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Golucci APBS, Marson FAL, Valente MFF, Branco MM, Prado CC, Nogueira RJN. Influence of AIDS antiretroviral therapy on the growth pattern. J Pediatr (Rio J) 2019; 95:7-17. [PMID: 29660296 DOI: 10.1016/j.jped.2018.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/23/2018] [Accepted: 12/07/2017] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Human immunodeficiency virus infection can result in the early impairment of anthropometric indicators in children and adolescents. However, combined antiretroviral therapy has improved, in addition to the immune response and viral infection, the weight and height development in infected individuals. Therefore, the objective was to evaluate the effect of combined antiretroviral on the growth development of human immunodeficiency virus infected children and adolescents. SOURCE OF DATA A systematic review was performed. In the study, the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) strategy was used as the eligibility criterion. The MEDLINE-PubMed and LILACS databases were searched using these descriptors: HIV, children, growth, antiretroviral therapy. The objective was defined by the population, intervention, comparison/control, and outcome (PICO) technique. Inclusion and exclusion criteria were applied for study selection. SYNTHESIS OF DATA Of the 549 studies indexed in MEDLINE-PubMed and LILACS, 73 were read in full, and 44 were included in the review (33 showed a positive impact of combined antiretroviral therapy on weight/height development, ten on weight gain, and one on height gain in children and adolescents infected with human immunodeficiency virus). However, the increase in growth was not enough to normalize the height of infected children when compared to children of the same age and gender without human immunodeficiency virus infection. CONCLUSIONS Combined antiretroviral therapy, which is known to play a role in the improvement of viral and immunological markers, may influence in the weight and height development in children infected with human immunodeficiency virus. The earlier the infection diagnosis and, concomitantly, of malnutrition and the start of combined antiretroviral therapy, the lower the growth impairment when compared to healthy children.
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Affiliation(s)
| | - Fernando Augusto Lima Marson
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Genética Médica, Campinas, SP, Brazil
| | | | - Maira Migliari Branco
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Hospital de Clínicas, Campinas, SP, Brazil
| | - Camila Carbone Prado
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Hospital de Clínicas, Campinas, SP, Brazil
| | - Roberto José Negrão Nogueira
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Faculdade São Leopoldo Mandic, Campinas, SP, Brazil.
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Influence of AIDS antiretroviral therapy on the growth pattern. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2019. [DOI: 10.1016/j.jpedp.2018.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Stinson K, Goemaere E, Coetzee D, van Cutsem G, Hilderbrand K, Osler M, Hennessey C, Wilkinson L, Patten G, Cragg C, Mathee S, Cox V, Boulle A. Cohort Profile: The Khayelitsha antiretroviral programme, Cape Town, South Africa. Int J Epidemiol 2018; 46:e21. [PMID: 27208042 DOI: 10.1093/ije/dyw057] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kathryn Stinson
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, South Africa and
| | - Eric Goemaere
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, South Africa and
| | - David Coetzee
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, South Africa and.,Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Gilles van Cutsem
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, South Africa and
| | - Katherine Hilderbrand
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, South Africa and
| | - Meg Osler
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, South Africa and
| | - Claudine Hennessey
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, South Africa and
| | - Lynne Wilkinson
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Gabriela Patten
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Carol Cragg
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Shaheed Mathee
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Vivian Cox
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Andrew Boulle
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, South Africa and
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Ramteke SM, Shiau S, Foca M, Strehlau R, Pinillos F, Patel F, Violari A, Liberty A, Coovadia A, Kuhn L, Arpadi SM. Patterns of Growth, Body Composition, and Lipid Profiles in a South African Cohort of Human Immunodeficiency Virus-Infected and Uninfected Children: A Cross-Sectional Study. J Pediatric Infect Dis Soc 2018; 7:143-150. [PMID: 28481997 PMCID: PMC5954242 DOI: 10.1093/jpids/pix026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 04/14/2017] [Indexed: 11/14/2022]
Abstract
BACKGROUND Prior research in sub-Saharan Africa reports dyslipidemia in perinatally human immunodeficiency virus (HIV)-infected children receiving ritonavir-boosted lopinavir (LPV/r) compared with efavirenz; however, interpretation of findings is limited by lack of comparison data from HIV-uninfected children. METHODS We conducted a cross-sectional analysis of lipid profiles and growth within a larger longitudinal cohort study of perinatally HIV-infected and HIV-uninfected children aged 4-9 years in Johannesburg, South Africa. At enrollment, anthropometrics, viral load, CD4, total cholesterol (TC), high-density lipoprotein, low-density lipoprotein (LDL), and triglycerides were measured. Weight-for-age Z-score (WAZ), height-for-age Z-score (HAZ), and body mass index-for-age Z-score (BAZ) were calculated. United States pediatric thresholds for dyslipidemia were used. RESULTS Five hundred fifty-three HIV-infected and 300 HIV-uninfected children (median age 6.9 years) of similar demographic characteristics were enrolled. Of the HIV-infected children, 94.8% were on combination antiretroviral therapy (cART) (65.4% on LPV/r- and 28.6% on efavirenz-based regimens). Among the treated, 94.3% had a viral load <200 copies/mL. Median CD4% was 34.4. The HIV-infected children had lower mean WAZ (-0.7 vs -0.3, P < .01) and HAZ (-1.1 vs -0.7, P < .01) compared with HIV-uninfected children. A lower proportion of HIV-infected children were overweight (BAZ >1) compared with HIV-uninfected children (14.4% vs 21.7%, P = .04). Whether on LPV/r or efavirenz, a higher proportion of HIV-infected children had borderline/elevated TC or abnormal triglycerides than HIV-uninfected children, although a higher proportion of those on LPV/r had borderline/elevated TC, borderline/elevated LDL, or abnormal triglycerides than those on efavirenz. CONCLUSIONS In a South African cohort of HIV-infected children and population-appropriate HIV-uninfected children, unfavorable alterations in lipid profiles were detected in HIV-infected children regardless of treatment regimen compared with HIV-uninfected children. The HIV-infected children were of smaller size than HIV-uninfected children, but there was a high prevalence of overweight in both groups. Strategies for optimizing growth and early life management of lipid alterations may be warranted.
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Affiliation(s)
- Sarah M Ramteke
- Gertrude H. Sergievsky Center, Columbia University, New York
| | - Stephanie Shiau
- Gertrude H. Sergievsky Center, Columbia University, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York,Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Marc Foca
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | - Renate Strehlau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francoise Pinillos
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Faeezah Patel
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Avy Violari
- Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Afaaf Liberty
- Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashraf Coovadia
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, Columbia University, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York,Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen M Arpadi
- Gertrude H. Sergievsky Center, Columbia University, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York,Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York,Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa,Correspondence: S. M. Arpadi, MD, MS, Gertrude H. Sergievsky Center, Columbia University, 622 W. 168th Street, PH 19—114, New York, NY 10032 ()
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Retention of HIV-Infected Children in the First 12 Months of Anti-Retroviral Therapy and Predictors of Attrition in Resource Limited Settings: A Systematic Review. PLoS One 2016; 11:e0156506. [PMID: 27280404 PMCID: PMC4900559 DOI: 10.1371/journal.pone.0156506] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/16/2016] [Indexed: 02/06/2023] Open
Abstract
Current UNAIDS goals aimed to end the AIDS epidemic set out to ensure that 90% of all people living with HIV know their status, 90% initiate and continue life-long anti-retroviral therapy (ART), and 90% achieve viral load suppression. In 2014 there were an estimated 2.6 million children under 15 years of age living with HIV, of which only one-third were receiving ART. Little literature exists describing retention of HIV-infected children in the first year on ART. We conducted a systematic search for English language publications reporting on retention of children with median age at ART initiation less than ten years in resource limited settings. The proportion of children retained in care on ART and predictors of attrition were identified. Twelve studies documented retention at one year ranging from 71–95% amongst 31877 African children. Among the 5558 children not retained, 4082 (73%) were reported as lost to follow up (LFU) and 1476 (27%) were confirmed to have died. No studies confirmed the outcomes of children LFU. Predictors of attrition included younger age, shorter duration of time on ART, and severe immunosuppression. In conclusion, significant attrition occurs in children in the first 12 months after ART initiation, the majority attributed to LFU, although true outcomes of children labeled as LFU are unknown. Focused efforts to ensure retention and minimize early mortality are needed as universal ART for children is scaled up.
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Sequencing paediatric antiretroviral therapy in the context of a public health approach. J Int AIDS Soc 2015; 18:20265. [PMID: 26639116 PMCID: PMC4670836 DOI: 10.7448/ias.18.7.20265] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/03/2015] [Accepted: 09/02/2015] [Indexed: 01/20/2023] Open
Abstract
Introduction As access to prevention of mother-to-child transmission (PMTCT) efforts has increased, the total number of children being born with HIV has significantly decreased. However, those children who do become infected after PMTCT failure are at particular risk of HIV drug resistance, selected by exposure to maternal or paediatric antiretroviral drugs used before, during or after birth. As a consequence, the response to antiretroviral therapy (ART) in these children may be compromised, particularly when non-nucleoside reverse transcriptase inhibitors (NNRTIs) are used as part of the first-line regimen. We review evidence guiding choices of first- and second-line ART. Discussion Children generally respond relatively well to ART. Clinical trials show the superiority of protease inhibitor (PI)- over NNRTI-based treatment in young children, but observational reports of NNRTI-containing regimens are usually favourable as well. This is reassuring as national guidelines often still recommend the use of NNRTI-based treatment for PMTCT-unexposed young children, due to the higher costs of PIs. After failure of NNRTI-based, first-line treatment, the rate of acquired drug resistance is high, but HIV may well be suppressed by PIs in second-line ART. By contrast, there are currently no adequate alternatives in resource-limited settings (RLS) for children failing either first- or second-line, PI-containing regimens. Conclusions Affordable salvage treatment options for children in RLS are urgently needed.
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McGrath CJ, Diener L, Richardson BA, Peacock-Chambers E, John-Stewart GC. Growth reconstitution following antiretroviral therapy and nutritional supplementation: systematic review and meta-analysis. AIDS 2015; 29:2009-23. [PMID: 26355573 PMCID: PMC4579534 DOI: 10.1097/qad.0000000000000783] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE As antiretroviral therapy (ART) expands for HIV-infected children, it is important to determine its impact on growth. We quantified growth and its determinants following ART in resource-limited (RLS) and developed settings. DESIGN Systematic review and meta-analysis. METHODS We searched publications reporting growth [weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) z scores] in HIV-infected children following ART through August 2014. Inclusion criteria were as follows: younger than 18 years; ART; at least 20 patients; growth at ART; and post-ART growth. Standardized and overall weighted mean differences were calculated using random-effects models. RESULTS A total of 67 articles were eligible (RLS = 54; developed settings = 13). Mean age was 5.8 years, and comparable between settings (P = 0.90). Baseline growth was substantially lower in RLS vs. developed settings (WAZ -2.1 vs. -0.5; HAZ -2.2 vs. -0.9; both P < 0.01). Rate of weight but not height reconstitution during 12 and 24 months was higher in RLS (12-month WAZ change 0.84 vs. 0.17, P < 0.01). Growth deficits persisted in RLS after 2 years ART (P = 0.04). Younger cohort age was associated with greater growth reconstitution. Protease inhibitor and nonnucleoside reverse-transcriptase inhibitor regimens yielded comparable growth. Adjusting for age and setting, cohorts with nutritional supplements had greater growth gains (24-month rate difference: WAZ 0.55, P = 0.03; HAZ 0.60, P = 0.007). Supplement benefits were attenuated after adjusting for baseline cohort growth. CONCLUSION RLS children had substantial growth deficits compared with developed settings counterparts at ART; growth shortfalls in RLS persisted despite reconstitution. Earlier age and nutritional supplementation at ART may improve growth outcomes. Scant data on supplementation limit evaluation of impact and underscores need for systematic data collection regarding supplementation in pediatric ART programmes/cohorts.
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Affiliation(s)
- Christine J McGrath
- aDepartment of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas bDepartment of Global Health cDepartment of Biostatistics dDivision of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington eDepartment of Pediatrics, Boston Medical Center, Boston, Massachusetts fDepartment of Medicine gDepartment of Pediatrics hDepartment of Epidemiology, University of Washington, Seattle, Washington, USA
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Vermund SH, Blevins M, Moon TD, José E, Moiane L, Tique JA, Sidat M, Ciampa PJ, Shepherd BE, Vaz LME. Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement. PLoS One 2014; 9:e110116. [PMID: 25330113 PMCID: PMC4203761 DOI: 10.1371/journal.pone.0110116] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 09/16/2014] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Residents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15-49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting. METHODS We studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006-July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk. RESULTS Of 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3-8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001). CONCLUSIONS We found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.
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Affiliation(s)
- Sten H. Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Troy D. Moon
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Eurico José
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Linda Moiane
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - José A. Tique
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Mohsin Sidat
- School of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Philip J. Ciampa
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Bryan E. Shepherd
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Lara M. E. Vaz
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
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Alvarez-Uria G, Pakam R, Naik PK, Midde M. Induction with lopinavir-based treatment followed by switch to nevirapine-based regimen versus non-nucleoside reverse transcriptase inhibitors-based treatment for first line antiretroviral therapy in HIV infected children three years and older. PLoS One 2014; 9:e108063. [PMID: 25232730 PMCID: PMC4169483 DOI: 10.1371/journal.pone.0108063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/25/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The World Health Organization recommends non-nucleoside reverse transcriptase inhibitors (NNRTIs)-based antiretroviral therapy (ART) for children three years and older. In younger children, starting ART with lopinavir boosted with ritonavir (LPVr) results in lower risk of virological failure, but data in children three years and older are scarce, and long-term ART with LPVr is problematic in resource-poor settings. METHODOLOGY Retrospective cohort of children three years and older who started triple ART including LPVr or a NNRTI between 2007 and 2013 in a rural setting in India. Children who started LPVr were switched to nevirapine-based ART after virological suppression. We analysed two outcomes, virological suppression (HIV-RNA <400 copies/ml) within one year of ART using logistic regression, and time to virological failure (HIV-RNA >1000 copies/ml) after virological suppression using Cox proportional hazard regression. A sensitivity analysis was performed using inverse probability of treatment weighting (IPTW) based of propensity score methods. FINDINGS Of 325 children having a viral load during the first year of ART, 74/83 (89.2%) in the LPVr group achieved virological suppression versus 185/242 (76.5%) in the NNRTI group. In a multivariable analysis, the use of LPVr-based ART was associated with higher probability of virological suppression (adjusted odds ratio 3.19, 95% confidence interval [CI] 1.11-9.13). After IPTW, the estimated risk difference was 12.2% (95% CI, 2.9-21.5). In a multivariable analysis including 292 children who had virological suppression and available viral loads after one year of ART, children switched from LPVr to nevirapine did not have significant higher risk of virological failure (adjusted hazard ratio 1.18, 95% CI 0.36-3.81). CONCLUSIONS In a cohort of HIV infected children three years and older in a resource-limited setting, an LPVr induction- nevirapine maintenance strategy resulted in more initial virological suppression and similar incidence of virological failure after initial virological suppression than NNRTI-based regimens.
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Affiliation(s)
- Gerardo Alvarez-Uria
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, AP, India
- * E-mail:
| | - Raghavakalyan Pakam
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, AP, India
| | - Praveen Kumar Naik
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, AP, India
| | - Manoranjan Midde
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, AP, India
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Ditkowsky JB, Schwartzman K. Potential cost-effectiveness of a new infant tuberculosis vaccine in South Africa--implications for clinical trials: a decision analysis. PLoS One 2014; 9:e83526. [PMID: 24454706 PMCID: PMC3893082 DOI: 10.1371/journal.pone.0083526] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 11/05/2013] [Indexed: 11/20/2022] Open
Abstract
Novel tuberculosis vaccines are in varying stages of pre-clinical and clinical development. This study seeks to estimate the potential cost-effectiveness of a BCG booster vaccine, while accounting for costs of large-scale clinical trials, using the MVA85A vaccine as a case study for estimating potential costs. We conducted a decision analysis from the societal perspective, using a 10-year time frame and a 3% discount rate. We predicted active tuberculosis cases and tuberculosis-related costs for a hypothetical cohort of 960,763 South African newborns (total born in 2009). We compared neonatal vaccination with bacille Calmette-Guérin alone to vaccination with bacille Calmette-Guérin plus a booster vaccine at 4 months. We considered booster efficacy estimates ranging from 40% to 70%, relative to bacille Calmette-Guérin alone. We accounted for the costs of Phase III clinical trials. The booster vaccine was assumed to prevent progression to active tuberculosis after childhood infection, with protection decreasing linearly over 10 years. Trial costs were prorated to South Africa's global share of bacille Calmette-Guérin vaccination. Vaccination with bacille Calmette-Guérin alone resulted in estimated tuberculosis-related costs of $89.91 million 2012 USD, and 13,610 tuberculosis cases in the birth cohort, over the 10 years. Addition of the booster resulted in estimated cost savings of $7.69–$16.68 million USD, and 2,800–4,160 cases averted, for assumed efficacy values ranging from 40%–70%. A booster tuberculosis vaccine in infancy may result in net societal cost savings as well as fewer active tuberculosis cases, even if efficacy is relatively modest and large scale Phase III studies are required.
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Affiliation(s)
- Jared B. Ditkowsky
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montreal, Quebec, Canada
| | - Kevin Schwartzman
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montreal, Quebec, Canada
- Respiratory Division, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- * E-mail:
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Temporal trends in the characteristics of children at antiretroviral therapy initiation in southern Africa: the IeDEA-SA Collaboration. PLoS One 2013; 8:e81037. [PMID: 24363808 PMCID: PMC3867284 DOI: 10.1371/journal.pone.0081037] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 10/18/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Since 2005, increasing numbers of children have started antiretroviral therapy (ART) in sub-Saharan Africa and, in recent years, WHO and country treatment guidelines have recommended ART initiation for all infants and very young children, and at higher CD4 thresholds for older children. We examined temporal changes in patient and regimen characteristics at ART start using data from 12 cohorts in 4 countries participating in the IeDEA-SA collaboration. METHODOLOGY/PRINCIPAL FINDINGS Data from 30,300 ART-naïve children aged <16 years at ART initiation who started therapy between 2005 and 2010 were analysed. We examined changes in median values for continuous variables using the Cuzick's test for trend over time. We also examined changes in the proportions of patients with particular disease severity characteristics (expressed as a binary variable e.g. WHO Stage III/IV vs I/II) using logistic regression. Between 2005 and 2010 the number of children starting ART each year increased and median age declined from 63 months (2006) to 56 months (2010). Both the proportion of children <1 year and ≥10 years of age increased from 12 to 19% and 18 to 22% respectively. Children had less severe disease at ART initiation in later years with significant declines in the percentage with severe immunosuppression (81 to 63%), WHO Stage III/IV disease (75 to 62%), severe anemia (12 to 7%) and weight-for-age z-score<-3 (31 to 28%). Similar results were seen when restricting to infants with significant declines in the proportion with severe immunodeficiency (98 to 82%) and Stage III/IV disease (81 to 63%). First-line regimen use followed country guidelines. CONCLUSIONS/SIGNIFICANCE Between 2005 and 2010 increasing numbers of children have initiated ART with a decline in disease severity at start of therapy. However, even in 2010, a substantial number of infants and children started ART with advanced disease. These results highlight the importance of efforts to improve access to HIV diagnostic testing and ART in children.
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Abstract
BACKGROUND There is scant data on young children receiving protease inhibitor-based therapy in real-life resource-limited settings and on the optimal timing of therapy among children who survive infancy. Our aim was to evaluate outcomes at the Hospital del Niño, Panama, where children have been routinely treated with lopinavir/ritonavir (LPV/r)-based therapy since 2002. METHODS Retrospective cohort analysis of all HIV-infected children enrolled in care between January 1, 1991, and June 1, 2011. Kaplan-Meier method and Cox proportional hazards regression were used to evaluate death, virologic suppression and virologic rebound. RESULTS Of 399 children contributing 1944 person-years of follow-up, 254 (63.7%) were treated with LPV/r and 94 (23.6%) were never treated with antiretrovirals (ARVs). Among infants, improved survival was associated with male gender (hazard rate of death[HRdeath] 0.54, 95% confidence interval [CI]: 0.32-0.92) and treatment with highly active antiretroviral therapy (HRdeath 0.32, 95% CI: 0.12-0.83), whereas residence outside of Panama City was associated with poorer survival (HRdeath 1.72, 95% CI: 1.01-2.94). Among children who survived to 1 year of age without exposure to ARVs, LPV/r-based therapy improved survival (HRdeath 0.07, 95% CI: 0.01-0.33). Virologic suppression was achieved in 42.1%, 70.5% and 85.1% by 12, 24 and 60 months of follow-up among children treated with LPV/r. Virologic suppression was not associated with prior ARV exposure or age at initiation of therapy but was associated with residence outside of Panama City (HR suppression 1.93, 95% CI: 1.19-3.14). Patients with a baseline viral load >100,000 copies/mL were less likely to achieve suppression (HR suppression 0.37, 95% CI: 0.21-0.66). No children who achieved virologic suppression after initiating LPV/r died. CONCLUSIONS LPV/r-based therapy improved survival not only in infants but also in children over 1 year of age. Age at initiation of LPV/r-based therapy or prior ARVs did not impact virologic outcomes.
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Sivapalasingam S, Mendillo M, Ahmed A, Mwamzuka M, Said S, Marshed F, Luhar Abdulaziz F, Fajans M, Holzman R. The importance of caregivers in the outcome of pediatric HIV management, Mombasa, Kenya. AIDS Care 2013; 26:425-33. [PMID: 24090313 DOI: 10.1080/09540121.2013.841829] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We assessed programmatic gaps that prevent the optimal treatment of pediatric HIV infection despite free antiretroviral care in Kenya. Of 626 HIV-infected Kenyan children, the median age was five years, 54% were male and the mortality rate was 3.2 per 100 person-years. A total of 380 (61%) children initiated antiretroviral therapy (ART) during the study period. Among the 246 children who never started ART, 129 (52%) met the criteria for ART initiation. Immunologic failure occurred in 20% of children who received ART for >24 weeks. In multivariate analysis, immunological failure was associated with having nonimmediate relative or unrelated caregivers accompanying the child to clinic (AOR = 69.16, p = 0.008). Having ≥ 3 types of accompanying caregivers was also associated with virologic failure in multivariate analysis (AOR = 3.84, p = 0.03). The lost to follow-up rate was 8.7/100 persons-years for the entire cohort, and significantly higher (17.7/100 persons-years) among children not on ART (p < 0.001). Among children who do initiate ART, those with the best treatment outcomes were those who had a limited number of close relatives as caregivers and good adherence to ART. Focus on early ART initiation and education of the right caregiver will likely improve retention and quality of pediatric HIV care in Kenya.
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Immunologic outcomes of antiretroviral therapy among HIV-infected Nigerian children and its association with early infant feeding and nutritional status at treatment initiation. Pediatr Infect Dis J 2013; 32:e291-7. [PMID: 23411626 PMCID: PMC9823951 DOI: 10.1097/inf.0b013e31828b2a2f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To evaluate immunologic response to antiretroviral treatment (ART) among HIV-infected Nigerian children (<36 months old) and to assess its association with early infant feeding pattern and nutritional status at treatment initiation. DESIGN Mixed prospective and retrospective cohort study. METHODS One hundred fifty HIV-infected children were followed for 12 months from initiation of ART. CD4 count/CD4% was assessed at baseline and every 4-6 months. Nutritional status was assessed by height-for-age, weight-for-age and weight-for-height Z scores using the 2006 World Health Organization growth reference. Children were classified into 4 feeding groups--exclusively breast-fed, predominantly breast-fed, mixed fed and exclusively formula fed. Logistic regression was used to model odds of failure to reach CD4% of ≥ 25% at the 12-month follow-up. Linear random effects models were used to model the longitudinal change in CD4%. RESULTS There was a significant increase in CD4% for all children from 13.8% at baseline to 28.5% after 12 months (ΔCD4% = 14.7%, 95% confidence interval: 12.1%-17.4%). There was no association of feeding pattern with immunologic outcomes. In adjusted analyses, children who were underweight (weight-for-age < -2.0) or with CD4% <15% at baseline were 4.30 (95% confidence interval: 1.16, 15.87; P < 0.05) times and 3.41 (95% confidence interval: 1.10, 10.52; P < 0.05) times, respectively, more likely not to attain CD4% of ≥ 25% at 12 months. CONCLUSION Baseline nutritional status and CD4% were independently associated with failure to reach CD4% ≥ 25% at 12 months among HIV-infected Nigerian children on ART. These results emphasize the importance of early screening and initiation of ART among children in resource-poor settings before malnutrition and severe immunosuppression sets in.
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Antiretroviral regimens containing a single protease inhibitor increase risk of virologic failure in young HIV-infected children. Pediatr Infect Dis J 2013; 32:361-3. [PMID: 23114373 DOI: 10.1097/inf.0b013e318279c800] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Rifampin-based tuberculosis treatment can cause subtherapeutic concentrations of protease inhibitors and virologic failure in children receiving antiretroviral therapy. Among 217 children on antiretroviral therapy, tuberculosis cotreatment (in 78) was associated with virologic failure. Ritonavir-based single protease inhibitor antiretroviral therapy regimen predicted virologic failure (adjusted odds ratio 3.7, 95% confidence interval 1.5-8.9, P = 0.004) on multivariate analysis.
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Puthanakit T, Jourdain G, Suntarattiwong P, Chokephaibulkit K, Siangphoe U, Suwanlerk T, Prasitsuebsai W, Sirisanthana V, Kosalaraksa P, Petdachai W, Hansudewechakul R, Waranawat N, Ananworanich J. High virologic response rate after second-line boosted protease inhibitor-based antiretroviral therapy regimens in children from a resource limited setting. AIDS Res Ther 2012; 9:20. [PMID: 22709957 PMCID: PMC3469338 DOI: 10.1186/1742-6405-9-20] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 06/09/2012] [Indexed: 11/10/2022] Open
Abstract
Background Limited data exist for the efficacy of second-line antiretroviral therapy among children in resource limited settings. We assessed the virologic response to protease inhibitor-based ART after failing first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. Methods A retrospective chart review was conducted at 8 Thai sites of children who switched to PI –based regimens due to failure of NNRTI –based regimens. Primary endpoints were HIV RNA < 400 copies/ml and CD4 change over 48 weeks. Results Data from 241 children with median baseline values before starting PI-based regimens of 9.1 years for age, 10% for CD4%, and 4.8 log10 copies/ml for HIV RNA were included; 104 (41%) received a single ritonavir-boosted PI (sbPI) with 2 NRTIs and 137 (59%) received double-boosted PI (dbPI) with/without NRTIs based on physician discretion. SbPI children had higher baseline CD4 (17% vs. 6%, p < 0.001), lower HIV RNA (4.5 vs. 4.9 log10 copies/ml, p < 0.001), and less frequent high grade multi-NRTI resistance (12.4% vs 60.5%, p < 0.001) than the dbPI children. At week 48, 81% had HIV RNA < 400 copies/ml (sbPI 83.1% vs. dbPI 79.8%, p = 0.61) with a median CD4 rise of 9% (+7%vs. + 10%, p < 0.005). However, only 63% had HIV RNA < 50 copies/ml, with better viral suppression seen in sbPI (76.6% vs. 51.4%, p 0.002). Conclusion Second-line PI therapy was effective for children failing first line NNRTI in a resource-limited setting. DbPI were used in patients with extensive drug resistance due to limited treatment options. Better access to antiretroviral drugs is needed.
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Zyl GUV, Rabie H, Nuttall JJ, Cotton MF. It is time to consider third-line options in antiretroviral-experienced paediatric patients? J Int AIDS Soc 2011; 14:55. [PMID: 22085598 PMCID: PMC3228719 DOI: 10.1186/1758-2652-14-55] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 11/15/2011] [Indexed: 11/10/2022] Open
Abstract
Background The historic use of full-dose ritonavir as part of an unboosted protease inhibitor (PI)-based antiretroviral therapy regimen in some South African children contributes to the frequent accumulation of major PI resistance mutations. Methods In order to describe the prevalence of major PI resistance in children failing antiretroviral therapy and to investigate the clinical, immunological and virological outcomes in children with PI resistance, we conducted a cross-sectional study, with a nested case series, following up those children with major PI resistance. The setting was public health sector antiretroviral clinics in the Western Cape province of South Africa, and the subjects were children failing antiretroviral therapy. The following outcome measures were investigated: CD4 count, viral load and resistance mutations. Results Fourteen (17%) of 82 patients, referred from tertiary hospitals, had major PI resistance. All these patients were exposed to regimens that included ritonavir as a single PI. Immune reconstitution and clinical benefit were achieved when using a lopinavir/ritonavir-based treatment regimen in these children with prior PI resistance. At first HIV-1 viral load follow up after initial resistance testing (n = 11), only one patient had a viral load of less than 400 copies/ml; at a subsequent follow up (n = 9), the viral loads of five patients were less than 400 copies/ml. Patients retained on LPV/r had lower viral loads than those switched to a non-nucleoside reverse transcriptase inhibitor (NNRTI). However, two of three patients with follow-up resistance tests accumulated additional PI resistance. Conclusions In children with pre-existing PI resistance, although initially effective, the long-term durability of a lopinavir/ritonavir-based treatment regimen can be compromised by the accumulation of resistance mutations. Furthermore, a second-line NNRTI regimen is often not durable in these patients. As genotypic resistance testing and third-line treatment regimens are costly and limited in availability, we propose eligibility criteria to identify patients with high risk for resistance and guidance on drug selection for children who would benefit from third-line therapy.
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Affiliation(s)
- Gert U van Zyl
- Division of Medical Virology, Stellenbosch University, and National Health Laboratory Service Tygerberg, Parow, Cape Town, South Africa.
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Taylor BS, Hunt G, Abrams EJ, Coovadia A, Meyers T, Sherman G, Strehlau R, Morris L, Kuhn L. Rapid development of antiretroviral drug resistance mutations in HIV-infected children less than two years of age initiating protease inhibitor-based therapy in South Africa. AIDS Res Hum Retroviruses 2011; 27:945-56. [PMID: 21345162 PMCID: PMC3161115 DOI: 10.1089/aid.2010.0205] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Data on the development of antiretroviral drug resistance in HIV-1-infected children receiving protease inhibitor (PI)-based antiretroviral therapy (ART) are limited. We examined antiretroviral resistance among a cohort of 323 South African HIV-infected children <2 years old exposed to nevirapine for prevention of mother-to-child transmission. Ritonavir (RTV) was used initially for 138 children who were <6 months old or receiving antimycobacterial therapy; otherwise children received lopinavir/ritonavir (LPV/r)-based ART. HIV-1 population sequencing of the pol gene was conducted on all pretreatment samples and on posttreatment samples for children who did not achieve HIV-1 plasma RNA <400 copies/ml by 52 weeks. Among children in the cohort, 38 died, 22 had <24 weeks follow-up, 209 achieved virologic suppression, and 54 did not. Of 41 children without virologic suppression with posttreatment HIV genotype data available, major resistance mutations were found in 32 (78%): 14 (36%) had PI mutations including V82A, M46I, and L90M; 29 (71%) had M184V/I; and three had NNRTI mutations (K103N, Y181C, and G190A). Among the children who did not achieve virologic suppression, none of the seven children treated exclusively with LPV/r developed PI-related mutations, compared with 14 of 32 (44%) who received RTV-based regimens (p=0.036); PI genotypes were unavailable for two children. Seventy-eight percent of children without virologic suppression developed resistance mutations that impact second-line ART options. Only children who received RTV-based ART developed major PI-related resistance mutations, and use of this regimen should be avoided.
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Affiliation(s)
- Barbara S. Taylor
- Division of Infectious Diseases, Department of Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas and College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Gillian Hunt
- AIDS Research Unit, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Elaine J. Abrams
- International Center for AIDS Programs, Mailman School of Public Health, Columbia University, New York, New York
| | - Ashraf Coovadia
- Empilweni Services and Research Unit, Rahima Moosa Mothers and Children Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Tammy Meyers
- Harriet Shezi Clinic, Chris Hani Baragwanath Hospital, Enhancing Childhood HIV Outcomes (ECHO), University of the Witwatersrand, Johannesburg, South Africa
| | - Gayle Sherman
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, and National Health Laboratory Service, Johannesburg, South Africa
| | - Renate Strehlau
- Empilweni Services and Research Unit, Rahima Moosa Mothers and Children Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Lynn Morris
- AIDS Research Unit, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Ahoua L, Guenther G, Rouzioux C, Pinoges L, Anguzu P, Taburet AM, Balkan S, Olson DM, Olaro C, Pujades-Rodríguez M. Immunovirological response to combined antiretroviral therapy and drug resistance patterns in children: 1- and 2-year outcomes in rural Uganda. BMC Pediatr 2011; 11:67. [PMID: 21791095 PMCID: PMC3176156 DOI: 10.1186/1471-2431-11-67] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 07/26/2011] [Indexed: 02/05/2023] Open
Abstract
Background Children living with HIV continue to be in urgent need of combined antiretroviral therapy (ART). Strategies to scale up and improve pediatric HIV care in resource-poor regions, especially in sub-Saharan Africa, require further research from these settings. We describe treatment outcomes in children treated in rural Uganda after 1 and 2 years of ART start. Methods Cross-sectional assessment of all children treated with ART for 12 (M12) and 24 (M24) months was performed. CD4 counts, HIV RNA levels, antiretroviral resistance patterns, and non-nucleoside reverse transcriptase inhibitor (NNRTI) plasma concentrations were determined. Patient adherence and antiretroviral-related toxicity were assessed. Results Cohort probabilities of retention in care were 0.86 at both M12 and M24. At survey, 71 (83%, M12) and 32 (78%, M24) children remained on therapy, and 84% participated in the survey. At ART start, 39 (45%) were female; median age was 5 years. Median initial CD4 percent was 11% [IQR 9-15] in children < 5 years old (n = 12); CD4 count was 151 cells/mm3 [IQR 38-188] in those ≥ 5 years old (n = 26). At M12, median CD4 gains were 11% [IQR 10-14] in patients < 5 years old, and 206 cells/mm3 [IQR 98-348] in ≥ 5 years old. At M24, median CD4 gains were 11% [IQR 5-17] and 132 cells/mm3 [IQR 87-443], respectively. Viral suppression (< 400 copies/mL) was achieved in 59% (M12) and 33% (M24) of children. Antiretroviral resistance was found in 25% (M12) and 62% (M24) of children. Overall, 29% of patients had subtherapeutic NNRTI plasma concentrations. Conclusions After one year of therapy, satisfactory survival and immunological responses were observed, but nearly 1 in 4 children developed viral resistance and/or subtherapeutic plasma antiretroviral drug levels. Regular weight-adjustment dosing and strategies to reinforce and maintain ART adherence are essential to maximize duration of first-line therapy in children in resource-limited countries.
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Ndondoki C, Dabis F, Namale L, Becquet R, Ekouevi D, Bosse-Amani C, Arrivé E, Leroy V. Survie et évolution clinique et biologique des enfants infectés par le VIH traités par les antiretroviraux en Afrique : revue de littérature, 2004–2009. Presse Med 2011. [DOI: 10.1016/j.lpm.2010.11.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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A biregional survey and review of first-line treatment failure and second-line paediatric antiretroviral access and use in Asia and southern Africa. J Int AIDS Soc 2011; 14:7. [PMID: 21306608 PMCID: PMC3058075 DOI: 10.1186/1758-2652-14-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 02/09/2011] [Indexed: 11/10/2022] Open
Abstract
Background To better understand the need for paediatric second-line antiretroviral therapy (ART), an ART management survey and a cross-sectional analysis of second-line ART use were conducted in the TREAT Asia Paediatric HIV Observational Database and the IeDEA Southern Africa (International Epidemiologic Databases to Evaluate AIDS) regional cohorts. Methods Surveys were conducted in April 2009. Analysis data from the Asia cohort were collected in March 2009 from 12 centres in Cambodia, India, Indonesia, Malaysia, and Thailand. Data from the IeDEA Southern Africa cohort were finalized in February 2008 from 10 centres in Malawi, Mozambique, South Africa and Zimbabwe. Results Survey responses reflected inter-regional variations in drug access and national guidelines. A total of 1301 children in the TREAT Asia and 4561 children in the IeDEA Southern Africa cohorts met inclusion criteria for the cross-sectional analysis. Ten percent of Asian and 3.3% of African children were on second-line ART at the time of data transfer. Median age (interquartile range) in months at second-line initiation was 120 (78-145) months in the Asian cohort and 66 (29-112) months in the southern African cohort. Regimens varied, and the then current World Health Organization-recommended nucleoside reverse transcriptase combination of abacavir and didanosine was used in less than 5% of children in each region. Conclusions In order to provide life-long ART for children, better use of current first-line regimens and broader access to heat-stable, paediatric second-line and salvage formulations are needed. There will be limited benefit to earlier diagnosis of treatment failure unless providers and patients have access to appropriate drugs for children to switch to.
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Affiliation(s)
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- TREAT Asia/amfAR - The Foundation for AIDS Research, Bangkok, Thailand.
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Peacock-Villada E, Richardson BA, John-Stewart GC. Post-HAART outcomes in pediatric populations: comparison of resource-limited and developed countries. Pediatrics 2011; 127:e423-41. [PMID: 21262891 PMCID: PMC3025421 DOI: 10.1542/peds.2009-2701] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2010] [Indexed: 11/24/2022] Open
Abstract
CONTEXT No formal comparison has been made between the pediatric post-highly active antiretroviral therapy (HAART) outcomes of resource-limited and developed countries. OBJECTIVE To systematically quantify and compare major baseline characteristics and clinical end points after HAART between resource-limited and developed settings. METHODS Published articles and abstracts (International AIDS Society 2009, Conference on Retroviruses and Opportunistic Infections 2010) were examined from inception (first available publication for each search engine) to March 2010. Publications that contained data on post-HAART mortality, weight-for-age z score (WAZ), CD4 count, or viral load (VL) changes in pediatric populations were reviewed. Selected studies met the following criteria: (1) patients were younger than 21 years; (2) HAART was given (≥ 3 antiretroviral medications); and (3) there were >20 patients. Data were extracted for baseline age, CD4 count, VL, WAZ, and mortality, CD4 and virologic suppression over time. Studies were categorized as having been performed in a resource-limited country (RLC) or developed country (DC) on the basis of the United Nations designation. Mean percentage of deaths per cohort and deaths per 100 child-years, baseline CD4 count, VL, WAZ, and age were calculated for RLCs and DCs and compared by using independent samples t tests. RESULTS Forty RLC and 28 DC publications were selected (N = 17 875 RLCs; N = 1835 DC). Mean percentage of deaths per cohort and mean deaths per 100 child-years after HAART were significantly higher in RLCs than DCs (7.6 vs 1.6, P < .001, and 8.0 vs 0.9, P < .001, respectively). Mean baseline CD4% was 12% in RLCs and 23% in DCs (P = .01). Mean baseline VLs were 5.5 vs 4.7 log(10) copies per mL in RLCs versus DCs (P < .001). CONCLUSIONS Baseline CD4% and VL differ markedly between DCs and RLCs, as does mortality after pediatric HAART. Earlier diagnosis and treatment of pediatric HIV in RLCs would be expected to result in better HAART outcomes.
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Monoboosted lopinavir/ritonavir as simplified second-line maintenance therapy in virologically suppressed children. AIDS 2011; 25:315-23. [PMID: 21157298 DOI: 10.1097/qad.0b013e32834231f5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Monoboosted protease inhibitor is being evaluated as a strategy to simplify therapy in virologically suppressed patients who are on complex regimens. METHODS Children with two consecutive HIV-RNA below 50 copies/ml at least 3 months apart while on double boosted protease inhibitor (dPI) were switched to monoboosted lopinavir/r (mLPV/r). The previous dPI regimen was resumed within 4 weeks in children who experienced virological failure defined as two HIV-RNA at least 500 or three HIV-RNA at least 50 copies/ml. Primary endpoint was the proportion of children still on mLPV/r and having HIV-RNA less than 50 copies/ml at week 48. RESULTS Forty children on LPV/r + saquinavir (90%) or LPV/r + indinavir (10%) were enrolled, 50% were female, median [interquartile range (IQR)] age was 11.7 (10.2-13.5) years, and body weight was 29.4 (24.1-40.2 kg). The median (IQR) CD4% was 27 (23.5-29.5%). At 48 weeks, none had died or had HIV disease progression. Thirty-one children were on mLPV/r and 29 (72.5%) had HIV-RNA less than 50 copies/ml. Nine resumed dPI due to mLPV/r failure with four achieving undetectable HIV-RNA. Overall, 31 children (82.5%) had HIV-RNA suppression. Predicting factor for failing mLPV/r was baseline HIV-RNA at least 50 copies/ml. No major protease mutations were found. CONCLUSION By simplifying second-line treatment from dPI to mLPV/r, the majority of children had sustained viral suppression at 48 weeks. Randomized study of simplified mono protease inhibitor therapy in children is warranted.
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Long-term outcome of children receiving antiretroviral treatment in rural South Africa: substantial virologic failure on first-line treatment. Pediatr Infect Dis J 2011; 30:52-6. [PMID: 20631647 DOI: 10.1097/inf.0b013e3181ed2af3] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Long-term (>12 months follow-up) virologic data of children receiving antiretroviral therapy (ART) in Sub-Saharan Africa are limited. Data from rural areas are especially scarce. The aim of this study was to evaluate the long-term virologic outcome of a pediatric cohort in rural South Africa. METHODS We performed a retrospective, observational cohort study, including children who initiated ART at least 1 year before data-analysis. Regular monitoring, including HIV-RNA testing, was performed. Genotypic resistance testing was done for children with virologic failure (HIV-RNA >1000 copies/mL). Logistic regression analysis was used to determine predictors of virologic failure. RESULTS A total of 101 children were included. Median duration since beginning ART was 31 months. Overall patient retention-rate was 76% (77/101), with early mortality being the main cause of attrition (13/24, 54%). Initial immunologic and virologic responses were excellent. However, 38% (31/81) of children subsequently experienced virologic failure. Correlation between virologic failure and immunologic decline was nearly absent. At the time of failure, multiple non-nucleoside reverse transcription inhibitor-associated mutations were observed in 52% (12/23) of children. No definite predictors of virologic failure could be determined. CONCLUSIONS ART provides significant benefits for children in this rural African setting, but the finding that a large proportion of children had virologic failure and developed major drug-resistance mutations on first-line ART is worrying. Causes of failure need to be analyzed and effective prevention strategies are needed. Because of the lack of a correlation between immunologic and virologic failure, treatment failure generally stays unnoticed in settings where HIV-RNA testing is not available.
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Hansudewechakul R, Sirisanthana V, Kurniati N, Puthanakit T, Lumbiganon P, Yusoff NKN, Fong SM, Nallusamy R, Srasuebkul P, Law M, Sohn AH, Chokephaibulkit K. Antiretroviral therapy outcomes of HIV-infected children in the TREAT Asia pediatric HIV observational database. J Acquir Immune Defic Syndr 2010; 55:503-9. [PMID: 20842043 PMCID: PMC2975064 DOI: 10.1097/qai.0b013e3181f5379a] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We report responses to combination antiretroviral therapy (cART) in the Therapeutics Research, Education, and AIDS Training in Asia Pediatric HIV Observational Database. METHODS Children included were those who had received cART (ie, ≥3 antiretrovirals) at <18 years. The analysis was intention-to-treat by the first cART regimen. Median values are provided with interquartile ranges; hazard ratios (HRs) with 95% confidence intervals. RESULTS Of the 1655 children included, 50.4% were male, with a median age at cART of 7.0 (3.9-9.8) years and CD4 of 8% (2.0%-15%); 92.5% were started on an NNRTI; median duration of follow-up was 2.9 (1.4-4.6) years. Loss-to-follow-up and death rates were 4.2 (3.7-4.8) and 2.1 (1.7-2.5) per 100 person-years, respectively. At 36 months, median CD4 was 26% (21%-31%); 81% of those with viral load (n = 302) were <400 copies per milliliter. Children who reached CD4 ≥25% within 5 years were more likely to be females (HR: 1.4; 1.2-1.7), start before 18 months old (HR: 3.8; 2.4-6.2), lack a history of monotherapy/dual therapy (HR: 1.7; 1.4-2.5), and have a higher baseline CD4 (per 10% increase: HR: 2; 1.9-2.2). CONCLUSIONS These data underscore the need for early diagnosis and cART initiation to preserve immune function.
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Affiliation(s)
| | | | - Nia Kurniati
- Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | | | | | | | | | - Preeyaporn Srasuebkul
- National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, Australia
| | - Matthew Law
- National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, Australia
| | - Annette H. Sohn
- TREAT Asia/amfAR – The Foundation for AIDS Research, Bangkok, Thailand
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Fatti G, Bock P, Grimwood A, Eley B. Increased vulnerability of rural children on antiretroviral therapy attending public health facilities in South Africa: a retrospective cohort study. J Int AIDS Soc 2010; 13:46. [PMID: 21108804 PMCID: PMC3002304 DOI: 10.1186/1758-2652-13-46] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 11/25/2010] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A large proportion of the 340,000 HIV-positive children in South Africa live in rural areas, yet there is little sub-Saharan data comparing rural paediatric antiretroviral therapy (ART) programme outcomes with urban facilities. We compared clinical, immunological and virological outcomes between children at seven rural and 37 urban facilities across four provinces in South Africa. METHODS We conducted a retrospective cohort study of routine data of children enrolled on ART between November 2003 and March 2008 in three settings, namely: urban residence and facility attendance (urban group); rural residence and facility attendance (rural group); and rural residents attending urban facilities (rural/urban group). Outcome measures were: death, loss to follow up (LTFU), virological suppression, and changes in CD4 percentage and weight-for-age-z (WAZ) scores. Kaplan-Meier estimates, logrank tests, multivariable Cox regression and generalized estimating equation models were used to compare outcomes between groups. RESULTS In total, 2332 ART-naïve children were included, (1727, 228 and 377 children in the urban, rural and rural/urban groups, respectively). At presentation, rural group children were older (6.7 vs. 5.6 and 5.8 years), had lower CD4 cell percentages (10.0% vs. 12.8% and 12.7%), lower WAZ scores (-2.06 vs. -1.46 and -1.41) and higher proportions with severe underweight (26% vs.15% and 15%) compared with the urban and rural/urban groups, respectively. Mortality was significantly higher in the rural group and LTFU significantly increased in the rural/urban group. After 24 months of ART, mortality probabilities were 3.4% (CI: 2.4-4.8%), 7.7% (CI: 4.5-13.0%) and 3.1% (CI: 1.7-5.6%) p = 0.0137; LTFU probabilities were 11.5% (CI: 9.3-14.0%), 8.8% (CI: 4.5-16.9%) and 16.6% (CI: 12.4-22.6%), p = 0.0028 in the urban, rural and rural/urban groups, respectively. The rural group had an increased adjusted mortality probability, adjusted hazards ratio 2.41 (CI: 1.25-4.67) and the rural/urban group had an increased adjusted LTFU probability, aHR 2.85 (CI: 1.41-5.79). The rural/urban group had a decreased adjusted probability of virological suppression compared with the urban group at any timepoint on treatment, adjusted odds ratio 0.67 (CI: 0.48-0.93). CONCLUSIONS Rural HIV-positive children are a vulnerable group, exhibiting delayed access to ART and an increased risk of poor outcomes while on ART. Expansion of rural paediatric ART programmes, with future research exploring improvements to rural health system effectiveness, is required.
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Affiliation(s)
- Geoffrey Fatti
- Kheth'Impilo, Green Square, 37 Hares Crescent, Woodstock, 7925, Cape Town, South Africa
- Lung Clinical Research Unit, University of Cape Town Lung Institute, George Street, Mowbray, Cape Town, South Africa
| | - Peter Bock
- Kheth'Impilo, Green Square, 37 Hares Crescent, Woodstock, 7925, Cape Town, South Africa
- Primary Healthcare Directorate, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Ashraf Grimwood
- Kheth'Impilo, Green Square, 37 Hares Crescent, Woodstock, 7925, Cape Town, South Africa
| | - Brian Eley
- Paediatric Infectious Diseases Unit, Red Cross Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Klipfontein Road, Rondebosch, Cape Town, South Africa
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Emmett SD, Cunningham CK, Mmbaga BT, Kinabo GD, Schimana W, Swai ME, Bartlett JA, Crump JA, Reddy EA. Predicting virologic failure among HIV-1-infected children receiving antiretroviral therapy in Tanzania: a cross-sectional study. J Acquir Immune Defic Syndr 2010; 54:368-75. [PMID: 20216225 PMCID: PMC4185279 DOI: 10.1097/qai.0b013e3181cf4882] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many HIV care and treatment programs in resource-limited settings rely on clinical and immunologic monitoring of antiretroviral therapy (ART), but accuracy of this strategy to detect virologic failure (VF) among children has not been evaluated. METHODS A cross-sectional sample of HIV-infected children aged 1-16 years on ART >or=6 months receiving care at a Tanzanian referral center underwent clinical staging, CD4 lymphocyte measurement, plasma HIV-1 RNA level, and complete blood count. Associations with VF (HIV-1 RNA >or=400 copies/mL) were determined utilizing bivariable and multivariate analyses; accuracy of current clinical and immunologic guidelines in identifying children with VF was assessed. FINDINGS Of 206 children (median age 8.7 years, ART duration 2.4 years), 65 (31.6%) demonstrated VF at enrollment. Clinical and immunological criteria identified 2 (3.5%) of 57 children with VF on first-line therapy, exhibiting 3.5% sensitivity and 100% specificity. VF was associated with younger age, receipt of nevirapine vs. efavirenz-based regimen, CD4% < 25%, and physician documentation of maladherence (P < 0.05 on bivariable analysis); the latter 2 factors remained significant on multivariate logistic regression. INTERPRETATION This study demonstrates poor performance of clinical and immunologic criteria in identifying children with virologic failure. Affordable techniques for measuring HIV-1 RNA level applicable in resource-limited settings are urgently needed.
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Affiliation(s)
- Susan D. Emmett
- Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Howard Hughes Medical Institute Research Training Fellowships for Medical Students, Bethesda, Maryland, USA
| | | | | | | | | | - Mark E. Swai
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - John A. Bartlett
- Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - John A. Crump
- Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical College, Tumaini University, Moshi, Tanzania
| | - Elizabeth A. Reddy
- Duke University Medical Center, Durham, North Carolina, USA
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
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Ramos J. Boosted protease inhibitors as a therapeutic option in the treatment of HIV-infected children. HIV Med 2010; 10:536-47. [PMID: 19785664 DOI: 10.1111/j.1468-1293.2009.00728.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Paediatric HIV treatment must address various special considerations. Administration of pharmacokinetically enhanced protease inhibitors (PIs) can improve paediatric therapeutic outcomes. The objective of this study was to review the use of boosted PI regimens in children. METHODS Systematic literature searches of published manuscripts and conference databases using generic drug names and specific keywords were performed to ensure thorough and balanced reporting of available data. RESULTS Boosted PI regimens offer multiple options across a range of ages and are efficacious in naïve and experienced children; safety and tolerability are similar to those observed in adults. Novel boosted PI simplification approaches may foster adherence and diminish resistance. CONCLUSIONS Boosted PIs are key components of first- and second-line treatments in children. Identifying factors associated with the response to highly active antiretroviral therapy in children may ultimately permit individualized therapies.
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Affiliation(s)
- Jt Ramos
- Department of Paediatrics, University Hospital of Getafe, Madrid, Spain.
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The influence of nutritional status on the response to HAART in HIV-infected children in South Africa. Pediatr Infect Dis J 2010; 29:511-3. [PMID: 20179664 DOI: 10.1097/inf.0b013e3181d1e989] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While the impact of HAART on growth in children is well established, the influence of prior nutritional status on the response to HAART is not well known. METHODS A retrospective study was conducted on 120 children in South Africa. Patients were divided into 3 groups (normal, moderately underweight, and severely underweight) based on weight-for-age z-scores (WAZ). Age, weight, height, CD4 cell percentage, and viral load were recorded at initiation of HAART and after 24 months of therapy. Data were analyzed using t-tests, chi tests, and one-way ANOVA. RESULTS At baseline, 58% of children were normal weight, 18% moderately underweight, and 23% severely underweight. After 24 months of HAART, WAZ improved significantly in moderately and severely underweight patient groups compared with the normal group. Height-for-age z-scores (HAZ) increased in all 3 groups with severely underweight children gaining more height than normal weight counterparts. Weight-for-height z-scores (WHZ) normalized in the severely underweight group. Mean CD4 cell percentages increased significantly in all 3 groups while viral loads decreased significantly in all groups with no differences among the groups at the end of 24 months of therapy. Of the entire cohort, 75% achieved undetectable HIV RNA viral loads. CONCLUSIONS Underlying malnutrition does not adversely affect growth, immunologic or virologic response to HAART in HIV-infected children. Underweight children exhibit an equally robust response to treatment as their well-nourished peers.
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Sauvageot D, Schaefer M, Olson D, Pujades-Rodriguez M, O'Brien DP. Antiretroviral therapy outcomes in resource-limited settings for HIV-infected children <5 years of age. Pediatrics 2010; 125:e1039-47. [PMID: 20385636 DOI: 10.1542/peds.2009-1062] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We describe medium-term outcomes for young children receiving antiretroviral therapy (ART) in resource-limited countries. METHODS Analyses were conducted on surveillance data for children <5 years of age receiving ART (initiated April 2002 to January 2008) in 48 HIV/AIDS treatment programs in Africa and Asia. Primary outcome measures were probability of remaining in care, probability of developing World Health Organization stage 4 clinical events, rate of switching to second-line ART, and drug toxicity, compared at 6, 12, 24, and 36 months of ART. RESULTS Of 3936 children (90% in Africa) initiating ART, 9% were <12 months, 50% were 12 to 35 months, and 41% were 36 to 59 months of age. The median time of ART was 10.5 months. Probabilities of remaining in care after 12, 24, and 36 months of ART were 0.85, 0.80, and 0.75, respectively. Compared with children 36 to 59 months of age at ART initiation, probabilities of remaining in care were significantly lower for children <12 months of age. Overall, 55% and 69% of deaths and losses to follow-up occurred in the first 3 and 6 months of ART, respectively. Probabilities of developing stage 4 clinical events after 12, 24, and 36 months of ART were 0.03, 0.06, and 0.09, respectively. Only 33 subjects (0.8%) switched to second-line regimens, and 151 (3.8%) experienced severe drug toxicities. CONCLUSIONS Large-scale ART for children <5 years of age in resource-limited settings is feasible, with encouraging clinical outcomes, but efforts should be increased to improve early HIV diagnosis and treatment.
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Reitz C, Coovadia A, Ko S, Meyers T, Strehlau R, Sherman G, Kuhn L, Abrams EJ. Initial response to protease-inhibitor-based antiretroviral therapy among children less than 2 years of age in South Africa: effect of cotreatment for tuberculosis. J Infect Dis 2010; 201:1121-31. [PMID: 20214476 DOI: 10.1086/651454] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND South African guidelines recommend protease-inhibitor-based antiretroviral therapy (ART) with lopinavir-ritonavir for human immunodeficiency virus (HIV)-infected children <36 months of age. We investigated factors associated with viral suppression and mortality among young children initiating ART. METHODS Treatment-naive, ART-eligible, HIV-infected children (aged 6-104 weeks) were enrolled in an ART strategies trial in South Africa and initiated protease-inhibitor-based ART. Mortality and the probability of viral suppression (defined as HIV RNA load of <400 copies/mL) by 39 weeks after ART initiation were investigated. RESULTS Of 254 children who initiated ART, 99 (39%) were cotreated for tuberculosis during follow-up. The mortality rate was 14%. Factors predicting mortality were lower pre-ART weight-for-age z score and higher HIV RNA load. By 39 weeks, 84% of surviving children achieved viral suppression. Children who were not cotreated for tuberculosis were more likely to achieve viral suppression (94.8%) than were children who were receiving cotreatment at ART initiation (74.2%) or who started tuberculosis cotreatment after ART initiation (51.6%; P < .001). Other factors predicting lower probability of viral suppression were lower pre-ART weight- and length-for-age z score, higher HIV RNA load, and World Health Organization disease stage. CONCLUSION High rates of viral suppression can be achieved among infants and young children who initiate protease-inhibitor-based ART. Cotreatment for tuberculosis reduced viral suppression. How best to treat HIV-infected children who require tuberculosis treatment warrants urgent investigation.
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Affiliation(s)
- Cordula Reitz
- Gertrude H. Sergievsky Center and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, New York 10032, USA
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Early clinical outcomes in children enrolled in human immunodeficiency virus infection care and treatment in lesotho. Pediatr Infect Dis J 2010; 29:340-5. [PMID: 20019645 DOI: 10.1097/inf.0b013e3181bf8ecb] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children are largely underrepresented among those accessing treatment of HIV infection in Africa. Reported outcomes of children enrolled in national care and treatment programs are needed to inform the widespread scale-up of pediatric HIV care in resource-limited settings. METHODS The objective of this article is to report on the early outcomes of a pediatric HIV infection care and treatment program in Lesotho during its first 14 months of operation. Clinical protocols are described, and characteristics and outcomes of the first cohort of children enrolled in care are reported, derived from a retrospective review of medical records. RESULTS In the program's first 14 months, 1566 children and adolescents aged between 0 and 16 years were evaluated for HIV, with 567 (36%) confirmed to be infected. Of infected patients, 61% presented with advanced or severe symptoms of HIV disease and 65% presented with CD4 profiles consistent with advanced or severe immunodeficiency, based on World Health Organization 2006 guidelines. Two hundred and eighty four children received highly active antiretroviral therapy. The mortality rate was 18.6 deaths per 100 patient years of follow-up. Ninety-nine percent of deaths occurred within 90 days of enrollment. Deceased patients were significantly younger, had higher rates of stunting and wasting, and were more likely to present with low CD4 cell counts. CONCLUSION Highly active antiretroviral therapy was well tolerated, but the early mortality rate was high despite concurrent management of HIV and comorbidities. Given that hundreds of thousands of children remain without access to HIV care, renewed efforts are needed to reach this underserved population.
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Prasitsuebsai W, Bowen AC, Pang J, Hesp C, Kariminia A, Sohn AH. Pediatric HIV clinical care resources and management practices in Asia: a regional survey of the TREAT Asia pediatric network. AIDS Patient Care STDS 2010; 24:127-31. [PMID: 20059355 DOI: 10.1089/apc.2009.0224] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Characterizing intraregional differences in current pediatric HIV care and treatment in Asia can guide the development of clinical practice guidelines and improve the understanding of local resource availability. The Therapeutics Research, Education, and AIDS Training in Asia (TREAT Asia) Pediatric Program is a collaboration of clinics and referral hospitals studying pediatric HIV outcomes in the region. A Web-based survey to characterize clinical management practices and monitoring resources was developed and distributed to 20 sites in January 2008. Seventeen (85%) sites from 6 countries responded through April 2008; 14 (82%) were hospital-based and 16 (94%) were public facilities. Of 4050 HIV-infected children under care, 3606 (89%) were on antiretroviral treatment; 80% were on their first mono-, dual-, or triple-drug regimen and 74% were on nevirapine- or efavirenz-based regimens. Fifteen (88%) sites had consistent access to polymerase chain reaction (PCR) testing for infant diagnosis. All sites had access to CD4 testing, with 13 (76%) routinely monitoring patients every 3-6 months; 7 (41%) sites monitored viral load at 6- to 12-month intervals. Although there is some variation in clinical practices, high levels of treatment and monitoring resources were available at these sites. The availability of PCR for early infant diagnosis positions them to implement recent WHO recommendations to treat HIV-infected children younger than 1 year of age. This information will be used to develop future research and programs to support children with HIV in Asia.
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Affiliation(s)
| | - Asha C. Bowen
- Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Joselyn Pang
- TREAT Asia, amfAR–The Foundation for AIDS Research, Bangkok, Thailand
| | - Cees Hesp
- PharmAccess, Amsterdam, The Netherlands
| | - Azar Kariminia
- National Centre in HIV Epidemiology and Clinical Research, Sydney, New South Wales, Australia
| | - Annette H. Sohn
- TREAT Asia, amfAR–The Foundation for AIDS Research, Bangkok, Thailand
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Sequencing of antiretroviral therapy in children in low- and middle-income countries. Curr Opin HIV AIDS 2010; 5:54-60. [DOI: 10.1097/coh.0b013e3283339bd8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Aurpibul L, Puthanakit T, Taecharoenkul S, Sirisanthana T, Sirisanthana V. Reversal of growth failure in HIV-infected Thai children treated with non-nucleoside reverse transcriptase inhibitor-based antiretroviral therapy. AIDS Patient Care STDS 2009; 23:1067-71. [PMID: 19909170 DOI: 10.1089/apc.2009.0093] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Growth failure is a common problem in HIV-infected children. The extent to which this growth failure could be reversed after the children receive antiretroviral therapy (ART) is not known. This study assessed the incidence of growth failure in HIV-infected Thai children, impact of ART on growth, and the predictors of growth reversal after initiating ART. Growth parameters and other characteristics were extracted from the database of a prospective cohort of HIV-infected children (age <or=15 years) who were enrolled to initiate non-nucleoside reverse transcriptase inhibitor-based ART between August 2002 and May 2007. Body weight and height measurements, CD4 cell counts, plasma HIV RNA levels were collected at baseline and 24-week intervals. A total of 225 HIV-infected children were included, 116 (51%) were males. The median age at baseline was 7.4 years (interquartile range [IQR] 5.2-9.8). Fifty-three percent were in Centers for Disease Control and Prevention (CDC) category C and 54% had CD4 percentage 5 or less. The mean (standard deviation [SD]) of baseline weight-for-age (WAZ) and height-for-age (HAZ) z-scores were -2.02 (1.17) and -2.22 (1.51). The median follow-up time was 216 weeks (IQR 120-240). The cumulative probability of growth reversal among the 179 subjects with growth failure at entry was 58% (95% confidence interval [CI] 49-67) at week 240. In a multivariate Cox regression model, higher entry WAZ (p < 0.001) and HAZ (p < 0.001), use of a nevirapine-based regimen (compared to efavirenz, p = 0.027) and larger CD4% gains to week 48 (p < 0.001) were significant predictors of growth reversal after initiating ART. NNRTI-based ART leads to a substantial improvement in growth of HIV-infected children. Initiation of ART before the children developed growth failure should be encouraged.
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Affiliation(s)
- Linda Aurpibul
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Thanyawee Puthanakit
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Thira Sirisanthana
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Virat Sirisanthana
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Abstract
Even as pediatric rollout programs are struggling to meet global need, increasing numbers of children are failing first-line antiretroviral therapy in low- and middle-income countries. Without better access to viral load monitoring, second-line antiretrovirals and research to guide optimal regimen selection, it will be difficult to ensure that HIV-infected children will survive into adulthood. Data available on pediatric drug resistance demonstrate that failure occurs early in childhood. Studies of salvage drug options have been promising, but are primarily conducted in adults. Evidence-based approaches to regimen selection, pediatric antiretroviral formulations and expanded access to novel drugs are now required to prepare for the future.
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Affiliation(s)
- Annette H Sohn
- TREAT Asia/amfAR – The Foundation for AIDS Research, Bangkok, Thailand
| | - Jintanat Ananworanich
- The Southeast Asia Research Collaboration with Hawaii (SEARCH), Bangkok, Thailand
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
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Mubiana-Mbewe M, Bolton-Moore C, Banda Y, Chintu N, Nalubamba-Phiri M, Giganti M, Guffey MB, Sambo P, Stringer EM, Stringer JSA, Chi BH. Causes of morbidity among HIV-infected children on antiretroviral therapy in primary care facilities in Lusaka, Zambia. Trop Med Int Health 2009; 14:1190-8. [PMID: 19708902 DOI: 10.1111/j.1365-3156.2009.02360.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the pattern of incident illness in children after initiation of antiretroviral therapy (ART) in a large public health sector programme in Lusaka, Zambia. METHODS Systematic chart review to retrospectively extract data from medical records of children (i.e. <15 years) initiating ART in the Lusaka, Zambia public sector. Incident conditions were listed separately and then grouped according to broad categories. Predictors for incident diagnoses were determined using univariate and multivariable analysis. RESULTS Between May 2004 and June 2006, 1705 HIV-infected children initiated ART. Of these, 1235 (72%) had their medical records reviewed. Median age at ART initiation was 77 months and 554 (45%) were females. Eight hundred and forty-one (68%) children had an incident condition during this period, with a median time of occurrence of 64 days from ART initiation. Twenty-eight incident conditions were documented. When categorized, the most common were mucocutaneous conditions [incidence rate (IR): 70.6 per 100 child-years, 95% CI: 64.5-77.2] and upper respiratory tract infection (IR: 70.1 per 100 child-years; 95% CI: 64.0-76.7). Children with severe immunosuppression (i.e. CD4 < 10%) were more likely to develop lower respiratory tract infection (16.3%vs. 10.2%; P = 0.003) and mucocutaneous conditions (43.9% vs. 35.3%; P = 0.005) than those with CD4 > or = 10%. CONCLUSION There is a high incidence of new illness after ART initiation, emphasizing the importance of close monitoring during this period. Early initiation of ART and use of antimicrobial prophylaxis may also help to reduce the occurrence of such co-morbidities.
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Müller A, Myer L, Jaspan H. Virological Suppression Achieved with Suboptimal Adherence Levels among South African Children Receiving Boosted Protease Inhibitor–Based Antiretroviral Therapy. Clin Infect Dis 2009; 48:e3-5. [DOI: 10.1086/595553] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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