seng R, Frange P, Faye A, Dollfus C, le Chenadec J, Boufassa F, Essat A, Goetghebuer T, Arezes E, Avettand-Fènoël V, Bigna JJ, Blanche S, Goujard C, Meyer L, Warszawski J, Viard JP. Immunovirological status in people with perinatal and adult-acquired HIV-1 infection: a multi-cohort analysis from France. THE LANCET REGIONAL HEALTH. EUROPE 2024; 40:100885. [PMID: 38576825 PMCID: PMC10993179 DOI: 10.1016/j.lanepe.2024.100885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 02/16/2024] [Accepted: 02/26/2024] [Indexed: 04/06/2024]
Abstract
Background No study has compared the virological and immunological status of young people with perinatally-acquired HIV infection (P-HIV) with that of people with HIV adulthood (A-HIV) having a similar duration of infection. Methods 5 French cohorts of P-HIV and A-HIV patients with a known date of HIV-infection and receiving antiretroviral treatment (ART), were used to compare the following proportions of: virological failure (VF) defined as plasma HIV RNA ≥ 50 copies/mL, CD4 cell percentages and CD4:CD8 ratios, at the time of the most recent visit since 2012. The analysis was stratified on time since infection, and multivariate models were adjusted for demographics and treatment history. Findings 310 P-HIV were compared to 1515 A-HIV (median current ages 20.9 [IQR:14.4-25.5] and 45.9 [IQR:37.9-53.5] respectively). VF at the time of the most recent evaluation was significantly higher among P-HIV (22.6%, 69/306) than A-HIV (3.3%, 50/1514); p ≤ 0.0001. The risk of VF was particularly high among the youngest children (2-5 years), adolescents (13-17 years) and young adults (18-24 years), compared to A-HIV with a similar duration of infection: adjusted Odds-Ratio (aOR) 7.0 [95% CI: 1.7; 30.0], 11.4 [4.2; 31.2] and 3.3 [1.0; 10.8] respectively. The level of CD4 cell percentages did not differ between P-HIV and A-HIV. P-HIV aged 6-12 and 13-17 were more likely than A-HIV to have a CD4:CD8 ratio ≥ 1: 84.1% vs. 58.8% (aOR = 3.5 [1.5; 8.3]), and 60.9% vs. 54.7% (aOR = 1.9 [0.9; 4.2]) respectively. Interpretation P-HIV were at a higher risk of VF than A-HIV with a similar duration of infection, even after adjusting for treatment history, whereas they were not at a higher risk of immunological impairment. Exposure to viral replication among young patients living with HIV since birth or a very early age, probably because of lower adherence, could have an impact on health, raising major concerns about the selection of resistance mutations and the risk of HIV transmission. Funding Inserm - ANRS MIE.
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Affiliation(s)
- Rémonie Seng
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Epidemiology and Public Health Department, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Pierre Frange
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Clinical Microbiology, Necker-Enfants Malades Hospital, Paris, France
- URP 7328 FETUS, Université Paris Cité, Paris, France
| | - Albert Faye
- Assistance Publique-Hôpitaux de Paris (AP-HP), General Pediatrics and Infectious Diseases, Robert Debré Hospital, Paris, France
- Université Paris Cité, Paris, France
| | - Catherine Dollfus
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pediatric Hematology and Oncology Department, Trousseau Hospital, Paris, France
| | | | - Faroudy Boufassa
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Asma Essat
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Tessa Goetghebuer
- Pediatric Department, Saint-Pierre Hospital, Brussels, Belgium
- Université Libre de Bruxelles, Belgium
| | - Elisa Arezes
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Véronique Avettand-Fènoël
- Université d’Orléans, CHU Orléans, Laboratoire de Virologie, Orléans, France
- Université Paris Cité, INSERM U1016, CNRS UMR8104, Institut Cochin, Paris, France
| | - Jean-Joël Bigna
- Department of Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Stéphane Blanche
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paediatric Immunology and Hematology Unit, Necker Enfants Malades Hospital, Paris, France
| | - Cécile Goujard
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Internal Medicine and Clinical Immunology Department, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Laurence Meyer
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Epidemiology and Public Health Department, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Josiane Warszawski
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Epidemiology and Public Health Department, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Jean-Paul Viard
- Assistance Publique-Hôpitaux de Paris (AP-HP), Immunology-Infectious Diseases Unit, Hôtel-Dieu Hospital, Université Paris Cité, Paris, France
| | - COVERTE
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Epidemiology and Public Health Department, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Clinical Microbiology, Necker-Enfants Malades Hospital, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), General Pediatrics and Infectious Diseases, Robert Debré Hospital, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pediatric Hematology and Oncology Department, Trousseau Hospital, Paris, France
- Pediatric Department, Saint-Pierre Hospital, Brussels, Belgium
- Université d’Orléans, CHU Orléans, Laboratoire de Virologie, Orléans, France
- Université Paris Cité, INSERM U1016, CNRS UMR8104, Institut Cochin, Paris, France
- Department of Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paediatric Immunology and Hematology Unit, Necker Enfants Malades Hospital, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Internal Medicine and Clinical Immunology Department, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Immunology-Infectious Diseases Unit, Hôtel-Dieu Hospital, Université Paris Cité, Paris, France
- Université Paris Cité, Paris, France
- Université Libre de Bruxelles, Belgium
- URP 7328 FETUS, Université Paris Cité, Paris, France
| | - PRIMO
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Epidemiology and Public Health Department, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Clinical Microbiology, Necker-Enfants Malades Hospital, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), General Pediatrics and Infectious Diseases, Robert Debré Hospital, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pediatric Hematology and Oncology Department, Trousseau Hospital, Paris, France
- Pediatric Department, Saint-Pierre Hospital, Brussels, Belgium
- Université d’Orléans, CHU Orléans, Laboratoire de Virologie, Orléans, France
- Université Paris Cité, INSERM U1016, CNRS UMR8104, Institut Cochin, Paris, France
- Department of Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paediatric Immunology and Hematology Unit, Necker Enfants Malades Hospital, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Internal Medicine and Clinical Immunology Department, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Immunology-Infectious Diseases Unit, Hôtel-Dieu Hospital, Université Paris Cité, Paris, France
- Université Paris Cité, Paris, France
- Université Libre de Bruxelles, Belgium
- URP 7328 FETUS, Université Paris Cité, Paris, France
| | - SEROPRI
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Epidemiology and Public Health Department, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Clinical Microbiology, Necker-Enfants Malades Hospital, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), General Pediatrics and Infectious Diseases, Robert Debré Hospital, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pediatric Hematology and Oncology Department, Trousseau Hospital, Paris, France
- Pediatric Department, Saint-Pierre Hospital, Brussels, Belgium
- Université d’Orléans, CHU Orléans, Laboratoire de Virologie, Orléans, France
- Université Paris Cité, INSERM U1016, CNRS UMR8104, Institut Cochin, Paris, France
- Department of Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paediatric Immunology and Hematology Unit, Necker Enfants Malades Hospital, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Internal Medicine and Clinical Immunology Department, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Immunology-Infectious Diseases Unit, Hôtel-Dieu Hospital, Université Paris Cité, Paris, France
- Université Paris Cité, Paris, France
- Université Libre de Bruxelles, Belgium
- URP 7328 FETUS, Université Paris Cité, Paris, France
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Rate of virological failure and HIV-1 drug resistance among HIV-infected adolescents in routine follow-up on health facilities in Cameroon. PLoS One 2022; 17:e0276730. [PMID: 36288365 PMCID: PMC9604952 DOI: 10.1371/journal.pone.0276730] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Abstract
The objective of this study was to determine the rates of virological failure (VF) and HIV drug resistance (HIVDR) amongst adolescents on antiretroviral Therapy (ART). A retrospectively designed study was conducted in 10 healthcare centers for adolescents living with HIV (ALHIV) in the two main cities of Cameroon (Yaoundé and Douala), from November 2018 to May 2019. Sociodemographic, clinical, therapeutic and laboratory parameters were collected from medical records. All enrolled ALHIV had viral load (VL) measurements following the national guidelines. All patients with a VL ≥ 1000 copies/ml were called to perform genotyping tests. The chi-square test was used to determine the factors associated with VF. Out of the 1316 medical records of ALHIV, we included 1083 ALHIV having a VL result. Among them, 276 (25.5%) were experiencing VF, and VF was significantly higher in ALHIV with suboptimal adherence (p<0.001), older adolescents (p<0.05), those who lived outside the city where they were receiving ART (p<0.006), severely immunocompromised (p<0.01) and started ART at infancy (p<0.02). Among the 45/276 (16.3%) participants with an available genotyping resistance testing (GRT) result, the overall rate of HIVDR was 93.3% (42/45). The most common mutations were K103N (n = 21/42, 52.3%) resulting in high-level resistance to Efavirenz and Nevirapine, followed by M184V (n = 20/42, 47.6%) and thymidine analog mutations (n = 15/42, 35.7%) associated with high-level resistance to Lamivudine and Zidovudine respectively. The high rate of VF and HIVDR among ALHIV regularly followed in health facilities in Cameroon highlights the need to develop interventions adapted to an adolescent-centered approach to preserve future ART options.
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3
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Mwangi A, van Wyk B. Factors Associated with Viral Suppression Among Adolescents on Antiretroviral Therapy in Homa Bay County, Kenya: A Retrospective Cross-Sectional Study. HIV AIDS (Auckl) 2021; 13:1111-1118. [PMID: 34992469 PMCID: PMC8713714 DOI: 10.2147/hiv.s345731] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background Despite the success in initiating adolescents living with HIV on antiretroviral therapy (ART), questions remain about factors affecting viral suppression. In Kenya, only 63% of adolescents (aged 10–19 years) on ART had achieved viral suppression in 2016. We investigated factors associated with viral suppression among adolescents initiated on ART before November 30, 2017 in Homa Bay County, Kenya. Methods A retrospective cross-sectional analysis of 908 adolescents registered on ART for at least 6 months and with at least one documented viral load in the last 12 months, in six health facilities in Homa Bay County was conducted. Data were extracted from the electronic medical records and exported into an excel spreadsheet. Bivariate and multivariate logistic regression analyses were conducted to identify factors associated with viral suppression and adjust for confounding, using Stata 12.0. Results Out of all participants, 80% (726) had achieved viral suppression (<1,000 copies of viral RNA/mL of blood at latest viral load count). After adjusting for other covariates, adolescents with good adherence to ART (AOR=2.3, 95% CI=1.38–3.84) and a most recent CD4 count of above 500 cells/mm3 (AOR=1.87, 95% CI=1.13–3.08), were more likely to be virally suppressed. Adolescents on second line ART treatment (AOR=0.45, 95% CI=0.28–0.73) and having inadequate adherence to ART (AOR=0.26, 95% CI=0.11–63) were less likely to be virally suppressed. Conclusion Viral suppression for adolescents on ART in this study is significantly higher than the national prevalence in 2016 (80% vs 63%), but it is still below the WHO target of 90%. Enhanced adherence support for adolescents on ART should be implemented to improve long-term adherence. Specific interventions are needed to “rescue” adolescents on second-line ART regimens who may have a history of poor adherence.
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Affiliation(s)
- Anne Mwangi
- School of Public Health, University of the Western Cape, Bellville, Western Cape Province, South Africa
| | - Brian van Wyk
- School of Public Health, University of the Western Cape, Bellville, Western Cape Province, South Africa
- Correspondence: Brian van Wyk Tel +27 82 8049055 Email
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4
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Bartlett AW, Sudjaritruk T, Mohamed TJ, Anugulruengkit S, Kumarasamy N, Phongsamart W, Ly PS, Truong KH, Van Nguyen L, Do VC, Ounchanum P, Puthanakit T, Chokephaibulkit K, Lumbiganon P, Kurniati N, Nik Yusoff NK, Wati DK, Sohn AH, Kariminia A. Identification, Management, and Outcomes of Combination Antiretroviral Treatment Failure in Adolescents With Perinatal Human Immunodeficiency Virus Infection in Asia. Clin Infect Dis 2021; 73:e1919-e1926. [PMID: 32589711 PMCID: PMC8492217 DOI: 10.1093/cid/ciaa872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/21/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Combination antiretroviral therapy (cART) failure is a major threat to human immunodeficiency virus (HIV) programs, with implications for individual- and population-level outcomes. Adolescents with perinatally acquired HIV infection (PHIVA) should be a focus for treatment failure given their poorer outcomes compared to children and adults. METHODS Data (2014-2018) from a regional cohort of Asian PHIVA who received at least 6 months of continuous cART were analyzed. Treatment failure was defined according to World Health Organization criteria. Descriptive analyses were used to report treatment failure and subsequent management and evaluate postfailure CD4 count and viral load trends. Kaplan-Meier survival analyses were used to compare the cumulative incidence of death and loss to follow-up (LTFU) by treatment failure status. RESULTS A total 3196 PHIVA were included in the analysis with a median follow-up period of 3.0 years, of whom 230 (7.2%) had experienced 292 treatment failure events (161 virologic, 128 immunologic, 11 clinical) at a rate of 3.78 per 100 person-years. Of the 292 treatment failure events, 31 (10.6%) had a subsequent cART switch within 6 months, which resulted in better immunologic and virologic outcomes compared to those who did not switch cART. The 5-year cumulative incidence of death and LTFU following treatment failure was 18.5% compared to 10.1% without treatment failure. CONCLUSIONS Improved implementation of virologic monitoring is required to realize the benefits of virologic determination of cART failure. There is a need to address issues related to accessibility to subsequent cART regimens, poor adherence limiting scope to switch regimens, and the role of antiretroviral resistance testing.
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Affiliation(s)
- Adam W Bartlett
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Tavitiya Sudjaritruk
- Department of Pediatrics, Faculty of Medicine, and Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Suvaporn Anugulruengkit
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site, VHS-Infectious Diseases Medical Centre, Voluntary Health Services, Chennai, India
| | - Wanatpreeya Phongsamart
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Penh Sun Ly
- National Centre for HIV/AIDS, Dermatology and Sexually Transmitted Diseases, Phnom Penh, Cambodia
| | | | | | - Viet Chau Do
- Children’s Hospital 2, Ho Chi Minh City, Vietnam
| | | | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pagakrong Lumbiganon
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nia Kurniati
- Cipto Mangunkusumo–Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | | | | | - Annette H Sohn
- TREAT Asia, amfAR—the Foundation for AIDS Research, Bangkok, Thailand
| | - Azar Kariminia
- Kirby Institute, University of New South Wales, Sydney, Australia
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5
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Prendergast AJ, Szubert AJ, Pimundu G, Berejena C, Pala P, Shonhai A, Hunter P, Arrigoni FIF, Musiime V, Bwakura-Dangarembizi M, Musoke P, Poulsom H, Kihembo M, Munderi P, Gibb DM, Spyer MJ, Walker AS, Klein N. The impact of viraemia on inflammatory biomarkers and CD4+ cell subpopulations in HIV-infected children in sub-Saharan Africa. AIDS 2021; 35:1537-1548. [PMID: 34270487 PMCID: PMC7611315 DOI: 10.1097/qad.0000000000002916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the impact of virological control on inflammation and cluster of differentiation 4 depletion among HIV-infected children initiating antiretroviral therapy (ART) in sub-Saharan Africa. DESIGN Longitudinal cohort study. METHODS In a sub-study of the ARROW trial (ISRCTN24791884), we measured longitudinal HIV viral loads, inflammatory biomarkers (C-reactive protein, tumour necrosis factor alpha, interleukin 6 (IL-6), soluble CD14) and (Uganda only) whole blood immunophenotype by flow cytometry in 311 Zimbabwean and Ugandan children followed for median 3.5 years on first-line ART. We classified each viral load measurement as consistent suppression, blip/post-blip, persistent low-level viral load or rebound. We used multi-level models to estimate rates of increase or decrease in laboratory markers, and Poisson regression to estimate the incidence of clinical events. RESULTS Overall, 42% children experienced viral blips, but these had no significant impact on immune reconstitution or inflammation. Persistent detectable viraemia occurred in one-third of children and prevented further immune reconstitution, but had little impact on inflammatory biomarkers. Virological rebound to ≥5000 copies/ml was associated with arrested immune reconstitution, rising IL-6 and increased risk of clinical disease progression. CONCLUSIONS As viral load testing becomes more available in sub-Saharan Africa, repeat testing algorithms will be required to identify those with virological rebound, who need switching to prevent disease progression, whilst preventing unnecessary second-line regimen initiation in the majority of children with detectable viraemia who remain at low risk of disease progression.
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Affiliation(s)
| | | | | | | | - Pietro Pala
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | | | | | | | - Victor Musiime
- Joint Clinical Research Centre, Kampala, Uganda
- Makerere University College of Health Sciences
| | | | | | | | | | | | | | | | | | - Nigel Klein
- UCL Great Ormond Street Institute of Child Health
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Kibalama Ssemambo P, Nalubega-Mboowa MG, Owora A, Serunjogi R, Kironde S, Nakabuye S, Ssozi F, Nannyonga M, Musoke P, Barlow-Mosha L. Virologic response of treatment experienced HIV-infected Ugandan children and adolescents on NNRTI based first-line regimen, previously monitored without viral load. BMC Pediatr 2021; 21:139. [PMID: 33752636 PMCID: PMC7983217 DOI: 10.1186/s12887-021-02608-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 03/11/2021] [Indexed: 11/18/2022] Open
Abstract
Background Many HIV-infected African children gained access to antiretroviral treatment (ART) through expansion of PEPFAR programs since 2004 and introduction of “Test and Treat” WHO guidelines in 2015. As ART access increases and children transition from adolescence to adulthood, treatment failure is inevitable. Viral load (VL) monitoring in Uganda was introduced in 2016 replacing clinical monitoring. However, there’s limited data on the comparative effectiveness of these two strategies among HIV-infected children in resource-limited settings (RLS). Methods HIV-infected Ugandan children aged 1–12 years from HIV-care programs with > 1 year of first-line ART using only immunologic and clinical criteria to monitor response to treatment were screened in 2010. Eligible children were stratified by VL ≤ 400 and > 400 copies/ml randomized to clinical and immunological (control) versus clinical, immunological and VL monitoring to determine treatment failure with follow-up at 12, 24, 36, and 48 weeks. Plasma VL was analyzed retrospectively for controls. Mixed-effects logistic regression models were used to compare the prevalence of viral suppression between study arms and identify factors associated with viral suppression. Results At baseline all children (n = 142) were on NNRTI based ART (75% Nevirapine, 25% efavirenz). One third of ART-experienced children had detectable VL at baseline despite high CD4%. Median age was 6 years (interquartile range [IQR]: 5–9) and 43% were female. Overall, the odds of viral suppression were not different between study arms: (arm by week interaction, p = 0.63), adjusted odds ratio [aOR]: 1.07; 95%CI: 0.53, 2.17, p = 0.57) and did not change over time (aOR: 0 vs 24 week: 1.15; 95% CI: 0.91, 1.46, p = 0.24 and 0 vs 48 weeks: 1.26; 95%CI: 0.92, 1.74, p = 0.15). Longer duration of a child’s ART exposure was associated with lower odds of viral suppression (aOR: 0.61; 95% CI: 0.42, 0.87, p < .01). Only 13% (9/71) of children with virologic failure were switched to second-line ART, in spite of access to real-time VL. Conclusion With increasing ART exposure, viral load monitoring is critical for early detection of treatment failure in RLS. Clinicians need to make timely informed decisions to switch failing children to second-line ART. Trial registration ClinicalTrials.gov NCT04489953, 28 Jul 2020. Retrospectively registered. (https://register.clinicaltrials.gov).
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Affiliation(s)
- Phionah Kibalama Ssemambo
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Upper Mulago Hill Road, Mulago, P.O.BOX 23491, Kampala, Uganda.
| | - Mary Gorrethy Nalubega-Mboowa
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Upper Mulago Hill Road, Mulago, P.O.BOX 23491, Kampala, Uganda.,Nsambya Home Care Project (NHC), Kampala, Uganda.,Clarke International University (Formerly IHSU), Namuwongo, Kampala, Uganda
| | - Arthur Owora
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Upper Mulago Hill Road, Mulago, P.O.BOX 23491, Kampala, Uganda.,Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Indiana, USA
| | - Robert Serunjogi
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Upper Mulago Hill Road, Mulago, P.O.BOX 23491, Kampala, Uganda
| | | | - Sarah Nakabuye
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Upper Mulago Hill Road, Mulago, P.O.BOX 23491, Kampala, Uganda
| | | | | | - Philippa Musoke
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Upper Mulago Hill Road, Mulago, P.O.BOX 23491, Kampala, Uganda.,Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Linda Barlow-Mosha
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Upper Mulago Hill Road, Mulago, P.O.BOX 23491, Kampala, Uganda
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7
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High rate of loss to follow-up and virological non-suppression in HIV-infected children on antiretroviral therapy highlights the need to improve quality of care in South Africa. Epidemiol Infect 2021; 149:e88. [PMID: 33745490 PMCID: PMC8080219 DOI: 10.1017/s0950268821000637] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Provision of high-quality care and ensuring retention of children on antiretroviral therapy (ART) are essential to reduce human immunodeficiency virus (HIV)-associated morbidity and mortality. Virological non-suppression (≥1000 viral copies/ml) is an indication of suboptimal HIV care and support. This retrospective cohort study included ART-naïve children who initiated first-line ART between July 2015 and August 2017 in Johannesburg and rural Mopani district. Of 2739 children started on ART, 29.5% (807/2739) were lost to care at the point of analysis in August 2018. Among retained children, overall virological non-suppression was 30.2% (469/1554). Virological non-suppression was associated with higher loss to care 30.3% (229/755) compared with suppressed children (9.7%, 136/1399, P < 0.001). Receiving treatment in Mopani was associated with virological non-suppression in children under 5 years (adjusted odds ratio (aOR) 1.7 (95% confidence interval (CI) 1.1-2.4), 5-9 years (aOR 1.8 (1.1-3.0)) and 10-14 years (aOR 1.9 (1.2-2.8)). Virological non-suppression was associated with lower CD4 count in children 5-9 years (aOR 2.1 (1.1-4.1)) and 10-14 years (aOR 2.1 (1.2-3.8)). Additional factors included a shorter time on ART (<5 years aOR 1.8-3.7 (1.3-8.2)), and male gender (5-9 years, aOR1.5 (1.01-2.3)), and receiving cotrimoxazole prophylaxis (10-14 years aOR 2.0 (1.2-3.6)). In conclusion, virological non-suppression is a factor of subsequent programme loss in both regions, and factors affecting the quality of care need to be addressed to achieve the third UNAIDS 90 in paediatric HIV.
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Anderson K, Muloiwa R, Davies MA. Long-term outcomes in perinatally HIV-infected adolescents and young adults on antiretroviral therapy: a review of South African and global literature. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2020; 19:1-12. [PMID: 32122278 DOI: 10.2989/16085906.2019.1676802] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Kim Anderson
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Paediatrics, Groote Schuur Hospital, Cape Town, South Africa
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Early and Late Virologic Failure After Virologic Suppression in HIV-Infected Asian Children and Adolescents. J Acquir Immune Defic Syndr 2019; 80:308-315. [PMID: 30531299 DOI: 10.1097/qai.0000000000001921] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Virologic failure is a major threat to maintaining effective combination antiretroviral therapy, especially for children in need of lifelong treatment. With efforts to expand access to HIV viral load testing, our understanding of pediatric virologic failure is evolving. SETTING An Asian cohort in 16 pediatric HIV services across 6 countries. METHODS From 2005 to 2014, patients younger than 20 years who achieved virologic suppression and had subsequent viral load testing were included. Early virologic failure was defined as a HIV RNA ≥1000 copies per milliliter within 12 months of virologic suppression, and late virologic as a HIV RNA ≥1000 copies per milliliter after 12 months following virologic suppression. Characteristics at combination antiretroviral therapy initiation and virologic suppression were described, and a competing risk time-to-event analysis was used to determine cumulative incidence of virologic failure and factors at virologic suppression associated with early and late virologic failure. RESULTS Of 1105 included in the analysis, 182 (17.9%) experienced virologic failure. The median age at virologic suppression was 6.9 years, and the median time to virologic failure was 24.6 months after virologic suppression. The incidence rate for a first virologic failure event was 3.3 per 100 person-years. Factors at virologic suppression associated with late virologic failure included older age, mostly rural clinic setting, tuberculosis, protease inhibitor-based regimens, and early virologic failure. No risk factors were identified for early virologic failure. CONCLUSIONS Around 1 in 5 experienced virologic failure in our cohort after achieving virologic suppression. Targeted interventions to manage complex treatment scenarios, including adolescents, tuberculosis coinfection, and those with poor virologic control are required.
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Teeraananchai S, Puthanakit T, Kerr SJ, Chaivooth S, Kiertiburanakul S, Chokephaibulkit K, Bhakeecheep S, Teeraratkul A, Law M, Ruxrungtham K. Attrition and treatment outcomes among adolescents and youths living with HIV in the Thai National AIDS Program. J Virus Erad 2019. [DOI: 10.1016/s2055-6640(20)30276-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Antiretroviral drug concentrations in hair are associated with virologic outcomes among young people living with HIV in Tanzania. AIDS 2018; 32:1115-1123. [PMID: 29438196 PMCID: PMC5945296 DOI: 10.1097/qad.0000000000001788] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We assessed the relationship of self-reported adherence versus antiretroviral therapy (ART) concentrations in hair with virologic outcomes among young people living with HIV. DESIGN This was a cross-sectional study that enrolled young people living with HIV age 11-24 years, who attended a youth HIV clinic in Moshi, Tanzania. METHODS ART adherence was assessed by self-report, drug concentration in hair samples, and plasma HIV-1 RNA measurements. Those with virologic failure, defined as plasma HIV-1 RNA more than 400 copies/ml, had genotypic resistance assessed. Receiver operating characteristic curves were used to evaluate ART-concentration threshold cutoffs for virologic suppression, after excluding those with known high-level resistance mutations. RESULTS Among 280 young people enrolled, 227 were included in the final analysis. Seventy-two (32%) self-reported inadequate adherence and 91 (40%) had virologic failure. Hair ART-concentration (P < 0.001), but not self-reported adherence (P = 0.53), was associated with virologic outcome. Sixty-seven (74%) of those with virologic failure had resistance testing performed, of whom 60% had high-level resistance. Receiver operating characteristic curves demonstrated moderate or high classification performance for association with virologic suppression with specific hair ART-concentration cutoffs for lopinavir (1.8 ng/mg), efavirenz (1.04 ng/mg), and nevirapine (33.2 ng/mg). CONCLUSION Hair ART-concentrations were significantly associated with virologic outcomes among young people living with HIV. ART-concentration thresholds associated with virologic suppression are proposed. Hair analysis may provide a noninvasive, cost-effective adherence assessment tool in settings with limited second and third-line treatment options.
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Abstract
BACKGROUND Persistent renal dysfunction (PRD) has been reported in up to 22% of perinatally HIV-infected adolescents (PHAs) in the United States and Europe. There are limited data available on PRD among PHAs in resource-limited settings regarding access to antiretroviral therapy (ART) at more advanced HIV stages. METHODS We retrospectively described the prevalence of PRD and associated factors in a Thai PHA cohort. Inclusion criteria were current age ≥10 years old and at least 2 serum creatinine (Cr) measurements after ART initiation. Cr and urine examination were performed every 6-12 months. PRD was defined as having ≥2 measurements of low estimated glomerular filtration rate (eGFR); either <60 mL/min/1.73 m2 or elevated Cr for age and eGFR 60-89 mL/min/1.73 m2, or proteinuria (dipstick proteinuria ≥1+). Factors associated with PRD were analyzed using a multivariate logistic regression analysis. RESULTS This study included 255 PHAs with median (interquartile range) age of 16.7 (14.5-18.8) and ART duration of 10.3 (7.1-12.4) years. Fifty-six percentage used boosted protease inhibitor (bPI)-based regimens, and 63% used tenofovir disoproxil fumarate (TDF). The overall PRD prevalence was 14.1% [95% confidence interval (CI): 10.1-19.0]; low eGFR 6.7%, proteinuria 3.5% and both 3.9%. Among 109 users of TDF with bPI, 22.9% had PRD and 2.8% discontinued/adjusted dosing of TDF because of nephrotoxicity. Factors associated with PRD were age 10-15 years old (adjusted odd ratio (aOR): 10.1, 95% CI: 4.1-25.2), male (aOR: 3.2, 95% CI: 1.4-7.7), CD4 nadir <150 cells/mm (aOR: 2.6, 95% CI: 1.1-6.1) and use of TDF with bPI (aOR: 9.6, 95% CI: 3.2-28.9). CONCLUSIONS PRD is common among PHAs. Almost one-fifth of adolescents using TDF with bPI had PRD. These adolescents should be a priority group for renal monitoring.
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Teeraananchai S, Kerr SJ, Puthanakit T, Bunupuradah T, Ruxrungtham K, Chaivooth S, Law MG, Chokephaibulkit K. Attrition and Mortality of Children Receiving Antiretroviral Treatment through the Universal Coverage Health Program in Thailand. J Pediatr 2017; 188:210-216.e1. [PMID: 28606372 DOI: 10.1016/j.jpeds.2017.05.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 03/30/2017] [Accepted: 05/12/2017] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To assess mortality and loss to follow-up of children with HIV infection who started antiretroviral therapy (ART) through the Universal Coverage Health Program (UC) in Thailand. STUDY DESIGN Children with HIV infection who initiated ART at age <15 years through the UC between 2008 and 2013 were included in the analysis. Death was ascertained through linkage with the National Death Registry. A competing-risks method was used to calculate subdistribution hazard ratios (SHRs) of predictors for loss to follow-up. Death was considered a competing risk. Cox proportional hazards models were used to assess predictors of mortality. RESULTS A total of 4618 children from 497 hospitals in Thailand were included in the study. Median age at ART initiation was 9 years (IQR, 6-12 years), and the median duration of tracking was 4.1 years (a total of 18 817 person-years). Three hundred and ninety-five children (9%) died, for a mortality rate of 2.1 (95% CI, 1.9-2.3) per 100 person-years, and 525 children (11%) were lost to follow-up, for a lost to follow-up rate of 2.9 (95% CI, 2.7-3.2) per 100 person-years. The cumulative incidence of loss to follow-up increased from 4% at 1 year to 8.8% at 3 years. Children who started ART at age ≥12 years were at the greatest risk of loss to follow-up. The probability of death was 3.2% at 6 months and 6.4% at 3 years. Age ≥12 years at ART initiation, lower baseline CD4%, advanced HIV staging, and loss to follow-up were associated with mortality. CONCLUSION The Thai national HIV treatment program has been very effective in treating children with HIV infection, with low mortality and modest rates of loss to follow-up.
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Affiliation(s)
- Sirinya Teeraananchai
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand; Kirby Institute, University of New South Wales, Sydney, Australia.
| | - Stephen J Kerr
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand; Kirby Institute, University of New South Wales, Sydney, Australia
| | - Thanyawee Puthanakit
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand; Department of Pediatrics, Faculty of Medicine, Chulalongkorn University
| | | | - Kiat Ruxrungtham
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand; Department of Medicine, Faculty of Medicine, Chulalongkorn University
| | - Suchada Chaivooth
- The HIV/AIDS, Tuberculosis and Infectious Diseases Program, National Health Security Office (NHSO)
| | - Matthew G Law
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Transitioning to Second-line Antiretroviral Therapy Among Adolescents in Copperbelt Province, Zambia: Predictors of Treatment Switching and Adherence to Second-line Regimens. Pediatr Infect Dis J 2017; 36:768-773. [PMID: 28099228 DOI: 10.1097/inf.0000000000001547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Adolescents living with HIV (ALHIV) experience less favorable antiretroviral therapy (ART) outcomes than other age groups. First-line treatment failure complicates ART management as second-line regimens can be costlier and have greater pill burdens. Understanding predictors of switching ART regimens and adherence among adolescents on second-line ART may help to prevent poor treatment outcomes. METHODS A quantitative survey was administered to 309 ALHIV attending 3 ART clinics in the Copperbelt Province, Zambia. Medical chart data, including pharmacy refill data, were abstracted. Associations between being on second-line ART and sociodemographic, psychosocial and ART adherence characteristics were tested. Cox proportional hazards models were used to estimate the effect of baseline ART variables on time to switching. RESULTS Ten percent of participants were on second-line regimens. Compared with ALHIV on first-line ART, adolescents on second-line regimens were older (P = 0.02), out of school due to completion of secondary studies (P = 0.04) and on ART longer (P = 0.03). Adolescents on second-line regimens were more likely to report missing ≥48 consecutive hours of drugs in the last 3 months (P = 0.01). Multivariable analysis showed that adolescents who initiated ART with efavirenz-based regimens were more likely to switch to second-line than those put on nevirapine-based regimens (hazard ratio = 2.6; 95% confidence interval: 1.1-6.4). CONCLUSIONS Greater support is needed for ALHIV who are on second-line regimens. Interventions for older adolescents that bridge the gap between school years and young adulthood would be helpful. More research is needed on why ALHIV who start on efavirenz-based regimens are more likely to switch within this population.
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First-Line Antiretroviral Treatment Outcomes and Durability in HIV-Infected Children Treated Through the Universal Coverage Health Program in Thailand. J Acquir Immune Defic Syndr 2017; 75:219-225. [PMID: 28498146 DOI: 10.1097/qai.0000000000001351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We assessed the treatment outcomes on first-line antiretroviral therapy (ART), and factors associated with switching regimen in HIV-infected children treated through the universal coverage health program (UC) in Thailand. METHODS Children aged <15 years at ART initiation who had been receiving ART for at least 6 months between 2008 and 2014 through UC were included in the analysis. The Kaplan-Meier method was used to estimate immunological recovery (IMR), immunological failure, and virological failure (VF). Cox models were used to assess predictors of IMR and VF. Competing risk models were used to assess factors associated with switching to a second-line regimen, with death considered as a competing risk. RESULTS A total of 4120 children initiated ART at a median (interquartile range) age of 9.3 (5.8-12.0) years. The median duration of ART was 3.7 years with 17,950 person-years of follow-up. Two thousand eight hundred five children achieved IMR, and the probability of IMR increased to 76% by 3 years after ART initiation. Among 1054 children switched to second-line regimens, 84% had VF and 19% had immunological failure. The cumulative rate of switching regimen increased from 4% to 20% from 1 to 3 years after treatment. Children aged ≥12 years at ART initiation, starting with nonnucleoside reverse-transcriptase inhibitors, and baseline CD4% <10% had an increased risk of switching to second-line regimens. CONCLUSIONS Children receiving ART through UC had good treatment outcomes, although a fifth required switching regimen by 3 years. Earlier treatment initiation and avoiding nonnucleoside reverse-transcriptase inhibitor first-line regimens in high-risk children may prevent treatment failure.
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Kekitiinwa A, Szubert AJ, Spyer M, Katuramu R, Musiime V, Mhute T, Bakeera-Kitaka S, Senfuma O, Walker AS, Gibb DM. Virologic Response to First-line Efavirenz- or Nevirapine-based Antiretroviral Therapy in HIV-infected African Children. Pediatr Infect Dis J 2017; 36:588-594. [PMID: 28505015 PMCID: PMC5533213 DOI: 10.1097/inf.0000000000001505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Poorer virologic response to nevirapine- versus efavirenz-based antiretroviral therapy (ART) has been reported in adult systematic reviews and pediatric studies. METHODS We compared drug discontinuation and viral load (VL) response in ART-naïve Ugandan/Zimbabwean children ≥3 years of age initiating ART with clinician-chosen nevirapine versus efavirenz in the ARROW trial. Predictors of suppression <80, <400 and <1000 copies/mL at 36, 48 and 144 weeks were identified using multivariable logistic regression with backwards elimination (P = 0.1). RESULTS A total of 445 (53%) children received efavirenz and 391 (47%) nevirapine. Children receiving efavirenz were older (median age, 8.6 vs. 7.5 years nevirapine, P < 0.001) and had higher CD4% (12% vs. 10%, P = 0.05), but similar pre-ART VL (P = 0.17). The initial non-nucleoside-reverse-transcriptase-inhibitor (NNRTI) was permanently discontinued for adverse events in 7 of 445 (2%) children initiating efavirenz versus 9 of 391 (2%) initiating nevirapine (P = 0.46); at switch to second line in 17 versus 23, for tuberculosis in 0 versus 26, for pregnancy in 6 versus 0 and for other reasons in 15 versus 5. Early (36-48 weeks) virologic suppression <80 copies/mL was superior with efavirenz, particularly in children with higher pre-ART VL (P = 0.0004); longer-term suppression was superior with nevirapine in older children (P = 0.05). Early suppression was poorer in the youngest and oldest children, regardless of NNRTI (P = 0.02); longer-term suppression was poorer in those with higher pre-ART VL regardless of NNRTI (P = 0.05). Results were broadly similar for <400 and <1000 copies/mL. CONCLUSION Short-term VL suppression favored efavirenz, but long-term relative performance was age dependent, with better suppression in older children with nevirapine, supporting World Health Organization recommendation that nevirapine remains an alternative NNRTI.
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Affiliation(s)
- Adeodata Kekitiinwa
- Baylor-Uganda, Paediatric Infectious Diseases Clinic, Mulago
Hospital, Kampala, Uganda
| | | | - Moira Spyer
- MRC Clinical Trials Unit at University College London, London,
UK
| | - Richard Katuramu
- Medical Research Council/Uganda Virus Research Institute Uganda
Research Unit on AIDS, Entebbe, Uganda
| | - Victor Musiime
- Joint Clinical Research Centre, Kampala, Uganda,Makerere University College of Health Sciences, Kampala,
Uganda
| | - Tawanda Mhute
- University of Zimbabwe College of Health Sciences, Harare,
Zimbabwe
| | - Sabrina Bakeera-Kitaka
- Baylor-Uganda, Paediatric Infectious Diseases Clinic, Mulago
Hospital, Kampala, Uganda,Makerere University College of Health Sciences, Kampala,
Uganda
| | | | - Ann Sarah Walker
- MRC Clinical Trials Unit at University College London, London,
UK
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London, London,
UK
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Bienczak A, Denti P, Cook A, Wiesner L, Mulenga V, Kityo C, Kekitiinwa A, Gibb DM, Burger D, Walker AS, McIlleron H. Determinants of virological outcome and adverse events in African children treated with paediatric nevirapine fixed-dose-combination tablets. AIDS 2017; 31:905-915. [PMID: 28060017 PMCID: PMC5572624 DOI: 10.1097/qad.0000000000001376] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Nevirapine is the only nonnucleoside reverse transcriptase inhibitor currently available as a paediatric fixed-dose-combination tablet and is widely used in African children. Nonetheless, the number of investigations into pharmacokinetic determinants of virological suppression in African children is limited, and the predictive power of the current therapeutic range was never evaluated in this population, thereby limiting treatment optimization. METHODS We analysed data from 322 African children (aged 0.3-13 years) treated with nevirapine, lamivudine, and either abacavir, stavudine, or zidovudine, and followed up to 144 weeks. Nevirapine trough concentration (Cmin) and other factors were tested for associations with viral load more than 100 copies/ml and transaminase increases more than grade 1 using proportional hazard and logistic models in 219 initially antiretroviral treatment (ART)-naive children. RESULTS Pre-ART viral load, adherence, and nevirapine Cmin were associated with viral load nonsuppression [hazard ratio = 2.08 (95% confidence interval (CI): 1.50-2.90, P < 0.001) for 10-fold higher pre-ART viral load, hazard ratio = 0.78 (95% CI: 0.68-0.90, P < 0.001) for 10% improvement in adherence, and hazard ratio = 0.94 (95% CI: 0.90-0.99, P = 0.014) for a 1 mg/l increase in nevirapine Cmin]. There were additional effects of pre-ART CD4 cell percentage and clinical site. The risk of virological nonsuppression decreased with increasing nevirapine Cmin, and there was no clear Cmin threshold predictive of virological nonsuppression. Transient transaminase elevations more than grade 1 were associated with high Cmin (>12.4 mg/l), hazard ratio = 5.18 (95% CI 1.95-13.80, P < 0.001). CONCLUSION Treatment initiation at lower pre-ART viral load and higher pre-ART CD4 cell percentage, increased adherence, and maintaining average Cmin higher than current target could improve virological suppression of African children treated with nevirapine without increasing toxicity.
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Affiliation(s)
- Andrzej Bienczak
- aDivision of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa bMRC Clinical Trials Unit at University College London, London, United Kingdom cDepartment of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia dJoint Clinical Research Centre eBaylor College of Medicine Bristol Myers Squibb Children's Clinical Centre of Excellence, Kampala, Uganda fGulu Regional Centre of Excellence, Gulu, Uganda gDepartment of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands. *Ann S. Walker and Helen McIlleron contributed equally to the article
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Ngo-Giang-Huong N, Wittkop L, Judd A, Reiss P, Goetghebuer T, Duiculescu D, Noguera-Julian A, Marczynska M, Giacquinto C, Ene L, Ramos JT, Cellerai C, Klimkait T, Brichard B, Valerius N, Sabin C, Teira R, Obel N, Stephan C, de Wit S, Thorne C, Gibb D, Schwimmer C, Campbell MA, Pillay D, Lallemant M. Prevalence and effect of pre-treatment drug resistance on the virological response to antiretroviral treatment initiated in HIV-infected children - a EuroCoord-CHAIN-EPPICC joint project. BMC Infect Dis 2016; 16:654. [PMID: 27825316 PMCID: PMC5101717 DOI: 10.1186/s12879-016-1968-2] [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] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 10/25/2016] [Indexed: 12/14/2022] Open
Abstract
Background Few studies have evaluated the impact of pre-treatment drug resistance (PDR) on response to combination antiretroviral treatment (cART) in children. The objective of this joint EuroCoord-CHAIN-EPPICC/PENTA project was to assess the prevalence of PDR mutations and their association with virological outcome in the first year of cART in children. Methods HIV-infected children <18 years initiating cART between 1998 and 2008 were included if having at least one genotypic resistance test prior to cART initiation. We used the World Health Organization 2009 resistance mutation list and Stanford algorithm to infer resistance to prescribed drugs. Time to virological failure (VF) was defined as the first of two consecutive HIV-RNA > 500 copies/mL after 6 months cART and was assessed by Cox proportional hazards models. All models were adjusted for baseline demographic, clinical, immunology and virology characteristics and calendar period of cART start and initial cART regimen. Results Of 476 children, 88 % were vertically infected. At cART initiation, median (interquartile range) age was 6.6 years (2.1–10.1), CD4 cell count 297 cells/mm3 (98–639), and HIV-RNA 5.2 log10copies/mL (4.7–5.7). Of 37 children (7.8 %, 95 % confidence interval (CI), 5.5–10.6) harboring a virus with ≥1 PDR mutations, 30 children had a virus resistant to ≥1 of the prescribed drugs. Overall, the cumulative Kaplan-Meier estimate for virological failure was 19.8 % (95 %CI, 16.4–23.9). Cumulative risk for VF tended to be higher among children harboring a virus with PDR and resistant to ≥1 drug prescribed than among those receiving fully active cART: 32.1 % (17.2–54.8) versus 19.4 % (15.9–23.6) (P = 0.095). In multivariable analysis, age was associated with a higher risk of VF with a 12 % reduced risk per additional year (HR 0.88; 95 %CI, 0.82–0.95; P < 0.001). Conclusions PDR was not significantly associated with a higher risk of VF in children in the first year of cART. The risk of VF decreased by 12 % per additional year at treatment initiation which may be due to fading of PDR mutations over time. Lack of appropriate formulations, in particular for the younger age group, may be an important determinant of virological failure. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1968-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicole Ngo-Giang-Huong
- IRD UMI 174 - PHPT-Faculty of Associated Medical Sciences, Chiang Mai University, 110, Intrawarorot Road, Sripoom, Muang, Chiang Mai, 50200, Thailand. .,Harvard T.H. Chan School of Public Health, Boston, USA.
| | - Linda Wittkop
- Univ. Bordeaux, ISPED; INSERM, Centre INSERM U1219; CHU de Bordeaux, Pole de Sante Publique, F-33000, Bordeaux, France
| | - Ali Judd
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Peter Reiss
- Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Dan Duiculescu
- "Dr. Victor Babes" Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | | | | | | | - Luminita Ene
- "Dr. Victor Babes" Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | | | | | | | | | - Niels Valerius
- Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Niels Obel
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Claire Thorne
- University College London, Institute of Child Health, London, UK
| | - Diana Gibb
- Medical Research Council Clinical Trials Unit, London, UK
| | | | | | | | - Marc Lallemant
- IRD UMI 174 - PHPT-Faculty of Associated Medical Sciences, Chiang Mai University, 110, Intrawarorot Road, Sripoom, Muang, Chiang Mai, 50200, Thailand
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