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Archary M, Sartorius B, La Russa P, Sibaya T, Healy M, Bobat RA. Effect of the Timing of Antiretroviral Treatment Initiation on Outcomes in Children Living With Human Immunodeficiency Virus Admitted With Severe Acute Malnutrition. J Pediatric Infect Dis Soc 2021; 10:259-266. [PMID: 32469406 PMCID: PMC8023316 DOI: 10.1093/jpids/piaa054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/08/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Delays in early infant diagnosis and antiretroviral treatment (ART) initiation in developing countries frequently result in malnutrition at initial presentation with associated higher mortality and delayed immune recovery. The optimal timing of ART initiation is yet to be established. METHODS Eighty-two children admitted with HIV and severe acute malnutrition (SAM) between July 2012 and December 2015 were enrolled. Patients were randomized to initiate ART within 14 days from admission (early arm) or delay ART initiation until nutritional recovery and >14 days after admission (delayed arm). All patients received a standardized treatment and feeding protocol and were followed to 48 weeks. RESULTS The mean age of the patients at baseline was 23.3 months (standard deviation [SD], 27.9; range, 1.6-129 months). The mean time from admission to ART initiation was 5.6 days (SD, 4.4) in the early arm and 23 days (SD, 5.8) in the delayed arm (P < .001). There was no significant difference in mortality (P = .62), virologic response (P = .53), and anthropometric response (P = .57) between the 2 groups at 48 weeks. However, the rates of change in CD4, viral load, weight for age z score, and height for age z score occurred earlier and favored the delayed arm at early time points but were not significant at 24 and 48 months. CONCLUSIONS Despite initial improved responses in the delayed arm, lack of difference in outcome at 48 weeks supports a pragmatic approach with earlier ART initiation in children living with HIV admitted with SAM.In this randomised controlled study of ART initiation in children admitted with HIV and severe acute malnutrition (SAM), despite initial improved responses in the delayed arm, lack of difference in outcome at 48 weeks supports a pragmatic approach with earlier ART initiation in children living with HIV admitted with SAM. CLINICAL TRIALS REGISTRATION PACTR 21609001751384.
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Affiliation(s)
- Moherndran Archary
- Paediatric Unit, King Edward VIII Hospital, Durban, South Africa
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Benn Sartorius
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Philip La Russa
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Thobekile Sibaya
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Micheal Healy
- Department of Medicine, Division of Infectious Diseases, Columbia University, New York, New York, USA
| | - Raziya A Bobat
- Paediatric Unit, King Edward VIII Hospital, Durban, South Africa
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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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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Aaradhana S, Ravi S, Vishnu M, Divya J, Kriti M. THE EFFECT OF NUTRITIONAL STATUS ON THE RESPONSE TO HIGHLY ACTIVE ANTIRETROVIRAL THERAPY IN HUMAN IMMUNODEFICIENCY VIRUS-INFECTED CHILDREN AT REGIONAL ANTIRETROVIRAL THERAPY CENTRE IN NORTHERN INDIA. INDIAN JOURNAL OF CHILD HEALTH 2018. [DOI: https://doi.org/10.32677/ijch.2018.v05.i02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
BACKGROUND Children living with HIV (CLHIV) commonly experience growth failure. We report growth parameters in CLHIV at baseline and during 3 years of antiretroviral therapy (ART). METHODS Records of CLHIV who had completed at least 3 years on ART were reviewed after excluding subjects who died, were lost to follow-up or developed treatment failure to assess impact of sustained administration of ART. Height-for-age (HFA) and body mass index for age (BFA) Z scores were calculated, and proportion of CLHIV with wasting and stunting estimated at baseline, 6, 12, 24 and 36 months after starting ART using the linear mixed model. Factors influencing significant changes in growth parameters were assessed. RESULTS HFA Z score improved steadily from -3.12 at baseline to -2.33 at 36 months of ART. The prevalence of stunting declined from 77.7% to 59.2% during this period. BFA Z scores improved from -1.2 at baseline to -0.4 at12 months on ART but declined to -1.0 at 36 months. The proportion of subjects with wasting was 29.3%, 9.7% and 16.7% at baseline, 12 and 36 months, respectively. Baseline clinical stage (1 + 2), absence of wasting and lower HFA Z score had significant positive influence on changes in HFA Z score, while younger age at ART initiation and a low baseline BFA Z score had a positive influence on catch-up in body mass index. Including data of children who died or developed treatment failure did not impact upon the results. CONCLUSION Majority of CLHIV are stunted at the start of ART. ART was only partially effective in countering malnutrition and growth failure in CLHIV.
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Ssebunya R, Wanyenze RK, Lukolyo H, Mutto M, Kisitu G, Amuge P, Maganda A, Kekitiinwa A. Antiretroviral therapy initiation within seven days of enrolment: outcomes and time to undetectable viral load among children at an urban HIV clinic in Uganda. BMC Infect Dis 2017. [PMID: 28629459 PMCID: PMC5477116 DOI: 10.1186/s12879-017-2550-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Viral suppression is a critical indicator of HIV treatment success. In the era of test-and-start, little is known about treatment outcomes and time to undetectable viral loads. This study compares treatment outcomes, median times to achieve undetectable viral loads and its predictors under different antiretroviral (ART) treatment initiation schedules (i.e. within seven days of enrolment or later). METHODS A retrospective cohort of 367 patients <18 years who enrolled in care between January 2010 and December 2015 with a baseline viral load of >5000 copies/ml were followed up for 60 months. Undetectable viral load measurements were based on both Roche (<20copies/ml) and Abbot (<75copies/ml). Clinical treatment outcomes were compared using chi-squared test. Survival experiences between the two cohorts were assessed through incidence rates and Kaplan Meier curves. A cox model with competing risks was used to assess predictors for time to undetectable viral load. RESULTS Of the 367 patients, 180 (49.1%) initiated ART within seven days from enrolment, 192 (52.3%) attained undetectable viral load of which 133 (69.3%) were children below six years and 101 (52.6%) were females. Among those who initiated ART within seven days 15 (8.3%) died and 6 (3.3%) were lost to follow-up compared to 27 (14.4%) and 16 (8.6%) respectively in the later initiators. The median time to undetectable viral load was 24.9 months (95% CI: 19.7, 28.5) among early ART initiators and 38.5 months (95% CI: 31.1, 44.5) among those initiating beyond seven days. There was a significant difference in failure estimates between those initiating within seven and those that deferred (log rank, p = 0.001). Significant predictors for time to undetectable viral load were; starting ART within seven days (SHR = 2.02, 95% CI: 1.24, 3.28), baseline WHO stage I or II (SHR = 1.59, 95% CI: 1.06, 2.28), inconsistent adherence on three consecutive clinic visits (SHR = 0.44, 95% CI: 0.28, 0.67), and baseline weight (SRH = 1.04, 95% CI: 1.01, 1.07). CONCLUSION Prompt initiation of ART within the first week of enrolment is associated with better treatment outcomes. Early timing, baseline WHO clinical stage and adherence rates should be major considerations while managing HIV among children.
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Affiliation(s)
- Rogers Ssebunya
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda.
| | - Rhoda K Wanyenze
- School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Heather Lukolyo
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda
| | - Milton Mutto
- School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Grace Kisitu
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda
| | - Pauline Amuge
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda
| | - Albert Maganda
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda
| | - Adeodata Kekitiinwa
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda
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Risk Factors for Growth Retardation in HIV-infected Senegalese Children on Antiretroviral Treatment: The ANRS 12279 MAGGSEN Pediatric Cohort Study. Pediatr Infect Dis J 2017; 36:e87-e92. [PMID: 28187062 DOI: 10.1097/inf.0000000000001454] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To describe prevalence and risk factors for wasting and stunting among HIV-infected children with a median duration of 3 years of antiretroviral therapy (ART) at the time of their enrollment in the cohort study. METHODS Wasting and stunting at ART initiation and enrollment were defined as weight-for-height/body mass index-for-age Z scores < -2 and height-for-age Z scores < -2, respectively. Logistic regression was used to assess risk factors for wasting and stunting. Main predictive factors were age at enrollment, nutritional status and age (< or ≥5 years) at ART initiation and ART duration (< or ≥3 years on first-line, or ≥3 years including a switch to second-line ART). RESULTS Two hundred forty-four children 2-16 years of age were enrolled. Overall, wasting and stunting prevalence dropped off consistently in children 2-10 years of age, between ART initiation and enrollment, while it remained at high levels, 52% and 42%, respectively, in children 10-16 years of age. Risk factors for wasting at enrollment were ART duration of ≥3 years including a switch to second-line [adjusted odds ratio (aOR): 3.9, 95% confidence interval (CI): 1.7-8.9] and wasting at ART initiation (aOR: 2.7, 95% CI: 1.4-5.2). The risk factor for stunting at enrollment was stunting at ART initiation (aOR: 11.6, 95% CI: 5.4-25.0), independent of ART duration. CONCLUSIONS Malnutrition at the time of ART initiation was the main predictor of malnutrition at enrollment among HIV-infected children on ART. Longer duration on ART had no overall protective effect on wasting and stunting. Growth and virologic monitoring are of utmost importance in the comprehensive care of children with HIV infection.
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Hu R, Mu W, Sun X, Wu H, Pang L, Wang L, Zhao Q, Wu Y, Zhao D, Chen M, Ma Y, Zhang F. Growth of HIV-Infected Children in the Early Stage of Antiretroviral Treatment: A Retrospective Cohort Study in China. AIDS Patient Care STDS 2016; 30:365-70. [PMID: 27509236 DOI: 10.1089/apc.2016.0131] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Malnutrition and human immunodeficiency virus (HIV)-related complications are commonly seen in HIV-infected children, and these have been shown in high-prevalent areas such as Africa. Antiviral therapy (ART) has notably controlled disease progression, whereas it effectively reverses underweight and growth retardation in HIV-infected children. This study was conducted to evaluate the growth status after initiation of ART in HIV-infected children in China. A retrospective cohort study was conducted based on the National Science and Technology Major Project. HIV-infected children who initiated antiretroviral treatment between January 1st, 2012 and December 31st, 2012 were followed up to December 31st, 2014. Z-scores of height and weight were calculated by WHO Anthro (plus). Linear mixed-effects models were used to model trajectories of weight- and height-for-age Z-scores. Seven hundred forty-four participants enrolled in the study, with 585 participants and 712 participants who had WAZ (weight-for-age Z-score) and HAZ (height-for-age Z-score), respectively, before initiation of ART. Among them, 125 (21.4%) were underweight and 301 (42.3%) were stunted. After treatment, among the 125 underweight children, WAZ improved in 69 patients, regained more than -2 on average. Among the 301 stunted children, HAZ improved in 123 patients, regained more than -2 on average. WAZ improved for the first 6 months by 0.052 units each month and then stabilized, whereas HAZ consistently improved by 0.014 units each month over time. Antiretroviral treatment reversed the adverse effects of HIV to some degree. Early diagnosis and treatment, with an effective nutrition program, is necessary to improve malnutrition further.
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Affiliation(s)
- Ran Hu
- National Centre for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
- Jiangsu Provincial Centre for Disease Control and Prevention, Nanjing, China
| | - Weiwei Mu
- National Centre for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Xin Sun
- Psychology Department, Public Health Institute, Harbin Medical University, Harbin, China
| | - Hao Wu
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Lin Pang
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Liming Wang
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qingxia Zhao
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, China
| | - Yasong Wu
- National Centre for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Decai Zhao
- National Centre for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Meiling Chen
- National Centre for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Ye Ma
- National Centre for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Fujie Zhang
- National Centre for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
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Abstract
BACKGROUND Information on antiretroviral therapy (ART) use in HIV-infected children with severe malnutrition (SM) is lacking. We investigated long-term ART outcomes in this population. METHODS Children enrolled in the TREAT Asia Pediatric HIV Observational Database who had SM (weight-for-height or body mass index-for-age Z score less than -3) at ART initiation were analyzed. Generalized estimating equations were used to investigate poor weight recovery (weight-for-age Z score less than -3) and poor CD4% recovery (CD4% <25), and competing risk regression was used to analyze mortality and toxicity-associated treatment modification. RESULTS Three hundred fifty-five (11.9%) of 2993 children starting ART had SM. Their median weight-for-age Z score increased from -5.6 at ART initiation to -2.3 after 36 months. Not using trimethoprim-sulfamethoxazole prophylaxis at baseline was associated with poor weight recovery [odds ratio: 2.49 vs. using; 95% confidence interval (CI): 1.66-3.74; P < 0.001]. Median CD4% increased from 3.0 at ART initiation to 27.2 after 36 months, and 56 (15.3%) children died during follow-up. More profound SM was associated with poor CD4% recovery (odds ratio: 1.78 for Z score less than -4.5 vs. -3.5 to less than -3.0; 95% CI: 1.08-2.92; P = 0.023) and mortality (hazard ratio: 2.57 for Z score less than -4.5 vs. -3.5 to less than -3.0; 95% CI: 1.24-5.33; P = 0.011). Twenty-two toxicity-associated ART modifications occurred at a rate of 2.4 per 100 patient-years, and rates did not differ by malnutrition severity. CONCLUSION Trimethoprim-sulfamethoxazole prophylaxis is important for the recovery of weight-for-age in severely malnourished children starting ART. The extent of SM does not impede weight-for-age recovery or antiretroviral tolerability, but CD4% response is compromised in children with a very low weight-for-height/body mass index-for-age Z score, which may contribute to their high rate of mortality.
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Feucht UD, Van Bruwaene L, Becker PJ, Kruger M. Growth in HIV-infected children on long-term antiretroviral therapy. Trop Med Int Health 2016; 21:619-29. [PMID: 26914715 DOI: 10.1111/tmi.12685] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe growth in HIV-infected children on long-term antiretroviral therapy (ART) and to assess social, clinical, immunological and virological factors associated with suboptimal growth. METHODS This observational cohort study included all HIV-infected children at an urban ART site in South Africa who were younger than 5 years at ART initiation and with more than 5 years of follow-up. Growth was assessed using weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ) and body mass index (BMI)-for-age Z-scores (BAZ). Children were stratified according to pre-treatment anthropometry and age. Univariate and mixed linear analysis were used to determine associations between independent variables and weight and height outcomes. RESULTS The majority of the 159 children presented with advanced clinical disease (90%) and immunosuppression (89%). Before treatment underweight, stunting and wasting were common (WAZ<-2 = 50%, HAZ<-2 = 73%, BAZ<-2 = 19%). Weight and BMI improved during the initial 12 months, while height improved over the entire 5-year period. Height at study exit was significantly worse for children with growth impairment at ART initiation (P < 0.001), and infants (<1 year) demonstrated superior improvement in terms of BMI (P = 0.04). Tuberculosis was an independent risk factor for suboptimal weight (P = 0.01) and height (P = 0.02) improvement. Weight gain was also hindered by lack of electricity (P = 0.04). Immune reconstitution and virological suppression were not associated with being underweight or stunted at study endpoint. CONCLUSIONS Malnutrition was a major clinical concern for this cohort of HIV-infected children. Early ART initiation, tuberculosis co-infection management and nutritional interventions are crucial to ensure optimal growth in HIV-infected children.
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Affiliation(s)
- Ute D Feucht
- Department of Paediatrics, Kalafong Hospital, University of Pretoria, Pretoria, South Africa
| | - Lore Van Bruwaene
- Department of Paediatrics, Kalafong Hospital, University of Pretoria, Pretoria, South Africa.,University Hospital Gasthuisberg, Leuven, Belgium
| | - Piet J Becker
- Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Mariana Kruger
- Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg, South Africa
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Rossouw TM, Feucht UD, Melikian G, van Dyk G, Thomas W, du Plessis NM, Avenant T. Factors Associated with the Development of Drug Resistance Mutations in HIV-1 Infected Children Failing Protease Inhibitor-Based Antiretroviral Therapy in South Africa. PLoS One 2015. [PMID: 26196688 PMCID: PMC4510388 DOI: 10.1371/journal.pone.0133452] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE Limited data are available from the developing world on antiretroviral drug resistance in HIV-1 infected children failing protease inhibitor-based antiretroviral therapy, especially in the context of a high tuberculosis burden. We describe the proportion of children with drug resistance mutations after failed protease inhibitor-based antiretroviral therapy as well as associated factors. METHODS Data from children initiated on protease inhibitor-based antiretroviral therapy with subsequent virological failure referred for genotypic drug resistance testing between 2008 and 2012 were retrospectively analysed. Frequencies of drug resistance mutations were determined and associations with these mutations identified through logistic regression analysis. RESULTS The study included 65 young children (median age 16.8 months [IQR 7.8; 23.3]) with mostly advanced clinical disease (88.5% WHO stage 3 or 4 disease), severe malnutrition (median weight-for-age Z-score -2.4 [IQR -3.7;-1.5]; median height-for-age Z-score -3.1 [IQR -4.3;-2.4]), high baseline HIV viral load (median 6.04 log10, IQR 5.34;6.47) and frequent tuberculosis co-infection (66%) at antiretroviral therapy initiation. Major protease inhibitor mutations were found in 49% of children and associated with low weight-for-age and height-for-age (p = 0.039; p = 0.05); longer duration of protease inhibitor regimens and virological failure (p = 0.001; p = 0.005); unsuppressed HIV viral load at 12 months of antiretroviral therapy (p = 0.001); tuberculosis treatment at antiretroviral therapy initiation (p = 0.048) and use of ritonavir as single protease inhibitor (p = 0.038). On multivariate analysis, cumulative months on protease inhibitor regimens and use of ritonavir as single protease inhibitor remained significant (p = 0.008; p = 0.033). CONCLUSION Major protease inhibitor resistance mutations were common in this study of HIV-1-infected children, with the timing of tuberculosis treatment and subsequent protease inhibitor dosing strategy proving to be important associated factors. There is an urgent need for safe, effective, and practicable HIV/tuberculosis co-treatment in young children and the optimal timing of treatment, optimal dosing of antiretroviral therapy, and alternative tuberculosis treatment strategies should be urgently addressed.
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Affiliation(s)
- Theresa M. Rossouw
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- * E-mail:
| | - Ute D. Feucht
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
| | - George Melikian
- AIDS Healthcare Foundation, Los Angeles, CA, United States of America
| | - Gisela van Dyk
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Winifred Thomas
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
| | - Nicolette M. du Plessis
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
| | - Theunis Avenant
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
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Suaysod R, Ngo-Giang-Huong N, Salvadori N, Cressey TR, Kanjanavanit S, Techakunakorn P, Krikajornkitti S, Srirojana S, Laomanit L, Chalermpantmetagul S, Lallemant M, Le Cœur S, McIntosh K, Traisathit P, Jourdain G. Treatment Failure in HIV-Infected Children on Second-line Protease Inhibitor-Based Antiretroviral Therapy. Clin Infect Dis 2015; 61:95-101. [PMID: 25838288 DOI: 10.1093/cid/civ271] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/21/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-infected children failing second-line antiretroviral therapy (ART) have no access to third-line antiretroviral drugs in many resource-limited settings. It is important to identify risk factors for second-line regimen failure. METHODS HIV-infected children initiating protease inhibitor (PI)-containing second-line ART within the Program for HIV Prevention and Treatment observational cohort study in Thailand between 2002 and 2010 were included. Treatment failure was defined as confirmed HIV type 1 RNA load >400 copies/mL after at least 6 months on second-line regimen or death. Adherence was assessed by drug plasma levels and patient self-report. Cox proportional hazards regression analyses were used to identify risk factors for failure. RESULTS A total of 111 children started a PI-based second-line regimen, including 59 girls (53%). Median first-line ART duration was 1.9 years (interquartile range [IQR], 1.4-3.3 years), and median age at second-line initiation was 10.7 years (IQR, 6.3-13.4 years). Fifty-four children (49%) experienced virologic failure, and 2 (2%) died. The risk of treatment failure 24 months after second-line initiation was 41%. In multivariate analyses, failure was independently associated with exposure to first-line ART for >2 years (adjusted hazard ratio [aHR], 1.8; P = .03), age >13 years (aHR, 2.9; P < .001), body mass index-for-age z score < -2 standard deviations at second-line initiation (aHR, 2.8; P = .03), and undetectable drug levels within 6 months following second-line initiation (aHR, 4.5; P < .001). CONCLUSIONS Children with longer exposure to first-line ART, entry to adolescence, underweight, and/or undetectable drug levels were at higher risk of failing second-line ART and thus should be closely monitored.
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Affiliation(s)
- Rapeepan Suaysod
- Institut de Recherche pour le Développement, UMI 174-PHPT Bioinformatics Research Laboratory, Faculty of Science
| | - Nicole Ngo-Giang-Huong
- Institut de Recherche pour le Développement, UMI 174-PHPT Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Nicolas Salvadori
- Institut de Recherche pour le Développement, UMI 174-PHPT Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand
| | - Tim R Cressey
- Institut de Recherche pour le Développement, UMI 174-PHPT Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | | | | | - Laddawan Laomanit
- Institut de Recherche pour le Développement, UMI 174-PHPT Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand
| | - Suwalai Chalermpantmetagul
- Institut de Recherche pour le Développement, UMI 174-PHPT Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand
| | - Marc Lallemant
- Institut de Recherche pour le Développement, UMI 174-PHPT Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sophie Le Cœur
- Institut de Recherche pour le Développement, UMI 174-PHPT Harvard T.H. Chan School of Public Health, Boston, Massachusetts Institut National d'Etudes Démographiques, Paris, France
| | - Kenneth McIntosh
- Boston Children's Hospital and Harvard Medical School, Massachusetts
| | - Patrinee Traisathit
- Institut de Recherche pour le Développement, UMI 174-PHPT Department of Statistics, Faculty of Science Center of Excellence for Innovation in Analytical Science and Technology, Chiang Mai University, Thailand
| | - Gonzague Jourdain
- Institut de Recherche pour le Développement, UMI 174-PHPT Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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13
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Noncommunicable diseases in HIV infection in low- and middle-income countries: gastrointestinal, hepatic, and nutritional aspects. J Acquir Immune Defic Syndr 2014; 67 Suppl 1:S79-86. [PMID: 25117963 DOI: 10.1097/qai.0000000000000260] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The purpose of this review was to outline the interaction between HIV and noncommunicable diseases affecting the gastrointestinal (GI) tract, liver, and nutritional disorders in low- and middle-income countries (LMICs), and to identify research priorities. Noncommunicable GI tract disorders are only moderately influenced by HIV, and peptic ulceration is actually less common. However, the impact of HIV on GI cancers needs further investigation. HIV interacts strongly with environmental enteropathy, exacerbating malabsorption of nutrients and drugs. HIV has 2 major effects on noncommunicable liver disease: drug-induced liver injury and nonalcoholic fatty liver disease (particularly in persons of African genetic descent). The effect of HIV on nutrition was one of the first markers of the epidemic in the 1980s, and HIV continues to have major nutritional consequences. Childhood malnutrition and HIV frequently coexist in some regions, for example, southern Africa, resulting in powerful negative interactions with poorer responses to standard nutritional rehabilitation. HIV and nutritional care need to be better integrated, but many questions on how best to do this remain unanswered. Across the spectrum of GI, hepatic, and nutritional disorders in HIV infection, there is increasing evidence that the microbiome may play an important role in disease pathogenesis, but work in this area, especially in low- and middle-income countries, is in its infancy.
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Shahrin L, Leung DT, Matin N, Kawser CA, Pervez MM, Chisti MJ. Clinical profile of hospitalized HIV-infected children in Bangladesh, a low-HIV-prevalence country. Paediatr Int Child Health 2014; 34:133-7. [PMID: 24164974 DOI: 10.1179/2046905513y.0000000100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Bangladesh has a low HIV prevalence and data on the risk factors and clinical presentation of HIV-infected children are lacking. OBJECTIVE To describe the clinical characteristics of hospitalized HIV-infected children in Bangladesh and determine the factors associated with a low CD4 count. METHODS An anonymous, retrospective review was undertaken of the medical records of all patients admitted to the HIV unit of the iccdr,b Dhaka Hospital between February 2009 and July 2012. Demographic, clinical and laboratory data were extracted from the electronic medical record system. HIV-infected children with a low absolute CD4 count (<200 cells/μl) were compared with HIV-infected children with a CD4 count ≧200 cells/μl. RESULTS Of 266 HIV-infected patients, 24 were children (9%), 13 (54%) of whom were male. Ages ranged from 2 to 17 years (median 7). Of the 21 (88%) children who acquired the infection by vertical transmission, median age at diagnosis was 5·2 years, and the parents of 19 (79%) reported a history of external migration. Children commonly presented with prolonged fever (n = 14, 58%), recurrent cough (n = 14, 58%), failure to thrive (n = 11, 46%) and recurrent diarrhoea (n = 4, 17%). Six (25%) patients had tuberculosis, four (16·7%) had herpes zoster and four (16·7%) were diagnosed with Pneumocystis jirovecii pneumonia. One child died during hospitalization. Children with a low CD4 count (<200 cells/μl) more often had severe wasting (95% CI 1·2-453·97) and severe under-nutrition (95% CI 1·39-196·25) than those with a higher CD4 count*. CONCLUSION The majority of HIV-infected children presenting to an inpatient speciality ward in Dhaka acquired HIV through vertical transmission, and most of the parents had a history of external migration. Further studies are needed to determine the optimal strategy for preventing mother-to-child transmission and for early identification and treatment of HIV-infected children in this low-prevalence country.
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Predictors of adverse outcomes in HIV-1-infected children receiving combination antiretroviral treatment: results from a DREAM cohort in sub-Saharan Africa. Pediatr Infect Dis J 2014; 33:295-300. [PMID: 23799517 DOI: 10.1097/inf.0b013e3182a0994b] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND HIV-infected children have less access to combination antiretroviral therapy as compared with adults in resource-limited settings. Growth faltering, loss to follow-up (LTFU) and high mortality are frequently seen. METHODS A retrospective cohort study was performed with parameters extracted from the Drug Resource Enhancement against AIDS and Malnutrition database for HIV-infected, antiretroviral naïve children under 15 years presenting for care at 17 Drug Resource Enhancement against AIDS and Malnutrition centers in Mozambique, Malawi and Guinea between January 2005 to December 2008. Predictors of time-to-death, time-to-LTFU and persistence of malnutrition by Cox's regression and Kaplan-Meier were determined. RESULTS 2215 children presented to care with 1343 (61%) being ≤ 5 years. At baseline, stunting and malnutrition occurred in 40% and 25%, respectively; 75% of 2149 children had CD4 cell percentages less than 20; median HIV RNA, log10 cp/mL, was 4.97 in 1927 patients. Over time 238 children died (10.7%; 2.7% person-years [PY]) 63 were LTFU (2.8%; 0.7% PY). By multivariate analysis, mortality was associated with virus load (hazards ratio: 1.19; confidence interval: 1.01-1.402, P = 0.038) and reduced weight-for-age Z scores (hazards ratio: 0.590; confidence interval: 0.53-0.66, P < 0.001). LTFU was associated with low weight-for-height Z scores (hazards ratio: 0.71; confidence interval: 0.51-0.97, P = 0.031). At 12 months after combination antiretroviral therapy, anthropometric parameters significantly improved in 1226 children (P < 0.001); virus load declined to <400 copies/mL in over 60%. CONCLUSIONS Despite advanced HIV disease, children initiating combination antiretroviral therapy had mortality rates of 2.7% p/PY with overall attrition rates of 11.7% p/100 PY, with significant reversal of negative anthropometric markers, and improvement of immunological and virological parameters in children with 12 months of follow-up.
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16
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Sturtevant D, Wimmer JS. Success and challenges of measuring program impacts: an international study of an infant nutrition program for AIDS orphans. EVALUATION AND PROGRAM PLANNING 2014; 42:50-56. [PMID: 24189160 DOI: 10.1016/j.evalprogplan.2013.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 09/20/2013] [Accepted: 09/29/2013] [Indexed: 06/02/2023]
Abstract
The HIV/AIDS epidemic in Zambia threatens maternal survival and jeopardizes the ability for families to care for their children. The Christian Alliance for Children in Zambia (CACZ) operates a program called Milk and Medicine (M&M) that distributes food, formula, and medicine at churches in the compounds. This article reports on a mixed methods study to evaluate the outcomes of the M&M program. On-site interviews with families combined with an analysis of a longitudinal data set were the methods used. The results of the study showed families face continuous hardship including hunger, unemployment, disease, and loss. Families expressed appreciation for the program and its staff and suggested improvements. The longitudinal data review helped researchers to recommend an improved protocol for data management. Improved data will assist researchers in an on-going evaluation to compare the growth rates of children in the study to the Zambian normal growth charts. Lessons learned from this evaluation validated the use of mixed methods design for exploratory research on an emerging program. Lessons were also learned about the difficulty of working in natural settings with political and cultural variations. Future evaluations of the M&M program are expected to shed light on more specific program impacts.
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Affiliation(s)
- Deborah Sturtevant
- Sociology and Social Work, Hope College, 41 Graves Place, Holland, MI 49423, United States.
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17
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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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Musiime V, Kayiwa J, Kiconco M, Tamale W, Alima H, Mugerwa H, Abwola M, Apilli E, Ahimbisibwe F, Kizito H, Abongomera G, Namusoke A, Makabayi A, Kiweewa F, Ssali F, Kityo C, Colebunders R, Mugyenyi P. Response to antiretroviral therapy of HIV type 1-infected children in urban and rural settings of Uganda. AIDS Res Hum Retroviruses 2012; 28:1647-57. [PMID: 22545751 DOI: 10.1089/aid.2011.0313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
From 2006 to 2011, a cohort study was conducted among 1000 children resident in urban and rural settings of Uganda to ascertain and compare the response to antiretroviral therapy (ART) among urban versus rural children and the factors associated with this response. Clinical, immunological, and virological parameters were ascertained at baseline and weeks 24, 48, 96, and 144 after ART initiation. Adherence to ART was assessed at enrollment by self-report (SR) and pill counts (PC). Overall, 499/948 (52.6%) children were resident in rural areas, 504/948 (53.1%) were male, and their mean age was 11.9±4.4 years (urban children) and 11.4±4.1 years (rural children). The urban children were more likely to switch to second-line ART at a rate of 39.9 per 1000 person-years (95% CI: 28.2-56.4) versus 14.9 per 1000 person-years (95% CI: 8.7-25.7), p=0.0038, develop any new WHO 3/4 events at 127/414 (30.7%) versus 108/466 (23.2%), p=0.012, and have a higher cumulative incidence of hospitalization of 54/449 (12.0%) versus 32/499 (6.4%), p=0.003, when compared to rural children. No differences were observed in mean changes in weight, height, CD4 count and percentage, and hemoglobin and viral load between urban and rural children. Adherence of ≥95% was observed in 88.2% of urban versus 91.3% of rural children by SR (p=0.130), and in 78.8% of urban versus 88.8% of rural children by PC (p<0.0001). In this study rural children had more favorable clinical outcomes and were more likely to adhere optimally to ART than urban children.
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Affiliation(s)
- Victor Musiime
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - Joshua Kayiwa
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - Mary Kiconco
- Joint Clinical Research Centre, Fort-Portal Regional Centre of Excellence, Fort-Portal, Uganda
| | - William Tamale
- Joint Clinical Research Centre, Kakira Regional Centre of Excellence, Jinja, Uganda
| | - Hillary Alima
- Joint Clinical Research Centre, Kabale Regional Centre of Excellence, Kabale, Uganda
| | - Henry Mugerwa
- Joint Clinical Research Centre, Mbarara Regional Centre of Excellence, Mbarara, Uganda
| | - Mary Abwola
- Joint Clinical Research Centre, Mbale Regional Centre of Excellence, Mbale, Uganda
| | | | | | - Hilda Kizito
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - George Abongomera
- Joint Clinical Research Centre, Gulu Regional Centre of Excellence, Gulu, Uganda
| | - Asia Namusoke
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - Agnes Makabayi
- Joint Clinical Research Centre, Mbale Regional Centre of Excellence, Mbale, Uganda
| | - Francis Kiweewa
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - Francis Ssali
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - Cissy Kityo
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | | | - Peter Mugyenyi
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
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Abstract
The delivery of safe and effective antiretroviral therapy to children and adolescents is crucial to save the lives of millions of children worldwide. The immunologic response to human immunodeficiency infection is closely related to a child's development and creates age-specific parameters for the evaluation of therapeutic response to antiretroviral therapy. Similarly, the development and maturation of organ systems involved in drug absorption, distribution, metabolism, and elimination determines significant changes in the pharmacokinetics of antiretroviral drugs throughout childhood. The authors review the evolution in treatment of pediatric HIV from infancy through adolescence.
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Affiliation(s)
- Natella Rakhmanina
- Division of Infectious Diseases, Children's National Medical Center, Washington, DC 20010, USA.
| | - Ryan Phelps
- Division of Infectious Disease, Washington University School of Medicine and Health Sciences, Washington, DC, USA,Department of Pediatrics, Children’s National Medical Center, Washington University School of Medicine and Health Sciences, Washington, DC, USA,USAID Office of HIV/AIDS, Washington, DC
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20
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Gsponer T, Weigel R, Davies MA, Bolton C, Moultrie H, Vaz P, Rabie H, Technau K, Ndirangu J, Eley B, Garone D, Wellington M, Giddy J, Ehmer J, Egger M, Keiser O. Variability of growth in children starting antiretroviral treatment in southern Africa. Pediatrics 2012; 130:e966-77. [PMID: 22987878 PMCID: PMC3457616 DOI: 10.1542/peds.2011-3020] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Poor growth is an indication for antiretroviral therapy (ART) and a criterion for treatment failure. We examined variability in growth response to ART in 12 programs in Malawi, Zambia, Zimbabwe, Mozambique, and South Africa. METHODS Treatment naïve children aged <10 years were included. We calculated weight for age z scores (WAZs), height for age z scores (HAZs), and weight for height z scores (WHZs) up to 3 years after starting ART, by using the World Health Organization standards. Multilevel regression models were used. RESULTS A total of 17990 children (range, 238-8975) were followed for 36181 person-years. At ART initiation, most children were underweight (50%) and stunted (66%). Lower baseline WAZ, HAZ, and WHZ were the most important determinants of faster catch-up growth on ART. WAZ and WHZ increased rapidly in the first year and stagnated or reversed thereafter, whereas HAZ increased continuously over time. Three years after starting ART, WAZ ranged from -2.80 (95% confidence interval [CI]: -3.66 to -2.02) to -1.98 (95% CI: -2.41 to -1.48) in children with a baseline z score < -3 and from -0.79 (95% CI: -1.62 to 0.02) to 0.05 (95% CI: -0.42 to 0.51) in children with a baseline WAZ ≥ -1. For HAZ, the corresponding range was -2.33 (95% CI: -2.62 to -2.02) to -1.27 (95% CI: -1.58 to -1.00) for baseline HAZ < -3 and -0.24 (95% CI: -0.56 to 0.15) to 0.84 (95% CI: 0.53 to 1.16) for HAZ ≥ -1. CONCLUSIONS Despite a sustained growth response and catch-up growth in children with advanced HIV disease treated with ART, normal weights and heights are not achieved over 3 years of ART.
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Affiliation(s)
- Thomas Gsponer
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Ralf Weigel
- Lighthouse Trust Clinic, Kamuzu Central Hospital, Lilongwe, Malawi;,Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Carolyn Bolton
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;,University of Alabama, Birmingham, Alabama
| | - Harry Moultrie
- Wits Reproductive Health and HIV Institute (Harriet Shezi Children’s Clinic, Chris Hani Baragwanath Hospital, Soweto);,University of Witwatersrand, Johannesburg, South Africa
| | - Paula Vaz
- Paediatric Day Hospital, Maputo, Mozambique
| | - Helena Rabie
- Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch, South Africa
| | - Karl Technau
- University of Witwatersrand, Johannesburg, South Africa;,Empilweni Services and Research Unit (Rahima Moosa Mother and Child Hospital, Johannesburg)
| | - James Ndirangu
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Brian Eley
- Red Cross Children\x{2019}s Hospital and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Daniela Garone
- Médecins Sans Frontières (MSF) South Africa, Khayelitsha, Cape Town, South Africa
| | | | - Janet Giddy
- Sinikithemba Clinic, McCord Hospital, Durban, South Africa; and
| | - Jochen Ehmer
- SolidarMed ART Programme, Zaka and Bikita Districts, Zimbabwe
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Olivia Keiser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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21
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Zanoni BC, Phungula T, Zanoni HM, France H, Cook EF, Feeney ME. Predictors of poor CD4 and weight recovery in HIV-infected children initiating ART in South Africa. PLoS One 2012; 7:e33611. [PMID: 22438965 PMCID: PMC3306429 DOI: 10.1371/journal.pone.0033611] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 02/13/2012] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To identify baseline demographic and clinical risk factors associated with poor CD4 and weight response after initiation of antiretroviral therapy (ART) in a cohort of human immunodeficiency virus (HIV)-infected children in KwaZulu-Natal, South Africa. METHODS We performed a retrospective cohort study of 674 children initiating antiretroviral therapy at McCord and St. Mary's hospitals in KwaZulu-Natal, South Africa, from August 2003 to December 2008. We extracted data from paper charts and electronic medical records to assess risk factors associated with CD4 and weight response using logistic regression. RESULTS From the initial cohort of 901 children <10 years old initiating ART between August 2003 and December 2008, we analyzed 674 children with complete baseline data. Viral suppression rates (<400 copies/ml) were 84% after six months of therapy and 88% after 12 months of therapy. Seventy-three percent of children achieved CD4 recovery after six months and 89% after 12 months. Weight-for-age Z-score (WAZ) improvements were seen in 58% of children after six months of ART and 64% after 12 months. After six months of ART, lower baseline hemoglobin (p = 0.037), presence of chronic diarrhea (p = 0.007), and virologic failure (p = 0.046) were all associated with poor CD4 recovery by multivariate logistic regression. After 12 months of ART, poor CD4 recovery was associated with higher baseline CD4% (p = 0.005), chronic diarrhea (p = 0.02), and virologic failure (p<0.001). Age less than 3 years at ART initiation (p = 0.0003), higher baseline CD4% (p<0.001), and higher baseline WAZ (p<0.001) were all associated with poor WAZ improvements after 6 months by multivariate logistic regression. CONCLUSION The presence of chronic diarrhea at baseline, independent of nutritional status and viral response, predicts poor CD4 recovery. Age at initiation of ART is an important factor in early WAZ response to ART, while viral suppression strongly predicts CD4 recovery but not WAZ improvement.
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Affiliation(s)
- Brian C. Zanoni
- The Ragon Institute of MGH, MIT and Harvard, Charlestown, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Thuli Phungula
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Holly M. Zanoni
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Holly France
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - E. Francis Cook
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Margaret E. Feeney
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
- Division of Experimental Medicine, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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22
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Unresolved antiretroviral treatment management issues in HIV-infected children. J Acquir Immune Defic Syndr 2012; 59:161-9. [PMID: 22138766 DOI: 10.1097/qai.0b013e3182427029] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Antiretroviral therapy in children has expanded dramatically in low-income and middle-income countries. The World Health Organization revised its pediatric HIV guidelines to recommend initiation of antiretroviral therapy in all HIV-infected children younger than 2 years, regardless of CD4 count or clinical stage. The number of children starting life-long antiretroviral therapy should therefore expand dramatically over time. The early initiation of antiretroviral therapy has indisputable benefits for children, but there is a paucity of definitive information on the potential adverse effects. In this review, a comprehensive literature search was conducted to provide an overview of our knowledge about the complications of treating pediatric HIV. Antiretroviral therapy in children, as in adults, is associated with enhanced survival, reduction in opportunistic infections, improved growth and neurocognitive function, and better quality of life. Despite antiretroviral therapy, HIV-infected children may continue to lag behind their uninfected peers in growth and development. In addition, epidemic concurrent conditions, such as tuberculosis, malaria, and malnutrition, can combine with HIV to yield more rapid disease progression and poor treatment outcomes. Additional studies are required to evaluate the long-term effects of antiretroviral therapy in HIV-infected infants, children, and adolescents, particularly in resource-limited countries where concomitant infections and conditions may enhance the risk of adverse effects. There is an urgent need to evaluate drug-drug interactions in children to determine optimal treatment regimens for both HIV and coinfections.
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23
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Challenges in the Management of HIV-Infected Malnourished Children in Sub-Saharan Africa. AIDS Res Treat 2012; 2012:790786. [PMID: 22606378 PMCID: PMC3353143 DOI: 10.1155/2012/790786] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 11/16/2011] [Accepted: 11/17/2011] [Indexed: 12/20/2022] Open
Abstract
Infection with HIV, and oftentimes coinfection with TB, complicates the care of severely malnourished children in sub-Saharan Africa. These superimposed infections challenge clinicians faced with a population of malnourished children for whose care evidence-based guidelines have not kept up. Even as the care of HIV-uninfected malnourished children has improved dramatically with the advent of community-based care and even as there are hopeful signs that the HIV epidemic may be stabilizing or ameliorating, significant gaps remain in the care of malnourished children with HIV. Here we summarize what is currently known, what remains unknown, and what remains challenging about how to treat severely malnourished children with HIV and TB.
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Sutcliffe CG, van Dijk JH, Munsanje B, Hamangaba F, Sinywimaanzi P, Thuma PE, Moss WJ. Weight and height z-scores improve after initiating ART among HIV-infected children in rural Zambia: a cohort study. BMC Infect Dis 2011; 11:54. [PMID: 21362177 PMCID: PMC3056795 DOI: 10.1186/1471-2334-11-54] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 03/01/2011] [Indexed: 11/25/2022] Open
Abstract
Background Deficits in growth observed in HIV-infected children in resource-poor settings can be reversed with antiretroviral treatment (ART). However, many of the studies have been conducted in urban areas with older pediatric populations. This study was undertaken to evaluate growth patterns after ART initiation in a young pediatric population in rural Zambia with a high prevalence of undernutrition. Methods Between 2007 and 2009, 193 HIV-infected children were enrolled in a cohort study in Macha, Zambia. Children were evaluated every 3 months, at which time a questionnaire was administered, height and weight were measured, and blood specimens were collected. Weight- and height-for-age z-scores were constructed from WHO growth standards. All children receiving ART at enrollment or initiating ART during the study were included in this analysis. Linear mixed effects models were used to model trajectories of weight and height-for-age z-scores. Results A high proportion of study children were underweight (59%) and stunted (72%) at treatment initiation. Improvements in both weight- and height-for-age z-scores were observed, with weight-for-age z-scores increasing during the first 6 months of treatment and then stabilizing, and height-for-age z-scores increasing consistently over time. Trajectories of weight-for-age z-scores differed by underweight status at treatment initiation, with children who were underweight experiencing greater increases in z-scores in the first 6 months of treatment. Trajectories of height-for-age z-scores differed by age, with children older than 5 years of age experiencing smaller increases over time. Conclusions Some of the effects of HIV on growth were reversed with ART initiation, although a high proportion of children remained underweight and stunted after two years of treatment. Partnerships between treatment and nutrition programs should be explored so that HIV-infected children can receive optimal nutritional support.
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Affiliation(s)
- Catherine G Sutcliffe
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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25
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Neely MN, Rakhmanina NY. Pharmacokinetic Optimization of Antiretroviral Therapy in Children and Adolescents. Clin Pharmacokinet 2011; 50:143-89. [DOI: 10.2165/11539260-000000000-00000] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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