1
|
Machila N, Libonda L, Habineza P, Velu RM, Kamboyi HK, Ndhlovu J, Wamunyima I, Sinadambwe MM, Mudenda S, Zyambo C, Bumbangi FN. Prevalence and predictors of virological failure in pediatric patients on HAART in sub-Saharan Africa: a systematic review and meta-analysis. Pan Afr Med J 2023; 45:98. [PMID: 37692980 PMCID: PMC10491719 DOI: 10.11604/pamj.2023.45.98.37017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 06/08/2023] [Indexed: 09/12/2023] Open
Abstract
Antiretroviral treatment failure has emerged as a challenge in the management of pediatric human immunodeficiency virus (HIV) patients, especially in resource-limited countries despite accessibility to Highly Active Antiretroviral Therapy (HAART). A systematic review and meta-analysis was conducted to synthesize virological failure (VF) prevalence and ascertain its predictors in children in sub-Saharan Africa. An electronic database search strategy was conducted from January to September 2021 on PubMed, EMBASE, SCOPUS, HINARI, and CINAHL. Further, manual searching was conducted on non-indexed journals. Utilizing the JASP© version 0.17.2 (2023) statistical software, a meta-analysis of pooled prevalence of VF was estimated using the standardized mean differences. Further, selection models were used to assess the risk of bias and heterogeneity. The pooled odds ratios were estimated for the respective studies reporting on predictors of VF. The overall pooled estimate of the prevalence of VF in sub-Saharan Africa among the sampled population was 29% (95% CI: 27.0-32.0; p<0.001). Predictors of VF were drug resistance (OR: 1.68; 95% CI: 0.88-2.49; p < 0.001), poor adherence (OR: 5.35; 95% CI: 5.26-5.45; p < 0.001), nevirapine (NVP)-based regimen (OR: 5.11; 95% CI: 4.66-5.56; p < 0.001), non-usage of cotrimoxazole prophylaxis (OR: 4.30; 95% CI: 4.13-4.47; p < 0.001), higher viral load at the initiation of antiretroviral therapy (ART) (OR: 244.32; 95% CI: 244.2-244.47; p <0.001), exposure to the prevention of mother to child transmission (PMTCT) (OR: 8.02; 95%CI: 7.58-8.46; p < 0.001), increased age/older age (OR: 3.37; 95% CI: 2.70-4.04; p < 0.001), advanced World Health Organization (WHO) stage (OR: 6.57; 95% CI: 6.17-6.98; p < 0.001), not having both parents as primary caregivers (OR: 3.01; 95% CI: 2.50-3.53; p < 0.001), and tuberclosis (TB) treatment (OR: 4.22; 95% CI: 3.68-4.76; p <0.001). The mean VF prevalence documented is at variance with studies in other developing countries outside the sub-Saharan region. The high prevalence of HIV cases contrasting with the limited expertise in the management of pediatric ART patients could explain this variance.
Collapse
Affiliation(s)
- Nchimunya Machila
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| | - Liyali Libonda
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| | - Paul Habineza
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| | | | - Harvey Kakoma Kamboyi
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
- Division of Infection and Immunity, International Institute for Zoonosis Control, Hokkaido University, Hokkaido, Japan
| | - Jacob Ndhlovu
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| | - Inonge Wamunyima
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| | | | - Steward Mudenda
- Department of Pharmacy, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Cosmas Zyambo
- Department of Community and Family Health, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Flavien Nsoni Bumbangi
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| |
Collapse
|
2
|
Lain MG, Vaz P, Sanna M, Ismael N, Chicumbe S, Simione TB, Cantarutti A, Porcu G, Rinaldi S, de Armas L, Dinh V, Pallikkuth S, Pahwa R, Palma P, Cotugno N, Pahwa S. Viral Response among Early Treated HIV Perinatally Infected Infants: Description of a Cohort in Southern Mozambique. Healthcare (Basel) 2022; 10:2156. [PMID: 36360495 PMCID: PMC9691232 DOI: 10.3390/healthcare10112156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/21/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022] Open
Abstract
Early initiation of antiretroviral therapy and adherence to achieve viral load suppression (VLS) are crucial for reducing morbidity and mortality of perinatally HIV-infected infants. In this descriptive cohort study of 39 HIV perinatally infected infants, who started treatment at one month of life in Mozambique, we aimed to describe the viral response over 2 years of follow up. VLS ≤ 400 copies/mL, sustained VLS and viral rebound were described using a Kaplan-Meier estimator. Antiretroviral drug transmitted resistance was assessed for a sub-group of non-VLS infants. In total, 61% of infants reached VLS, and 50% had a rebound. Cumulative probability of VLS was 36%, 51%, and 69% at 6, 12 and 24 months of treatment, respectively. The median duration of VLS was 7.4 months (IQR 12.6) and the cumulative probability of rebound at 6 months was 30%. Two infants had resistance biomarkers to drugs included in their treatment regimen. Our findings point to a low rate of VLS and high rate of viral rebound. More frequent viral response monitoring is advisable to identify infants with rebound and offer timely adherence support. It is urgent to tailor the psychosocial support model of care to this specific age group and offer differentiated service delivery to mother-baby pairs.
Collapse
Affiliation(s)
- Maria Grazia Lain
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo P.O.Box 2822, Mozambique
| | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo P.O.Box 2822, Mozambique
| | - Marco Sanna
- Research Unit of Clinical Immunology and Vaccinology, Children’s Hospital Bambino Gesù, IRCCS, 0165 Rome, Italy
| | - Nalia Ismael
- Technological Platforms Department, Instituto Nacional de Saúde, Marracuene, Maputo 1120, Mozambique
| | - Sérgio Chicumbe
- Health System and Policy Program, Instituto Nacional de Saúde, Marracuene, Maputo 1120, Mozambique
| | | | - Anna Cantarutti
- National Centre for Healthcare Research and Pharmaco-Epidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmaco-Epidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Stefano Rinaldi
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Lesley de Armas
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Vinh Dinh
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Suresh Pallikkuth
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Rajendra Pahwa
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Paolo Palma
- Research Unit of Clinical Immunology and Vaccinology, Children’s Hospital Bambino Gesù, IRCCS, 0165 Rome, Italy
- Department of Systems Medicine, University of Rome “Tor Vergata”, 0133 Rome, Italy
| | - Nicola Cotugno
- Research Unit of Clinical Immunology and Vaccinology, Children’s Hospital Bambino Gesù, IRCCS, 0165 Rome, Italy
- Department of Systems Medicine, University of Rome “Tor Vergata”, 0133 Rome, Italy
| | - Savita Pahwa
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| |
Collapse
|
3
|
Altered Response Pattern following AZD5582 Treatment of SIV-Infected, ART-Suppressed Rhesus Macaque Infants. J Virol 2022; 96:e0169921. [PMID: 35293766 PMCID: PMC9006931 DOI: 10.1128/jvi.01699-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The "shock and kill" strategy for HIV-1 cure incorporates latency-reversing agents (LRA) in combination with interventions that aid the host immune system in clearing virally reactivated cells. LRAs have not yet been investigated in pediatric clinical or preclinical studies. Here, we evaluated an inhibitor of apoptosis protein (IAP) inhibitor (IAPi), AZD5582, that activates the noncanonical NF-κB (ncNF-κB) signaling pathway to reverse latency. Ten weekly doses of AZD5582 were intravenously administered at 0.1 mg/kg to rhesus macaque (RM) infants orally infected with SIVmac251 at 4 weeks of age and treated with a triple ART regimen for over 1 year. During AZD5582 treatment, on-ART viremia above the limit of detection (LOD, 60 copies/mL) was observed in 5/8 infant RMs starting at 3 days post-dose 4 and peaking at 771 copies/mL. Of the 135 measurements during AZD5582 treatment in these 5 RM infants, only 8 were above the LOD (6%), lower than the 46% we have previously reported in adult RMs. Pharmacokinetic analysis of plasma AZD5582 levels revealed a lower Cmax in treated infants compared to adults (294 ng/mL versus 802 ng/mL). RNA-Sequencing of CD4+ T cells comparing pre- and post-AZD5582 dosing showed many genes that were similarly upregulated in infants and adults, but the expression of key ncNF-κB genes, including NFKB2 and RELB, was significantly higher in adult RMs. Our results suggest that dosing modifications for this latency reversal approach may be necessary to maximize virus reactivation in the pediatric setting for successful "shock and kill" strategies. IMPORTANCE While antiretroviral therapy (ART) has improved HIV-1 disease outcome and reduced transmission, interruption of ART results in rapid viral rebound due to the persistent latent reservoir. Interventions to reduce the viral reservoir are of critical importance, especially for children who must adhere to lifelong ART to prevent disease progression. Here, we used our previously established pediatric nonhuman primate model of oral SIV infection to evaluate AZD5582, identified as a potent latency-reversing agent in adult macaques, in the controlled setting of daily ART. We demonstrated the safety of the IAPi AZD5582 and evaluate the pharmacokinetics and pharmacodynamics of repeated dosing. The response to AZD5582 in macaque infants differed from what we previously showed in adult macaques with weaker latency reversal in infants, likely due to altered pharmacokinetics and less inducibility of infant CD4+ T cells. These data supported the contention that HIV-1 cure strategies for children are best evaluated using pediatric model systems.
Collapse
|
4
|
Millar JR, Bengu N, Vieira VA, Adland E, Roider J, Muenchhoff M, Fillis R, Sprenger K, Ntlantsana V, Fatti I, Archary M, Groll A, Ismail N, García-Guerrero MC, Matthews PC, Ndung'u T, Puertas MC, Martinez-Picado J, Goulder P. Early initiation of antiretroviral therapy following in utero HIV infection is associated with low viral reservoirs but other factors determine subsequent plasma viral rebound. J Infect Dis 2021; 224:1925-1934. [PMID: 33963757 PMCID: PMC8643423 DOI: 10.1093/infdis/jiab223] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background Early HIV diagnosis allows combination antiretroviral therapy (cART) initiation in the first days of life following in utero (IU) infection. The impact of early cART initiation on infant viral reservoir size in the setting of high-frequency cART nonadherence is unknown. Methods Peripheral blood total HIV DNA from 164 early treated (day 0–21 of life) IU HIV-infected South African infants was measured using droplet digital PCR at birth and following suppressive cART. We evaluated the impact of cART initiation timing on HIV reservoir size and decay, and on the risk of subsequent plasma viremia in cART-suppressed infants. Results Baseline HIV DNA (median 2.8 log10 copies/million peripheral blood mononuclear cells, range 0.7–4.8) did not correlate with age at cART initiation (0–21 days) but instead with maternal antenatal cART use. In 98 infants with plasma viral suppression on cART, HIV DNA half-life was 28 days. However, the probability of maintenance of plasma aviremia was low (0.46 at 12 months) and not influenced by HIV DNA load. Unexpectedly, longer time to viral suppression was associated with protection against subsequent viral rebound. Conclusions With effective prophylaxis against mother-to-child transmission, cART initiation timing in the first 3 weeks of life is not critical to reservoir size.
Collapse
Affiliation(s)
- Jane R Millar
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Department of Paediatrics, University of Oxford, Oxford, UK
| | - Nomonde Bengu
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | | | - Emily Adland
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Julia Roider
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Department of Paediatrics, University of Oxford, Oxford, UK.,Africa Health Research Institute (AHRI), Durban, South Africa.,German Center for Infection Research (DZIF), Partner site Munich, Germany.,Department of Infectious Diseases, Ludwig-Maximilians-University, Munich
| | - Maximilian Muenchhoff
- German Center for Infection Research (DZIF), Partner site Munich, Germany.,Max von Pettenkofer Institute, Virology, National Reference Center for Retroviruses, Faculty of Medicine, LMU München, Munich, Germany
| | - Rowena Fillis
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Kenneth Sprenger
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Vuyokazi Ntlantsana
- School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Isabella Fatti
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Moherndran Archary
- Department of Paediatrics, King Edward VIII Hospital/University of KwaZulu-Natal, Durban, South Africa
| | - Andreas Groll
- TU Dortmund University, Department of Statistics, Vogelpothsweg, Dortmund
| | - Nasreen Ismail
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | | | - Philippa C Matthews
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Microbiology and Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford BRC, John Radcliffe Hospital, Oxford, UK
| | - Thumbi Ndung'u
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Africa Health Research Institute (AHRI), Durban, South Africa.,Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA.,Max Planck Institute for Infection Biology, Berlin, Germany.,Division of Infection and Immunity, University College London, London, UK
| | | | - Javier Martinez-Picado
- IrsiCaixa AIDS Research Institute, Badalona, Spain.,University of Vic-Central University of Catalonia (UVic-UCC), Vic, Spain.,Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.,Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain
| | - Philip Goulder
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Department of Paediatrics, University of Oxford, Oxford, UK.,Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
| |
Collapse
|
5
|
Ndongo FA, Tejiokem MC, Penda CI, Ndiang ST, Ndongo JA, Guemkam G, Sofeu CL, Tagnouokam-Ngoupo PA, Kfutwah A, Msellati P, Faye A, Warszawski J. Long-term outcomes of early initiated antiretroviral therapy in sub-Saharan children: a Cameroonian cohort study (ANRS-12140 Pediacam study, 2008-2013, Cameroon). BMC Pediatr 2021; 21:189. [PMID: 33882903 PMCID: PMC8059165 DOI: 10.1186/s12887-021-02664-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In most studies, the virological response is assessed during the first two years of antiretroviral treatment initiated in HIV-infected infants. However, early initiation of antiretroviral therapy exposes infants to very long-lasting treatment. Moreover, maintaining viral suppression in children is difficult. We aimed to assess the virologic response and mortality in HIV-infected children after five years of early initiated antiretroviral treatment (ART) and identify factors associated with virologic success in Cameroon. METHODS In the ANRS-12140 Pediacam cohort study, 2008-2013, Cameroon, we included all the 149 children who were still alive after two years of early ART. Virologic response was assessed after 5 years of treatment. The probability of maintaining virologic success between two and five years of ART was estimated using Kaplan-Meier curve. The immune status and mortality were also studied at five years after ART initiation. Factors associated with a viral load < 400 copies/mL in children still alive at five years of ART were studied using logistic regressions. RESULTS The viral load after five years of early ART was suppressed in 66.8% (60.1-73.5) of the 144 children still alive and in care. Among the children with viral suppression after two years of ART, the probability of maintaining viral suppression after five years of ART was 64.0% (54.0-74.0). The only factor associated with viral suppression after five years of ART was achievement of confirmed virological success within the first two years of ART (OR = 2.7 (1.1-6.8); p = 0.033). CONCLUSIONS The probability of maintaining viral suppression between two and five years of early initiated ART which was quite low highlights the difficulty of parents to administer drugs daily to their children in sub-Saharan Africa. It also stressed the importance of initial viral suppression for achieving and maintaining virologic success in the long-term. Further studies should focus on identifying strategies that would enhance better retention in care and improved adherence to treatment within the first two years of ART early initiated in Sub-Saharan HIV-infected children.
Collapse
Affiliation(s)
- Francis Ateba Ndongo
- Université Paris-Sud, Centre Mère et Enfant de la Fondation Chantal Biya, Francis, POB 1936, Yaounde, Cameroon.
| | | | - Calixte Ida Penda
- MPH, PH-PU, Université Douala; Hôpital Laquintinie, Douala, Cameroon
| | | | | | - Georgette Guemkam
- Centre Mère et Enfant de la Fondation Chantal Biya, Yaounde, Cameroon
| | - Casimir Ledoux Sofeu
- Université Yaoundé I; Centre Pasteur du Cameroun, Service d'Epidémiologie et de Santé Publique, Yaounde, Cameroon
| | | | - Anfumbom Kfutwah
- Centre Pasteur du Cameroun, Service de Virologie, Yaounde, Cameroon
| | | | - Albert Faye
- Université Paris Diderot, Sorbonne Paris Cité; Assistance Publique des Hôpitaux de Paris, Pédiatrie Générale, Hôpital Robert Debré, INSERM UMR 1123, ECEVE, Paris, France
| | - Josiane Warszawski
- Université Paris-Sud, Assistance Publique des Hôpitaux de Paris, CESP INSERM U1018, team 4 "HIV and STD", Hôpital Bicêtre, 94276, Le Kremlin-Bicêtre, France
| |
Collapse
|
6
|
Desmonde S, Ciaranello AL, Malateste K, Musick B, Patten G, Vu AT, Edmonds A, Neilan AM, Duda SN, Wools-Kaloustian K, Davies MA, Leroy V. Age-specific mortality rate ratios in adolescents and youth aged 10-24 years living with perinatally versus nonperinatally acquired HIV. AIDS 2021; 35:625-632. [PMID: 33252479 PMCID: PMC7904586 DOI: 10.1097/qad.0000000000002765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To measure mortality incidence rates and incidence rate ratios (IRR) in adolescents and youth living with perinatally acquired HIV (YPHIV) compared with those living with nonperinatally acquired HIV (YNPHIV), by region, by sex, and during the ages of 10-14, 15-19, and 20-24 years in IeDEA. DESIGN AND METHODS All those with a confirmed HIV diagnosis, antiretroviral therapy (ART)-naive at enrollment, and who have post-ART follow-up while aged 10-24 years between 2004 and 2016 were included. We estimated post-ART mortality incidence rates and 95% confidence intervals (95% CI) per 100 person-years for YPHIV (enrolled into care <10 years of age) and YNPHIV (enrolled ≥10 years and <25 years). We estimate mortality IRRs in a negative binomial regression model, adjusted for sex, region time-varying age, CD4+ cell count at ART initiation (<350 cells/μl, ≥350 cells/μl, unknown), and time on ART (<12 and ≥12 months). RESULTS Overall, 104 846 adolescents and youth were included: 21 340 (20%) YPHIV (50% women) and 83 506 YNPHIV (80% women). Overall mortality incidence ratios were higher among YNPHIV (incidence ratio: 2.3/100 person-years; 95% CI: 2.2-2.4) compared with YPHIV (incidence ratio: 0.7/100 person-years; 95% CI: 0.7-0.8). Among adolescents aged 10-19 years, mortality was lower among YPHIV compared with YNPHIV (all IRRs <1, ranging from 0.26, 95% CI: 0.13-0.49 in 10-14-year-old boys in the Asia-Pacific to 0.51, 95% CI: 0.30-0.87 in 15-19-year-old boys in West Africa). CONCLUSION We report substantial amount of deaths occurring during adolescence. Mortality was significantly higher among YNPHIV compared to YPHIV. Specific interventions including HIV testing and early engagement in care are urgently needed to improve survival among YNPHIV.
Collapse
Affiliation(s)
- Sophie Desmonde
- Inserm U1027, Université Paul Sabatier Toulouse 3, Toulouse, France
| | - Andrea L. Ciaranello
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen Malateste
- Inserm U1219
- Bordeaux Population Health Center, Université de Bordeaux, Bordeaux, France
| | - Beverly Musick
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Gabriela Patten
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - An Thien Vu
- Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne M. Neilan
- Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Stephany N. Duda
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Mary-Ann Davies
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Valériane Leroy
- Inserm U1027, Université Paul Sabatier Toulouse 3, Toulouse, France
| |
Collapse
|
7
|
Bricker KM, Obregon-Perko V, Uddin F, Williams B, Uffman EA, Garrido C, Fouda GG, Geleziunas R, Robb M, Michael N, Barouch DH, Chahroudi A. Therapeutic vaccination of SIV-infected, ART-treated infant rhesus macaques using Ad48/MVA in combination with TLR-7 stimulation. PLoS Pathog 2020; 16:e1008954. [PMID: 33104758 PMCID: PMC7644092 DOI: 10.1371/journal.ppat.1008954] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/05/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023] Open
Abstract
Globally, 1.8 million children are living with HIV-1. While antiretroviral therapy (ART) has improved disease outcomes, it does not eliminate the latent HIV-1 reservoir. Interventions to delay or prevent viral rebound in the absence of ART would be highly beneficial for HIV-1-infected children who now must remain on daily ART throughout their lifespan. Here, we evaluated therapeutic Ad48-SIV prime, MVA-SIV boost immunization in combination with the TLR-7 agonist GS-986 in rhesus macaque (RM) infants orally infected with SIVmac251 at 4 weeks of age and treated with a triple ART regimen beginning 4 weeks after infection. We hypothesized immunization would enhance SIV-specific T cell responses during ART-mediated suppression of viremia. Compared to controls, vaccinated infants had greater magnitude SIV-specific T cell responses (mean of 3475 vs 69 IFN-γ spot forming cells (SFC) per 106 PBMCs, respectively, P = 0.01) with enhanced breadth of epitope recognition and increased CD8+ and CD4+ T cell polyfunctionality (P = 0.004 and P = 0.005, respectively). Additionally, SIV-specific gp120 antibodies against challenge and vaccine virus strains were significantly elevated following MVA boost (P = 0.02 and P < 0.001, respectively). GS-986 led to expected immune stimulation demonstrated by activation of monocytes and T cells 24 hours post-dose. Despite the vaccine-induced immune responses, levels of SIV DNA in peripheral and lymph node CD4+ T cells were not significantly different from controls and a similar time to viral rebound and viral load set point were observed following ART interruption in both groups. We demonstrate infant RMs mount a robust immunological response to this immunization, but vaccination alone was not sufficient to impact viral reservoir size or modulate rebound dynamics following ART release. Our findings hold promise for therapeutic vaccination as a part of a combination cure approach in children and highlight the importance of a pediatric model to evaluate HIV-1 cure interventions in this unique setting of immune development. While antiretroviral therapy (ART) has improved disease outcome and reduced HIV-1 transmission, it is not a cure, as interruption of ART results in rapid viral rebound due to the persistent latent reservoir. Interventions to induce HIV-1 remission in the absence of ART would be highly beneficial to children living with HIV-1, sparing them from the associated adherence requirements, side effects, and cost of ART. Here, we used our previously established pediatric model of oral SIV infection and ART suppression of viremia in infant rhesus macaques (RMs) to evaluate the safety and efficacy of an Ad48-SIV prime, MVA-SIV boost therapeutic vaccine approach plus TLR-7 stimulation. Our study demonstrates this vaccination strategy is immunogenic in infants; however, unlike previously reported results in adult RMs using a similar approach, vaccination did not result in a difference in the level of CD4+ T cell-associated SIV DNA or viral rebound dynamics after ART interruption when compared to control infant RMs. These results highlight the importance of pre-clinical studies using pediatric models and indicate potential HIV-1 cure strategies may differentially impact adults and children.
Collapse
Affiliation(s)
- Katherine M. Bricker
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Veronica Obregon-Perko
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Ferzan Uddin
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Brianna Williams
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Emilie A. Uffman
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, United States of America
| | - Carolina Garrido
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, United States of America
| | - Genevieve G. Fouda
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, United States of America
- Departments of Molecular Genetics and Microbiology and Pediatrics, Duke University School of Medicine, Durham, NC, United States of America
| | - Romas Geleziunas
- Gilead Sciences, Inc., Foster City, CA, United States of America
| | - Merlin Robb
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, United States of America
| | - Nelson Michael
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, United States of America
| | - Dan H. Barouch
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, United States of America
| | - Ann Chahroudi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America
- Yerkes National Primate Research Center, Emory University, Atlanta, GA, United States of America
- Center for Childhood Infections and Vaccines of Children’s Healthcare of Atlanta and Emory University, Atlanta, GA, United States of America
- * E-mail:
| |
Collapse
|
8
|
The changing profile of paediatric HIV infection: An experience from the Middle East. Int J Infect Dis 2020; 97:347-351. [PMID: 32526391 DOI: 10.1016/j.ijid.2020.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To describe the clinical and epidemiological profiles of HIV-infected Omani children before and after the implementation of the prevention of mother-to-child transmission of HIV (PMTCT) programme. METHODS A retrospective review of HIV-infected children seen at a national paediatric HIV unit between 1992 and 2015 was performed. RESULTS Ninety-one HIV-infected children were identified; 59 (65%) were ≤5 years of age at diagnosis, with 28 (47.5%) of these being <1 year old. The average annual incidence of infection per million children (≤14 years old) was 5.7, and the highest (11.6) was in 2010. At diagnosis, 48 (60%) patients had a CD4 count of ˂200cells/mm3. The median HIV viral load was 81600copies/ml at diagnosis and 5911copies/ml at 12 months after HIV treatment (p=0.015). The median CD4 count was 586cells/mm3 at diagnosis and 800cells/mm3 at 12 months after therapy (p=0.004). Compared to those diagnosed before 2009 (n=68), HIV-infected children diagnosed after 2009 (n=22) were more likely to be asymptomatic at the time of HIV diagnosis (23.5% (16/68) vs. 59.1% (13/22); p=0.002) and to have a favourable clinical outcome (42.6% (29/68) vs. 86.4% (19/22); p<0001). CONCLUSIONS The number of HIV-infected children in Oman has decreased substantially since the introduction of the PMTCT programme. Furthermore, the HIV-infected children diagnosed after 2009 had higher proportions of asymptomatic HIV infections at diagnosis and favourable clinical outcomes, in comparison to those diagnosed before 2009.
Collapse
|
9
|
Millar JR, Bengu N, Fillis R, Sprenger K, Ntlantsana V, Vieira VA, Khambati N, Archary M, Muenchhoff M, Groll A, Grayson N, Adamson J, Govender K, Dong K, Kiepiela P, Walker BD, Bonsall D, Connor T, Bull MJ, Nxele N, Roider J, Ismail N, Adland E, Puertas MC, Martinez-Picado J, Matthews PC, Ndung'u T, Goulder P. HIGH-FREQUENCY failure of combination antiretroviral therapy in paediatric HIV infection is associated with unmet maternal needs causing maternal NON-ADHERENCE. EClinicalMedicine 2020; 22:100344. [PMID: 32510047 PMCID: PMC7264978 DOI: 10.1016/j.eclinm.2020.100344] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Early combination antiretroviral therapy (cART) reduces the size of the viral reservoir in paediatric and adult HIV infection. Very early-treated children may have higher cure/remission potential. METHODS In an observational study of 151 in utero (IU)-infected infants in KwaZulu-Natal, South Africa, whose treatment adhered strictly to national guidelines, 76 infants diagnosed via point-of-care (PoC) testing initiated cART at a median of 26 h (IQR 18-38) and 75 infants diagnosed via standard-of-care (SoC) laboratory-based testing initiated cART at 10 days (IQR 8-13). We analysed mortality, time to suppression of viraemia, and maintenance of aviraemia over the first 2 years of life. FINDINGS Baseline plasma viral loads were low (median 8000 copies per mL), with 12% of infants having undetectable viraemia pre-cART initiation. However, barely one-third (37%) of children achieved suppression of viraemia by 6 months that was maintained to >12 months. 24% had died or were lost to follow up by 6 months. Infant mortality was 9.3%. The high-frequency virological failure in IU-infected infants was associated not with transmitted or acquired drug-resistant mutations but with cART non-adherence (plasma cART undetectable/subtherapeutic, p<0.0001) and with concurrent maternal cART failure (OR 15.0, 95%CI 5.6-39.6; p<0.0001). High-frequency virological failure was observed in PoC- and SoC-tested groups of children. INTERPRETATION The success of early infant testing and cART initiation strategies is severely limited by subsequent cART non-adherence in HIV-infected children. Although there are practical challenges to administering paediatric cART formulations, these are overcome by mothers who themselves are cART-adherent. These findings point to the ongoing obligation to address the unmet needs of the mothers. Eliminating the particular barriers preventing adequate treatment for these vulnerable women and infants need to be prioritised in order to achieve durable suppression of viraemia on cART, let alone HIV cure/remission, in HIV-infected children. FUNDING Wellcome Trust, National Institutes of Health.
Collapse
Affiliation(s)
- Jane R Millar
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Nomonde Bengu
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Rowena Fillis
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Ken Sprenger
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | | | - Vinicius A Vieira
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Nisreen Khambati
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Moherndran Archary
- Department of Paediatrics, University of KwaZulu-Natal, Durban, South Africa
| | - Maximilian Muenchhoff
- Max von Pettenkofer Institute, Virology, National Reference Center for Retroviruses, Faculty of Medicine, LMU München, Munich, Germany
- German Center for Infection Research (DZIF), Partner site Munich, Germany
| | - Andreas Groll
- TU Dortmund University, Department of Statistics, Vogelpothsweg 87, 44227 Dortmund
| | - Nicholas Grayson
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - John Adamson
- Africa Health Research Institute (AHRI), Durban, South Africa
| | - Katya Govender
- Africa Health Research Institute (AHRI), Durban, South Africa
| | - Krista Dong
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, United States
- Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Photini Kiepiela
- South African Medical Research Council, Durban 4001, SC Africa
- Wits Health Consortium, Johannesburg 2193, SC Africa
| | - Bruce D Walker
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, United States
- Institute for Medical Engineering and Sciences and Department of Biology, Massachusetts Institute of Technology, Cambridge MA 02139, United States
- Howard Hughes Medical Institute, Chevy Chase MD 20815, United States
| | - David Bonsall
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Thomas Connor
- Cardiff University School of Biosciences, The Sir Martin Evans Building, Cardiff University, Cardiff, United Kingdom
| | - Matthew J Bull
- Pathogen Genomics Unit, Public Health Wales Microbiology Cardiff, University Hospital of Wales, Cardiff, United Kingdom
| | - Nelisiwe Nxele
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Julia Roider
- German Center for Infection Research (DZIF), Partner site Munich, Germany
- Department of Infectious Diseases, Ludwig-Maximilians-University, Munich
| | - Nasreen Ismail
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Emily Adland
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | - Javier Martinez-Picado
- AIDS Research Institute IrsiCaixa, Badalona, Spain
- University of Vic-Central University of Catalonia (UVic-UCC), Vic, Spain
- Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Philippa C Matthews
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Microbiology and Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford BRC, John Radcliffe Hospital, Oxford, United Kingdom
| | - Thumbi Ndung'u
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute (AHRI), Durban, South Africa
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, United States
- Max Planck Institute for Infection Biology, Berlin, Germany
| | - Philip Goulder
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, United States
| |
Collapse
|
10
|
Kubheka SE, Archary M, Naidu KK. HIV viral load testing coverage and timeliness after implementation of the wellness anniversary in a paediatric and adolescent HIV clinic in KwaZulu-Natal, South Africa. South Afr J HIV Med 2020; 21:1016. [PMID: 32158554 PMCID: PMC7059249 DOI: 10.4102/sajhivmed.v21i1.1016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 08/24/2019] [Indexed: 11/03/2022] Open
Abstract
Background The UNAIDS 2020 Global strategy to reduce the transmission of HIV includes ensuring HIV viral load (VL) testing coverage of at least 90% on all patients on antiretroviral therapy (ART). Routine VL monitoring has been shown to result in earlier detection of treatment failure, timely regimen switches, promotion of adherence to treatment and improved survival. We wanted to assess the introduction of the wellness anniversary in improving routine viral load monitoring. Objectives We retrospectively assessed effects of the wellness anniversary on routine VL coverage, timeliness and suppression rates. Method The month when the patient initiated ART was designated as the wellness anniversary. On the anniversary month a package of care, which included a routine VL, was delivered. We conducted a retrospective chart audit to assess VL coverage and timeliness between two time periods, from January 2016 to December 2016 (pre-implementation) and from January 2017 to December 2017 (post-implementation). Results Timeliness of VL testing improved from 27.5% in the pre-implementation cohort to 49.7% in the post-implementation cohort. Our study showed high VL testing coverage before the implementation of the wellness anniversary with an average of 98.3% VL. There was a significant correlation between timeliness and VL suppression (VLS) in the post-implementation group. Conclusion Implementation of the wellness anniversary may improve timeliness of routine VL testing in settings with high VL coverage. Studies looking at the effect of timeliness on VLS and clinical outcomes are needed.
Collapse
Affiliation(s)
- Sibusiso E Kubheka
- Department of Paediatrics and Child Health, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Moherndran Archary
- Department of Paediatrics and Child Health, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Kevindra K Naidu
- Maternal, Child and Adolescent Health, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
11
|
Kaplan S, Nteso KS, Ford N, Boulle A, Meintjes G. Loss to follow-up from antiretroviral therapy clinics: A systematic review and meta-analysis of published studies in South Africa from 2011 to 2015. South Afr J HIV Med 2019; 20:984. [PMID: 31956435 PMCID: PMC6956684 DOI: 10.4102/sajhivmed.v20i1.984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background South Africa has the largest antiretroviral therapy (ART) programme in the world. To optimise programme outcomes, it is critical that patients are retained in care and that retention is accurately measured. Objectives To identify all studies published in South Africa from 2011 to 2015 that used loss to follow-up (LTFU) as an indicator or outcome to describe the variation in definitions and to estimate the proportion of patients lost to care across studies. Method All studies published between 01 January 2011 and October 2015 that included loss to follow-up or default from ART care in a South African cohort were included by use of a broad search strategy across multiple databases. To be included, the cohort had to include any patient ART data, including follow-up time, from 01 January 2010. Two authors, working independently, extracted data and assessed risk of bias from all manuscripts. Meta-analysis was performed for studies stratified by the same loss to follow-up definition. Results Forty-eight adult, 15 paediatric and 4 pregnant cohorts were included. Median cohort size was 3737; follow-up time ranged from 9 weeks to 5 years. Meta-analysis did not reveal an important difference in LTFU estimates in adult cohorts at 1 year between loss to follow-up defined as 3 months (11.0%, n = 4; 95% CI 10.7% – 11.2%) compared with 6 months (12.0%, n = 4; 95% CI 11.8% – 12.2%). Only two cohorts reported reliable LTFU estimates at 5 years: this was 25.1% (95% CI 24.8% – 25.4%). Conclusion South Africa should standardise a LTFU definition. This would aid in monitoring and evaluation of ART programmes, with the broader goal of improving patient outcomes.
Collapse
Affiliation(s)
- Samantha Kaplan
- Department of Internal Medicine, University of Washington, Seattle, United States
| | - Katleho S Nteso
- Medical Care Development International, Maseru, Lesotho, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
12
|
Time to First-Line ART Failure and Time to Second-Line ART Switch in the IeDEA Pediatric Cohort. J Acquir Immune Defic Syndr 2019; 78:221-230. [PMID: 29509590 DOI: 10.1097/qai.0000000000001667] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Globally, 49% of the estimated 1.8 million children living with HIV are accessing antiretroviral therapy (ART). There are limited data concerning long-term durability of first-line ART regimens and time to transition to second-line. METHODS Children initiating their first ART regimen between 2 and 14 years of age and enrolled in one of 208 sites in 30 Asia-Pacific and African countries participating in the Pediatric International Epidemiology Databases to Evaluate AIDS consortium were included in this analysis. Outcomes of interest were: first-line ART failure (clinical, immunologic, or virologic), change to second-line, and attrition (death or loss to program ). Cumulative incidence was computed for first-line failure and second-line initiation, with attrition as a competing event. RESULTS In 27,031 children, median age at ART initiation was 6.7 years. Median baseline CD4% for children ≤5 years of age was 13.2% and CD4 count for those >5 years was 258 cells per microliter. Almost all (94.4%) initiated a nonnucleoside reverse transcriptase inhibitor; 5.3% a protease inhibitor, and 0.3% a triple nucleoside reverse transcriptase inhibitor-based regimen. At 1 year, 7.7% had failed and 14.4% had experienced attrition; by 5 years, the cumulative incidence was 25.9% and 29.4%, respectively. At 1 year after ART failure, 13.7% had transitioned to second-line and 11.2% had experienced attrition; by 5 years, the cumulative incidence was 31.6% and 25.9%, respectively. CONCLUSIONS High rates of first-line failure and attrition were identified in children within 5 years after ART initiation. Of children meeting failure criteria, only one-third were transitioned to second-line ART within 5 years.
Collapse
|
13
|
Humphrey JM, Genberg BL, Keter A, Musick B, Apondi E, Gardner A, Hogan JW, Wools‐Kaloustian K. Viral suppression among children and their caregivers living with HIV in western Kenya. J Int AIDS Soc 2019; 22:e25272. [PMID: 30983148 PMCID: PMC6462809 DOI: 10.1002/jia2.25272] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 03/12/2019] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Despite the central role of caregivers in managing HIV treatment for children living with HIV, viral suppression within caregiver-child dyads in which both members are living with HIV is not well described. METHODS We conducted a retrospective analysis of children living with HIV <15 years of age and their caregivers living with HIV attending HIV clinics affiliated with the Academic Model Providing Access to Healthcare (AMPATH) in Kenya between 2015 and 2017. To be included in the analysis, children and caregivers must have had ≥1 viral load (VL) during the study period while receiving antiretroviral therapy (ART) for ≥6 months, and the date of the caregiver's VL must have occurred ±90 days from the date of the child's VL. The characteristics of children, caregivers and dyads were descriptively summarized. Multivariable logistic regression was used to estimate the odds of viral non-suppression (≥ 1000 copies/mL) in children, adjusting for caregiver and child characteristics. RESULTS Of 7667 children who received care at AMPATH during the study period, 1698 were linked to a caregiver living with HIV and included as caregiver-child dyads. For caregivers, 94% were mothers, median age at ART initiation 32.8 years, median CD4 count at ART initiation 164 cells/mm3 and 23% were not virally suppressed. For children, 52% were female, median age at ART initiation 4.2 years, median CD4 values at ART initiation were 15% (age < 5 years) and 396 cells/mm3 (age ≥ 5 years), and 38% were not virally suppressed. In the multivariable model, children were found more likely to not be virally suppressed if their caregivers were not suppressed compared to children with suppressed caregivers (aOR = 2.40, 95% CI: 1.86 to 3.10). Other characteristics associated with child viral non-suppression included caregiver ART regimen change prior to the VL, caregiver receipt of a non-NNRTI-based regimen at the time of the VL, younger child age at ART initiation and child tuberculosis treatment at the time of the VL. CONCLUSIONS Children were at higher risk of viral non-suppression if their caregivers were not virally suppressed compared to children with suppressed caregivers. A child's viral suppression status should be closely monitored if his or her caregiver is not suppressed.
Collapse
Affiliation(s)
| | - Becky L Genberg
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Alfred Keter
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Beverly Musick
- Department of BiostatisticsIndiana UniversityIndianapolisINUSA
| | - Edith Apondi
- Department of PaediatricsMoi Teaching and Referral HospitalEldoretKenya
| | - Adrian Gardner
- Department of MedicineIndiana UniversityIndianapolisINUSA
| | - Joseph W Hogan
- Department of BiostatisticsBrown UniversityProvidenceRIUSA
| | | |
Collapse
|
14
|
Teasdale CA, Sogaula N, Yuengling KA, Wang C, Mutiti A, Arpadi S, Nxele M, Pepeta L, Mogashoa M, Rivadeneira ED, Abrams EJ. HIV viral suppression and longevity among a cohort of children initiating antiretroviral therapy in Eastern Cape, South Africa. J Int AIDS Soc 2018; 21:e25168. [PMID: 30094952 PMCID: PMC6085595 DOI: 10.1002/jia2.25168] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 07/09/2018] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION There are limited data on viral suppression (VS) in children with HIV receiving antiretroviral therapy (ART) in routine care in low-resource settings. We examined VS in a cohort of children initiating ART in routine HIV care in Eastern Cape Province, South Africa. METHODS The Pediatric Enhanced Surveillance Study enrolled HIV-infected ART eligibility children zero to twelve years at five health facilities from 2012 to 2014. All children received routine HIV care and treatment services and attended quarterly study visits for up to 24 months. Time to VS among those starting treatment was measured from ART start date to first viral load (VL) result <1000 and VL <50 copies/mL using competing risk estimators (death as competing risk). Multivariable sub-distributional hazards models examined characteristics associated with VS and VL rebound following suppression among those with a VL >30 days after the VS date. RESULTS Of 397 children enrolled, 349 (87.9%) started ART: 118 (33.8%) children age <12 months, 122 (35.0%) one to five years and 109 (31.2%) six to twelve years. At study enrolment, median weight-for-age z-score (WAZ) was -1.7 (interquartile range (IQR):-3.1 to -0.4) and median log VL was 5.6 (IQR: 5.0 to 6.2). Cumulative incidence of VS <1000 copies/mL at six, twelve and twenty-four months was 57.6% (95% CI 52.1 to 62.7), 78.7% (95% CI 73.7 to 82.9) and 84.0% (95% CI 78.9 to 87.9); for VS <50 copies/mL: 40.3% (95% CI 35.0 to 45.5), 63.9% (95% CI 58.2 to 69.0) and 72.9% (95% CI 66.9 to 78.0). At 12 months only 46.6% (95% CI 36.6 to 56.0) of children <12 months had achieved VS <50 copies/mL compared to 76.9% (95% CI 67.9 to 83.7) of children six to twelve years (p < 0.001). In multivariable models, children with VL >1 million copies/mL at ART initiation were half as likely to achieve VS <50 copies/mL (adjusted sub-distributional hazards 0.50; 95% CI 0.36 to 0.71). Among children achieving VS <50 copies/mL, 37 (19.7%) had VL 50 to 1000 copies/mL and 31 (16.5%) had a VL >1000 copies/mL. Children <12 months had twofold increased risk of VL rebound to VL >1000 copies/mL (adjusted relative risk 2.03, 95% CI: 1.10 to 3.74) compared with six to twelve year olds. CONCLUSIONS We found suboptimal VS among South African children initiating treatment and high proportions experiencing VL rebound, particularly among younger children. Greater efforts are needed to ensure that all children achieve optimal outcomes.
Collapse
Affiliation(s)
- Chloe A Teasdale
- ICAP at ColumbiaMailman School of Public HealthColumbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthColumbia University New YorkNYUSA
| | - Nonzwakazi Sogaula
- ICAP at ColumbiaMailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | | | - Chunhui Wang
- ICAP at ColumbiaMailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Anthony Mutiti
- ICAP at ColumbiaMailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Stephen Arpadi
- ICAP at ColumbiaMailman School of Public HealthColumbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthColumbia University New YorkNYUSA
| | | | - Lungile Pepeta
- Port Elizabeth Hospital ComplexPort ElizabethSouth Africa
- Faculty of Health SciencesNelson Mandela UniversityPort ElizabethSouth Africa
| | - Mary Mogashoa
- US Centers for Disease Control and PreventionPretoriaSouth Africa
| | | | - Elaine J Abrams
- ICAP at ColumbiaMailman School of Public HealthColumbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthColumbia University New YorkNYUSA
- College of Physicians & SurgeonsColumbia UniversityNew YorkNYUSA
| |
Collapse
|
15
|
Amedee AM, Phillips B, Jensen K, Robichaux S, Lacour N, Burke M, Piatak M, Lifson JD, Kozlowski PA, Van Rompay KK, De Paris K. Early Sites of Virus Replication After Oral SIV mac251 Infection of Infant Macaques: Implications for Pathogenesis. AIDS Res Hum Retroviruses 2018; 34:286-299. [PMID: 29237287 DOI: 10.1089/aid.2017.0169] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Despite optimization of preventative measures for vertical HIV-1 transmission, daily, roughly 400 infants become HIV infected, most of them through breastfeeding. Viral entry has been presumed to occur in the gastrointestinal tract; however, the exact entry site(s) have not been defined. Therefore, we quantified simian immunodeficiency virus (SIV) RNA and DNA in oral, intestinal, and systemic tissues of 15 infant macaques within 48-96 h after oral SIVmac251 exposure. SIV DNA was detected as early as 48 h, whereas SIV RNA was typically detected at later time points (72-96 h). Transmitted founder viruses were identical or very similar to a single genotype in the SIVmac251 challenge stock. SIV RNA and DNA were most frequently found in lymph nodes (LNs) draining the oral cavity and in the ileum. Using in situ hybridization, SIV-infected cells in LNs were exclusively represented by CD3+ T cells. SIV RNA and DNA were also detected in the lungs of 20% of the animals, and 60% of the animals had detectable SIV DNA in the cerebrum. The early detection of viral RNA or DNA in lung and brain tissues emphasizes the need for early treatment of pediatric HIV infection to prevent damage not only to the immune system but also to the respiratory tract and central nervous system.
Collapse
Affiliation(s)
- Angela M. Amedee
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Bonnie Phillips
- Department of Microbiology and Immunology and Center for AIDS Research, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kara Jensen
- Department of Microbiology and Immunology and Center for AIDS Research, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Spencer Robichaux
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Nedra Lacour
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Mark Burke
- Howard University, Washington, District of Columbia
| | - Michael Piatak
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Jeffrey D. Lifson
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Pamela A. Kozlowski
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Koen K.A. Van Rompay
- California National Primate Research Center, University of California, Davis, Davis, California
| | - Kristina De Paris
- Department of Microbiology and Immunology and Center for AIDS Research, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
16
|
Virologic Response to Early Antiretroviral Therapy in HIV-infected Infants: Evaluation After 2 Years of Treatment in the Pediacam Study, Cameroon. Pediatr Infect Dis J 2018; 37:78-84. [PMID: 28841582 DOI: 10.1097/inf.0000000000001745] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Little is known about virologic responses to early antiretroviral therapy (ART) in HIV-infected infants in resource-limited settings. We estimated the probability of achieving viral suppression within 2 years of ART initiation and investigated the factors associated with success. METHODS We analyzed all 190 infants from the Cameroon Pediacam who initiated ART by 12 months of age. The main outcome measure was viral suppression (<1000 copies/mL) on at least 1 occasion; the other outcome measures considered were viral suppression (<400 copies/mL) on at least 1 occasion and confirmed viral suppression (both thresholds) on 2 consecutive occasions. We used competing-risks regression for a time-to-event analysis to estimate the cumulative incidence of outcomes and univariate and multivariate models to identify risk factors. RESULTS During the first 24 months of ART, 20.0% (38) of the infants died, giving a mortality rate of 11.9 deaths per 100 infant-years (95% confidence interval: 8.1-15.7). The probability of achieving a viral load below 1000 or 400 copies/mL was 80.0% (69.0-81.0) and 78.0% (66.0-79.0), respectively. The probability of virologic suppression (with these 2 thresholds) on 2 consecutive occasions was 67.0% (56.0-70.0) and 60.0% (49.0-64.0), respectively. Virologic success was associated with not having missed any doses of treatment before the visit, but not with socioeconomic and living conditions. CONCLUSION Many early treated children failed to achieve virologic suppression, likely due to a combination of adherence difficulties, drug dosing and viral resistance, which highlights the need for routine viral load monitoring. The high infant mortality despite early ART initiation needs to be addressed in sub-Saharan countries.
Collapse
|
17
|
Ben-Farhat J, Schramm B, Nicolay N, Wanjala S, Szumilin E, Balkan S, Pujades-Rodríguez M. Mortality and clinical outcomes in children treated with antiretroviral therapy in four African vertical programmes during the first decade of paediatric HIV care, 2001-2010. Trop Med Int Health 2017; 22:340-350. [PMID: 27992677 DOI: 10.1111/tmi.12830] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To assess mortality and clinical outcomes in children treated with antiretroviral therapy (ART) in four African vertical programmes between 2001 and 2010. METHODS Cohort analysis of data from HIV-infected children (<15 years old) initiating ART in four sub-Saharan HIV programmes in Kenya, Uganda and Malawi, between December 2001 and December 2010. Rates of mortality, programme attrition and first-line clinico-immunological failure were calculated by age group (<2, 2-4 and 5-14 years), 1 or 2 years after ART initiation, and risk factors were examined. RESULTS A total of 3949 children, 22.7% aged <2 years, 32.2% 2-4 years and 45.1% 5-14 years, were included. At ART initiation, 60.8% had clinical stage 3 or 4, and 46.5% severe immunosuppression. Overall mortality, attrition and 1-year failure rates were 5.1, 10.8 and 9.0 per 100 person-years, respectively. Immunosuppression, stage 3 or 4, and underweight were associated with increased rates of mortality, attrition and treatment failure. Adjusted estimates showed lower mortality hazard ratios (HR) among children aged 2-4 years (HR = 0.57, 95% CI 0.42-0.77 than children aged 5-14 years). One-year treatment failure incidence rate ratios (IRR) were similar regardless of age (IRR = 0.91, 95% CI 0.67-1.25 for <2 years; 1.01, 95% CI 0.83-1.23 for 2-4 years, vs. 5-14 years). CONCLUSIONS Good treatment outcomes were achieved during the first decade of HIV paediatric care despite the late start of therapy. Encouraging early HIV infant diagnosis in and outside prevention of mother-to-child transmission programmes, and linkage to care services for early ART initiation, is needed to reduce mortality and delay treatment failure.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Mar Pujades-Rodríguez
- Epicentre, Paris, France.,MRC Medical Bioinformatics Centre, University of Leeds, Leeds, UK
| |
Collapse
|
18
|
Adedimeji A, Edmonds A, Hoover D, Shi Q, Sinayobye JD, Nduwimana M, Lelo P, Nash D, Anastos K, Yotebieng M. Characteristics of HIV-Infected Children at Enrollment into Care and at Antiretroviral Therapy Initiation in Central Africa. PLoS One 2017; 12:e0169871. [PMID: 28081230 PMCID: PMC5230784 DOI: 10.1371/journal.pone.0169871] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 12/22/2016] [Indexed: 01/22/2023] Open
Abstract
Background Despite the World Health Organization (WHO) regularly updating guidelines to recommend earlier initiation of antiretroviral therapy (ART) in children, timely enrollment into care and initiation of ART in sub-Saharan Africa in children lags behind that of adults. The impact of implementing increasingly less restrictive ART guidelines on ART initiation in Central Africa has not been described. Materials and Methods Data are from the Central Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) pediatric cohort of 3,426 children (0–15 years) entering HIV care at 15 sites in Burundi, DRC, and Rwanda. Measures include CD4 count, WHO clinical stage, age, and weight-for-age Z score (WAZ), each at enrollment into HIV care and at ART initiation. Changes in the medians or proportions of each measure by year of enrollment and year of ART initiation were assessed to capture potential impacts of changing ART guidelines. Results Median age at care enrollment decreased from 77.2 months in 2004–05 to 30.3 months in 2012–13. The median age at ART initiation (n = 2058) decreased from 83.0 months in 2004–05 to 66.9 months in 2012–13. The proportion of children ≤24 months of age at enrollment increased from 12.7% in 2004–05 to 46.7% in 2012–13, and from 9.6% in 2004–05 to 24.2% in 2012–13 for ART initiation. The median CD4 count at enrollment into care increased from 563 (IQR: 275, 901) in 2004–05 to 660 (IQR: 339, 1071) cells/μl in 2012–13, and the median CD4 count at ART initiation increased from 310 (IQR:167, 600) in 2004–05 to 589 (IQR: 315, 1113) cells/μl in 2012–13. From 2004–05 to 2012–13, median WAZ improved from -2 (IQR: -3.4, -1.1) to -1 (IQR: -2.5, -0.2) at enrollment in care and from -2 (IQR: -3.8, -1.6) to -1 (IQR: -2.6, -0.4) at ART initiation. Discussion and Conclusion Although HIV-infected children ≤24 months of age accounted for half of all children enrolling in care in our cohort during 2012–13, they represented less than a quarter of all those who were initiated on ART during the same period. Further research is needed to identify barriers to timely diagnosis, linkage to care, and initiation of ART among children with HIV infection.
Collapse
Affiliation(s)
- Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
- * E-mail:
| | - Andrew Edmonds
- Department of Epidemiology, The University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Donald Hoover
- Department of Statistics, Rutgers University, New Brunswick, New Jersey, United States of America
| | - Qiuhu Shi
- Department of Epidemiology and Community Health, New York Medical College, Valhalla, New York, United States of America
| | - Jean d’Amour Sinayobye
- Division of Research and Clinical Education, The Rwanda Military Hospital, Kanombe, Kigali Rwanda
| | - Martin Nduwimana
- Department of Pediatrics, University Hospital of Kamenge, Faculty of Medicine, University of Burundi, Bujumbura, Burundi
| | - Patricia Lelo
- Kalembe Lembe Pediatric Hospital, Kinshasa, The Democratic Republic of Congo
| | - Denis Nash
- Epidemiology and Biostatistics Program at the City University of New York School of Public Health, New York, New York, United States of America
| | - Kathryn Anastos
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Medicine, Montefiore Medical Center, Bronx, New York, United States of America
| | - Marcel Yotebieng
- College of Public Health, Division of Epidemiology, The Ohio State University, Columbus, Ohio, United States of America
| |
Collapse
|
19
|
Differences in virologic and immunologic response to antiretroviral therapy among HIV-1-infected infants and children. AIDS 2016; 30:2835-2843. [PMID: 27603293 DOI: 10.1097/qad.0000000000001244] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Virologic and immunologic responses to antiretroviral treatment (ART) in infants may differ from older children due to immunologic, clinical, or epidemiologic characteristics. METHODS Longitudinal ART responses were modeled and compared in HIV-infected infants and children enrolled in cohorts in Nairobi, Kenya. Participants were enrolled soon after HIV diagnosis, started on ART, and followed for 2 years. Viral load decline was compared between infant and child cohorts using a nonlinear mixed effects model and CD4% reconstitution using a linear mixed effects model. RESULTS Among 121 infants, median age at ART was 3.9 months; among 124 children, median age was 4.8 years. At baseline, viral load was higher among infants than children (6.47 vs. 5.91 log10 copies/ml, P < 0.001). Infants were less likely than children to suppress viral load to less than 250 copies/ml following 6 months of ART (32% infants vs. 73% children, P < 0.0001). CD4% was higher at baseline in infants than children (19 vs. 7.3%, P < 0.001). Older children had more rapid CD4% reconstitution than infants, but failed to catch up to infant CD4%. CONCLUSION Despite substantially higher CD4% at ART initiation, viral suppression was significantly slower among infants than older children. New strategies are needed to optimize infant outcomes on ART.
Collapse
|
20
|
Pediatric Access and Continuity of HIV Care Before the Start of Antiretroviral Therapy in Sub-Saharan Africa. Pediatr Infect Dis J 2016; 35:981-6. [PMID: 27187757 DOI: 10.1097/inf.0000000000001213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The number of HIV-infected children starting antiretroviral treatment (ART) has increased in resource-limited settings during the past decades. However, there are still few published data on the characteristics of pediatric patients at program enrolment and on the dynamics of dropping out before the start of ART. METHODS We performed a retrospective cohort study among HIV-infected pediatric patients (age, 5-14 years) not yet started on ART enrolled in 4 HIV sub-Saharan African programs. Descriptive and risk factors for mortality and lost to follow-up (LFU) were investigated using adjusted parametric or Cox proportional hazard models. RESULTS A total of 2244 patients (52.8% girls) were enrolled in HIV care, a median of 2 days [interquartile range (IQR), 0-8 days] after HIV diagnosis. Baseline median CD4 cell count was 409 cells/μL (IQR, 203-478 cells/μL); 43% were in clinical stage 3 or 4, 71% required ART and 76.2% of these patients initiated therapy. Of those eligible not started on ART, 14% died and 59% were LFU. Median pre-ART follow-up was 4.4 months (IQR, 1.3-20 months) and was shorter for eligible patients. Mortality rates were 6.2 of 100 person-years [95% confidence interval (CI), 4.6-8.3] in the 0- to 6-month period and 1.3 of 100 person-years (95% CI, 0.9-2.0) in the 6- to 60-month period. LFU rates were 37.4 of 100 (95% CI, 33.0-42.4) and 8.3 of 100 person-years (95% CI, 7.1-9.8), respectively. Advanced HIV disease at presentation (low body mass index, stage 3 or 4, low CD4 count or tuberculosis diagnosis) was associated with increased mortality and LFU. CONCLUSIONS Late presentation and delays in initiating ART among eligible children were responsible for the large incidence of patient losses during pre-ART follow-up in sub-Saharan Africa.
Collapse
|
21
|
Naik NM, Bacha J, Gesase AE, Barton T, Schutze GE, Wanless RS, Minde MM, Mwita LF, Tolle MA. Antiretroviral Therapy in Children Less Than 24 Months of Age at Pediatric HIV Centers in Tanzania: 12-Month Clinical Outcomes and Survival. J Int Assoc Provid AIDS Care 2016; 15:440-8. [PMID: 27225854 DOI: 10.1177/2325957416649668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Without antiretroviral therapy (ART), approximately one-half of HIV-infected infants will die by two years. In 2010, the World Health Organization (WHO) recommended that all HIV-infected infants < 24 months be initiated on ART regardless of their clinical/immunologic status. However, there remains little published data detailing cohorts of infants on ART in Sub-Saharan Africa. This study describes baseline characteristics and 12 month outcomes of a cohort of HIV-infected children < 24 months of age at pediatric HIV centers in Mwanza and Mbeya, Tanzania. MATERIALS AND METHODS Retrospective chart review. INCLUSION CRITERIA children < 24 months of age, initiated on ART at Baylor Children s Foundation Tanzania clinics, between March-December 2011. RESULTS Baseline: Ninety-three children were initiated on ART at a median age of 13.4 months. Sixty-seven percent had severe immunosuppression and 31.5% had severe malnutrition. OUTCOME Seventy-three patients were still in care at 12 month follow-up, there were four (4.3%) deaths, five (5.4%) patients transferred, and 11 (11.8%) loss to follow-up. Average CD4% was 32.7 (p < 0.001). Ninety percent of patients were WHO treatment stage I (p < 0.001). Eighty-six percent had normal nutritional status (p < 0.001). CONCLUSION Our cohort of HIV infected children < 24 months initiated on ART did well clinically at 12 month outcomes despite being severely immunocompromised and malnourished at baseline. Nevirapine based regimens had good 12 month clinical outcomes, regardless of maternal exposure. Loss to follow-up rate was high for our cohort, demonstrating the need to develop strong mechanisms to counteract this.
Collapse
Affiliation(s)
- Neel Mahesh Naik
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Jason Bacha
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | | | - Theresa Barton
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Gordon E Schutze
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | | | | | | | - Mike A Tolle
- Baylor Children's Foundation Tanzania, Mwanza, Tanzania
| |
Collapse
|
22
|
Nuwagaba-Biribonwoha H, Wang C, Kilama B, Jowhar FK, Antelman G, Panya MF, Abrams EJ. Implementation of antiretroviral therapy guidelines for under-five children in Tanzania: translating recommendations into practice. J Int AIDS Soc 2015; 18:20303. [PMID: 26690303 PMCID: PMC4685962 DOI: 10.7448/ias.18.1.20303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 10/15/2015] [Accepted: 11/02/2015] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Paediatric antiretroviral therapy (ART) guidelines have been updated several times in recent years. We assessed implementation of ART guidelines among under-five children to inform the transition to universal paediatric ART in Tanzania. METHODS We conducted a retrospective cohort analysis of infants (0 to 11 months) and children (12 to 59 months) enrolled between 2010 and 2012 using routinely collected data. Infants and children were initiated on ART according to the 2008 World Health Organization (WHO) recommendations/2009 Tanzania guidelines (universal ART for infants). Cumulative ART initiation incidence and correlates of ART initiation were examined using competing risk methods accounting for attrition (death or loss to follow-up). Kaplan-Meier methods and Cox regression models were used to examine attrition on ART and its correlates. RESULTS A total of 1679 children were enrolled at 69 clinics: 469 (28%) infants and 1210 (74%) children. Infant cumulative ART initiation incidence was 59.6, 71.3 and 78.0% at one, three and six months of follow-up. Infants were more likely to start ART if enrolled in 2012 [adjusted sub-hazard ratio (AsHR)=2.2, 95% confidence interval (CI): 1.7 to 2.8] or 2011 (AsHR=1.8, 95% CI: 1.4 to 2.3) compared to 2010; they were more likely to start ART from prevention of mother-to-child HIV transmission (AsHR=1.6, 95% CI: 1.3 to 2.1) and inpatient wards (AsHR=1.5, 95% CI: 1.2 to 2.0) versus being enrolled from voluntary counselling and testing centres. Attrition at 12 months on ART was 33.9% and was more likely among infants with WHO Stage 4 [adjusted hazard ratio (AHR)=3.1. 95% CI: 1.8 to 5.2] and severe malnutrition (AHR=1.4, 95% CI: 1.0 to 1.9).Among 599 children eligible for ART at enrollment, cumulative ART initiation incidence was 51.8, 68.6 and 76.1% at one, three, and six months. Children were more likely to start ART if enrolled in 2012 (AsHR=1.8, 95% CI: 1.4 to 2.3) or 2011 (AsHR=1.5, 95% CI: 1.2 to 1.8) compared to 2010; they were more likely to start ART at primary health facilities (AsHR=1.5, 95% CI: 1.1 to 2.0) and less likely at urban facilities (AsHR=0.6, 95% CI: 0.5 to 0.9) and facilities without CD4 testing on site (AsHR=0.7, 95% CI: 0.5 to 0.9). Attrition at 12 months on ART was 23.1% and was more likely with severe malnutrition (AHR=1.8, 95% CI: 1.1 to 3.0), WHO Stage 4 (AHR=3.0, 95% CI: 1.0 to 8.5) and outpatient enrolees (AHR=1.7, 95% CI: 1.1 to 2.7). CONCLUSIONS Our findings suggest the gradual adoption of guidelines over calendar time. Interventions to expedite ART initiation and support retention on ART are needed.
Collapse
Affiliation(s)
- Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA;
| | - Chunhui Wang
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Bonita Kilama
- National AIDS Control Program, Dar Es Salaam, Tanzania
| | | | - Gretchen Antelman
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Milembe F Panya
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| |
Collapse
|
23
|
Makadzange AT, Higgins-Biddle M, Chimukangara B, Birri R, Gordon M, Mahlanza T, McHugh G, van Dijk JH, Bwakura-Dangarembizi M, Ndung’u T, Masimirembwa C, Phelps B, Amzel A, Ojikutu BO, Walker BD, Ndhlovu CE. Clinical, Virologic, Immunologic Outcomes and Emerging HIV Drug Resistance Patterns in Children and Adolescents in Public ART Care in Zimbabwe. PLoS One 2015; 10:e0144057. [PMID: 26658814 PMCID: PMC4678607 DOI: 10.1371/journal.pone.0144057] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 11/12/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine immunologic, virologic outcomes and drug resistance among children and adolescents receiving care during routine programmatic implementation in a low-income country. METHODS A cross-sectional evaluation with collection of clinical and laboratory data for children (0-<10 years) and adolescents (10-19 years) attending a public ART program in Harare providing care for pediatric patients since 2004, was conducted. Longitudinal data for each participant was obtained from the clinic based medical record. RESULTS Data from 599 children and adolescents was evaluated. The participants presented to care with low CD4 cell count and CD4%, median baseline CD4% was lower in adolescents compared with children (11.0% vs. 15.0%, p<0.0001). The median age at ART initiation was 8.0 years (IQR 3.0, 12.0); median time on ART was 2.9 years (IQR 1.7, 4.5). On ART, median CD4% improved for all age groups but remained below 25%. Older age (≥ 5 years) at ART initiation was associated with severe stunting (HAZ <-2: 53.3% vs. 28.4%, p<0.0001). Virologic failure rate was 30.6% and associated with age at ART initiation. In children, nevirapine based ART regimen was associated with a 3-fold increased risk of failure (AOR: 3.5; 95% CI: 1.3, 9.1, p = 0.0180). Children (<10 y) on ART for ≥4 years had higher failure rates than those on ART for <4 years (39.6% vs. 23.9%, p = 0.0239). In those initiating ART as adolescents, each additional year in age above 10 years at the time of ART initiation (AOR 0.4 95%CI: 0.1, 0.9, p = 0.0324), and each additional year on ART (AOR 0.4, 95%CI 0.2, 0.9, p = 0.0379) were associated with decreased risk of virologic failure. Drug resistance was evident in 67.6% of sequenced virus isolates. CONCLUSIONS During routine programmatic implementation of HIV care for children and adolescents, delayed age at ART initiation has long-term implications on immunologic recovery, growth and virologic outcomes.
Collapse
Affiliation(s)
- A. T. Makadzange
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, United States of America
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - B. Chimukangara
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
- African Institute of Biomedical Sciences, Harare, Zimbabwe
| | - R. Birri
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - M. Gordon
- HIV Pathogenesis Program, University of Kwa-Zulu Natal, Durban, South Africa
| | - T. Mahlanza
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - G. McHugh
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - J. H. van Dijk
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - M. Bwakura-Dangarembizi
- Department of Pediatrics, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - T. Ndung’u
- HIV Pathogenesis Program, University of Kwa-Zulu Natal, Durban, South Africa
| | | | - B. Phelps
- United States Agency for International Development (USAID), Washington, DC, United States of America
| | - A. Amzel
- United States Agency for International Development (USAID), Washington, DC, United States of America
| | - B. O. Ojikutu
- John Snow Inc, Boston, Massachusetts, United States of America
| | - B. D. Walker
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - C. E. Ndhlovu
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| |
Collapse
|
24
|
|
25
|
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.
Collapse
|
26
|
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.
Collapse
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
| | | | | | | | | |
Collapse
|
27
|
Porter M, Davies MA, Mapani MK, Rabie H, Phiri S, Nuttall J, Fairlie L, Technau KG, Stinson K, Wood R, Wellington M, Haas AD, Giddy J, Tanser F, Eley B. Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004-2012. J Acquir Immune Defic Syndr 2015; 69:593-601. [PMID: 26167620 PMCID: PMC4509628 DOI: 10.1097/qai.0000000000000683] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are limited published data on the outcomes of infants starting antiretroviral therapy (ART) in routine care in Southern Africa. This study aimed to examine the baseline characteristics and outcomes of infants initiating ART. METHODS We analyzed prospectively collected cohort data from routine ART initiation in infants from 11 cohorts contributing to the International Epidemiologic Database to Evaluate AIDS in Southern Africa. We included ART-naive HIV-infected infants aged <12 months initiating ≥3 antiretroviral drugs between 2004 and 2012. Kaplan-Meier estimates were calculated for mortality, loss to follow-up (LTFU), transfer out, and virological suppression. We used Cox proportional hazard models stratified by cohort to determine baseline characteristics associated with outcomes mortality and virological suppression. RESULTS The median (interquartile range) age at ART initiation of 4945 infants was 5.9 months (3.7-8.7) with follow-up of 11.2 months (2.8-20.0). At ART initiation, 77% had WHO clinical stage 3 or 4 disease and 87% were severely immunosuppressed. Three-year mortality probability was 16% and LTFU 29%. Severe immunosuppression, WHO stage 3 or 4, anemia, being severely underweight, and initiation of treatment before 2010 were associated with higher mortality. At 12 months after ART initiation, 17% of infants were severely immunosuppressed and the probability of attaining virological suppression was 56%. CONCLUSIONS Most infants initiating ART in Southern Africa had severe disease with high probability of LTFU and mortality on ART. Although the majority of infants remaining in care showed immune recovery and virological suppression, these responses were suboptimal.
Collapse
Affiliation(s)
- Mireille Porter
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | | | - Helena Rabie
- Tygerberg Academic Hospital and Stellenbosch University, Tygerberg, W Cape
| | - Sam Phiri
- Lighthouse Trust Clinic, Lilongwe, Malawi
| | - James Nuttall
- Red Cross War Memorial Children's Hospital, Cape Town, and School of Child and Adolescent Health, University of Cape Town, South Africa
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Karl-Günter Technau
- Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - Kathryn Stinson
- Médecins Sans Frontierès, Khayelitsha and School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Robin Wood
- Gugulethu Community Health Centre and Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, South Africa
| | | | - Andreas D. Haas
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
| | | | - Frank Tanser
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Brian Eley
- Red Cross War Memorial Children's Hospital, Cape Town, and School of Child and Adolescent Health, University of Cape Town, South Africa
| |
Collapse
|
28
|
Meyers T, Sawry S, Wong JY, Moultrie H, Pinillos F, Fairlie L, van Zyl G. Virologic failure among children taking lopinavir/ritonavir-containing first-line antiretroviral therapy in South Africa. Pediatr Infect Dis J 2015; 34:175-9. [PMID: 25741970 PMCID: PMC4352713 DOI: 10.1097/inf.0000000000000544] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report the outcomes, clinical management decisions and results of resistance testing among a group of children who developed virologic failure on first-line lopinavir/ritonavir (LPV/r)-based therapy from a large cohort of antiretroviral therapy-treated children in Soweto. DESIGN Historical cohort study. METHODS Children with virologic failure were identified from a group of 1692 children <3 years who had initiated first-line LPV/r-containing therapy since 2000 up to the end November 2011. Genotyping was conducted in some children, and outcomes, management decisions and resistance results were described. RESULTS A total of 152 children with virologic failure on first-line LPV/r-containing antiretroviral therapy were included. Resistance testing was performed in 75/152 (49%), and apart from a younger age (11.1 vs. 15.1 months, P = 0.04), the children with versus those without resistance testing were similar for baseline characteristics (weight, CD4, viral load and time to failure). Genotyping revealed that 8/75 (10.7%) had significant LPV/r-associated resistance mutations, including 2 with intermediate darunavir resistance. Among 63/75 (84%) children remaining on LPV/r-based therapy, 32/63 (51%) achieved virologic suppression, and 2 of these children with significant LPV mutations. In accordance with the local guidelines at the time, 12/152 (8%) children were switched to non-nucleoside reverse-transcriptase inhibitors-based therapy. Of these, 4/12 (33%) resuppressed, and the rest did not achieve virologic suppression including the 2 with lopinavir mutations. CONCLUSIONS Virologic failure of LPV/r-containing first-line regimens is associated with accumulation of LPV/r mutations in children. The implications are unclear, and surveillance at selected sites is warranted for long-term virologic outcomes and development of resistance.
Collapse
Affiliation(s)
- Tammy Meyers
- Department of Paediatrics, Chris Hani Baragwanath Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jessica Y. Wong
- Division of Epidemiology and Biostatistics, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Harry Moultrie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francoise Pinillos
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gert van Zyl
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg
| |
Collapse
|
29
|
Yotebieng M, Meyers T, Behets F, Davies MA, Keiser O, Ngonyani KZ, Lyamuya RE, Kariminia A, Hansudewechakul R, Leroy V, Koumakpai S, Newman J, Van Rie A. Age-specific and sex-specific weight gain norms to monitor antiretroviral therapy in children in low-income and middle-income countries. AIDS 2015; 29:101-9. [PMID: 25562494 PMCID: PMC4383257 DOI: 10.1097/qad.0000000000000506] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Viral load and CD4% are often not available in resource-limited settings for monitoring children's responses to antiretroviral therapy (ART). We aimed to construct normative curves for weight gain at 6, 12, 18, and 24 months following initiation of ART in children, and to assess the association between poor weight gain and subsequent responses to ART. DESIGN Analysis of data from HIV-infected children younger than 10 years old from African and Asian clinics participating in the International epidemiologic Databases to Evaluate AIDS. METHODS The generalized additive model for location, scale, and shape was used to construct normative percentile curves for weight gain at 6, 12, 18, and 24 months following ART initiation. Cox proportional models were used to assess the association between lower percentiles (< 50th) of weight gain distribution at the different time points and subsequent death, virological suppression, and virological failure. RESULTS Among 7173 children from five regions of the world, 45% were underweight at baseline. Weight gain below the 50th percentile at 6, 12, 18, and 24 months of ART was associated with increased risk of death, independent of baseline characteristics. Poor weight gain was not associated with increased hazards of virological suppression or virological failure. CONCLUSION Monitoring weight gain on ART using age-specific and sex-specific normative curves specifically developed for HIV-infected children on ART is a simple, rapid, sustainable tool that can aid in the identification of children who are at increased risk of death in the first year of ART.
Collapse
Affiliation(s)
- Marcel Yotebieng
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH
- The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC
| | - Tammy Meyers
- Department of Pediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Frieda Behets
- The University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| | - Mary-Ann Davies
- University of Cape Town, School of Public Health and Family Medicine, Cape Town, South Africa
| | - Olivia Keiser
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | | | | | - Azar Kariminia
- University of New South Wales, The Kirby Institute for infection and immunity in Society, Darlinghurst, NSW, Australia
| | | | - Valeriane Leroy
- Université Bordeaux, Institut de Santé Publique Epidémiologie et Développement, Bordeaux, France
- Inserm, Centre Inserm U897 “Epidémiologie et Biostatistique”, Bordeaux, France
| | | | - Jamie Newman
- RTI International, Biostatistics and Epidemiology, Research Triangle Park, NC
| | - Annelies Van Rie
- The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC
| |
Collapse
|
30
|
Auld AF, Tuho MZ, Ekra KA, Kouakou J, Shiraishi RW, Adjorlolo-Johnson G, Marlink R, Ellerbrock TV. Tuberculosis in human immunodeficiency virus-infected children starting antiretroviral therapy in Côte d'Ivoire. Int J Tuberc Lung Dis 2014; 18:381-7. [PMID: 24670690 DOI: 10.5588/ijtld.13.0395] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING In Côte d'Ivoire, more than 2000 human immunodeficiency virus (HIV) infected children aged <15 years were started on antiretroviral therapy (ART) during 2004-2008. OBJECTIVES To estimate tuberculosis (TB) incidence and determinants among ART enrollees. DESIGN A nationally representative retrospective cohort study among 2110 children starting ART during 2004-2008 at 29 facilities. RESULTS At ART initiation, the median age was 5.1 years; 82% had World Health Organization Stage III/IV, median CD4% was 11%, 42% were severely undernourished (weight-for-age Z-score [WAZ] <-3), and 150 (7%) were taking anti-tuberculosis treatment. Documentation of TB screening before ART declined from 63% to 46% during 2004-2008. Children taking anti-tuberculosis treatment at ART enrollment had a lower median CD4% (9.0% vs. 11.0%, P = 0.037) and a higher prevalence of WAZ <-3 (59% vs. 40%, P < 0.001). Among children considered TB-free at ART enrollment, TB incidence was 6.28/100 child-years during days 0-90 of ART, declining to 0.56/100 child-years after 180 days. Children with one unit higher WAZ at ART enrollment had 13% lower TB incidence (adjusted HR 0.87, 95%CI 0.77-1.00, P= 0.047). CONCLUSIONS Ensuring clinician compliance with TB screening before ART and ensuring earlier ART initiation before children suffer from advanced HIV disease and nutritional compromise might reduce TB morbidity during ART.
Collapse
Affiliation(s)
- A F Auld
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - M Z Tuho
- Ministry of Health, National Programme for Medical Care of Persons Living with HIV/AIDS, Abidjan, Côte d'Ivoire
| | - K A Ekra
- Division of Global HIV/AIDS, CDC, Abidjan, Côte d'Ivoire
| | - J Kouakou
- Division of Global HIV/AIDS, CDC, Abidjan, Côte d'Ivoire
| | - R W Shiraishi
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | | | - R Marlink
- Elizabeth Glaser Pediatric AIDS Foundation, Los Angeles, California, USA
| | - T V Ellerbrock
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| |
Collapse
|
31
|
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.
Collapse
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
| |
Collapse
|
32
|
Moultrie H, McIlleron H, Sawry S, Kellermann T, Wiesner L, Kindra G, Gous H, Van Rie A. Pharmacokinetics and safety of rifabutin in young HIV-infected children receiving rifabutin and lopinavir/ritonavir. J Antimicrob Chemother 2014; 70:543-9. [PMID: 25281400 PMCID: PMC4291235 DOI: 10.1093/jac/dku382] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives Co-treatment of HIV and TB in young children is complicated by limited treatment options and complex drug–drug interactions. Rifabutin is an alternative to rifampicin for adults receiving a ritonavir-boosted PI. We aimed to evaluate the short-term safety and pharmacokinetics of rifabutin when given with lopinavir/ritonavir in children. Patients and methods We conducted an open-label study of rifabutin dosed at 5 mg/kg three times a week in HIV-infected children ≤5 years of age receiving lopinavir/ritonavir. Intensive steady-state pharmacokinetic sampling was conducted after six doses. The Division of AIDS 2004, clarification 2009, table for grading severity of adverse events was used to classify drug toxicities. The study was registered with ClinicalTrials.gov, number NCT01259219. Results Six children completed the study prior to closure by institutional review boards. The median (range) AUC0–48 of rifabutin was 6.91 (3.52–8.67) μg · h/mL, the median (range) Cmax of rifabutin was 0.39 (0.19–0.46) μg/mL, the median (range) AUC0–48 of 25-O-desacetyl rifabutin was 5.73 (2.85–9.13) μg · h/mL and the median (range) Cmax of 25-O-desacetyl rifabutin was 0.17 (0.08–0.32) μg/mL. The neutrophil count declined in all children; two children experienced grade 4 neutropenia, which resolved rapidly without complications. There was strong correlation between AUC0–48 measures and neutrophil counts. Conclusions Rifabutin dosed at 5 mg/kg three times per week resulted in lower AUC0–48, AUC0–24 and Cmax values for rifabutin and 25-O-desacetyl rifabutin compared with adults receiving 150 mg of rifabutin daily, the current recommended dose. We observed high rates of severe transient neutropenia, possibly due to immaturity of CYP3A4 in young children. It remains unclear whether a safe and effective rifabutin dose exists for treatment of TB in children receiving lopinavir/ritonavir.
Collapse
Affiliation(s)
- Harry Moultrie
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Tracy Kellermann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gurpreet Kindra
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Hermien Gous
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Annelies Van Rie
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
33
|
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.
Collapse
|
34
|
Bost BP, Fairlie L, Karstaedt AS. Evaluation of parent-child pairs on antiretroviral therapy in separate adult and pediatric clinics. J Int Assoc Provid AIDS Care 2013; 13:555-9. [PMID: 24114725 DOI: 10.1177/2325957413503367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In Africa, HIV infection is considered a family disease. A retrospective cohort analysis was performed to describe the characteristics and outcome in 35 parent-child pairs taking antiretroviral therapy (ART) in separate adult and pediatric HIV clinics. In 26 pairs, ART was first initiated in children. Baseline median CD4 count was 122/mm(3) in adults and 376/mm(3) in children. World Health Organization stage 3 or 4 disease affected 49% of adults and 83% of children. In all, 3 parents and 1 child died. Hospitalization, poor adherence, missed appointments, or regimen change affected >50% of pairs on ART. Following tuberculosis diagnosis in their parents, 2 of the 5 children were not investigated. By week 104, 29 (83%) pairs remained on ART, and 69% of patients on ART were virologically suppressed. Parent-child pairs with advanced HIV infection had good outcomes when cared for in separate clinics. Establishing lines of communication between clinics is important. Family-centered services may provide more integrated care.
Collapse
Affiliation(s)
- Brian P Bost
- Department of Medicine, Division of Infectious Diseases, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - Lee Fairlie
- Faculty of Health Sciences, Wits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Alan S Karstaedt
- Department of Medicine, Division of Infectious Diseases, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
35
|
Poor early virologic performance and durability of abacavir-based first-line regimens for HIV-infected children. Pediatr Infect Dis J 2013; 32:851-5. [PMID: 23860481 PMCID: PMC3717192 DOI: 10.1097/inf.0b013e31828c3738] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Concerns about stavudine (d4T) toxicity have led to increased use of abacavir (ABC) in first-line pediatric antiretroviral treatment (ART) regimens. Field experience with ABC in ART-naïve children is limited. METHODS Deidentified demographic, clinical and laboratory data on HIV-infected children initiating ART between 2004 and 2011 in a large pediatric HIV treatment program in Johannesburg, South Africa, were used to compare viral suppression at 6 and 12 months by initial treatment regimen, time to suppression (<400 copies/mL) and rebound (>1000 copies/mL after initial suppression). Adjusted logistic regression was used to investigate confounders and calendar effects. RESULTS Two thousand thirty-six children initiated either d4T/3TC- or ABC/3TC-based first-line regimens in combination with either boosted lopinavir (LPV/r) or efavirenz (EFV). 1634 received d4T regimens (LPV/r n = 672; EFV n = 962) and 402 ABC regimens (LPV/r n = 192; EFV n = 210). At 6 and 12 months on ART, viral suppression rate was poorer in ABC versus d4T groups within both the LPV/r and EFV groups (P < 0.0001 for all points). In ABC groups, time to suppression was significantly slower (log-rank P < 0.0001 and P = 0.0092 for LPV/r- and EFV-based, respectively) and time to rebound after suppression significantly faster (log-rank P = 0.014 and P = 0.0001 for LPV/r- and EFV-based, respectively). Logistic regression confirmed the worse outcomes in the ABC groups even after adjustment for confounders. CONCLUSION Data from this urban pediatric ART service program show significantly poorer virological performance of ABC compared with d4T-based regimens, a signal that urgently warrants further investigation.
Collapse
|
36
|
Agwu AL, Fairlie L. Antiretroviral treatment, management challenges and outcomes in perinatally HIV-infected adolescents. J Int AIDS Soc 2013; 16:18579. [PMID: 23782477 PMCID: PMC3687074 DOI: 10.7448/ias.16.1.18579] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 04/17/2013] [Indexed: 02/06/2023] Open
Abstract
Three decades into the HIV/AIDS epidemic there is a growing cohort of perinatally HIV-infected adolescents globally. Their survival into adolescence and beyond represent one of the major successes in the battle against the disease that has claimed the lives of millions of children. This population is diverse and there are unique issues related to antiretroviral treatment and management. Drawing from the literature and experience, this paper discusses several broad areas related to antiretroviral management, including: 1) diverse presentation of HIV, (2) use of combination antiretroviral therapy including in the setting of co-morbidities and rapid growth and development, (3) challenges of cART, including nonadherence, resistance, and management of the highly treatment-experienced adolescent patient, (4) additional unique concerns and management issues related to PHIV-infected adolescents, including the consequences of longterm inflammation, risk of transmission, and transitions to adult care. In each section, the experience in both resource-rich and limited settings are discussed with the aim of highlighting the differences and importantly the similarities, to share lessons learnt and provide insight into the multi-faceted approaches that may be needed to address the challenges faced by this unique and resilient population.
Collapse
Affiliation(s)
- Allison L Agwu
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Johns Hopkins School of Medicine Baltimore, MD, USA.
| | | |
Collapse
|
37
|
Teasdale CA, Abrams EJ, Coovadia A, Strehlau R, Martens L, Kuhn L. Adherence and viral suppression among infants and young children initiating protease inhibitor-based antiretroviral therapy. Pediatr Infect Dis J 2013; 32:489-94. [PMID: 23249913 PMCID: PMC3624073 DOI: 10.1097/inf.0b013e31827e84ba] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND High levels of adherence to antiretroviral therapy are considered necessary to achieve viral suppression. We analyzed data from a cohort of HIV-infected children who were <2 years of age receiving protease inhibitor-based antiretroviral therapy to investigate associations between viral suppression and adherence ascertained using different methods. METHODS Data were from the prerandomization phase of a clinical trial in South Africa of HIV-infected children initiating either ritonavir-boosted lopinavir (LPV/r) or ritonavir-based antiretroviral therapy. At scheduled visits during the first 24 weeks of enrollment, study pharmacists measured quantities of medications returned to the clinic. Caregivers answered questionnaires on missed doses and adherence barriers. Associations between adherence and viral suppression (HIV-1 RNA <400 copies/mL) were investigated by regimen. RESULTS By 24 weeks, 197 of the 269 (73%) children achieved viral suppression. There was no association between viral suppression and caregiver reported missed doses or adherence barriers. For children receiving the LPV/r-based regimen, medication return adherence to each of the 3 drugs in the regimen (LPV/r, lamivudine or stavudine) individually or together was associated with viral suppression at different adherence thresholds. For example, <85% adherence to any of the 3 medications significantly increased odds of lack of viral suppression (odds ratio: 2.30, 95% confidence interval: 1.30-4.07, P = 0.004). In contrast, for children receiving the ritonavir-based regimen, there was no consistent pattern of association between medication return and viral suppression. CONCLUSIONS Caregiver reports of missed doses did not predict virologic response to treatment. Pharmacist medication reconciliation correlated strongly with virologic response for children taking a LPV/r-based regimen and appears to be a valid method for measuring pediatric adherence.
Collapse
Affiliation(s)
- Chloe A Teasdale
- ICAP, Mailman School of Public Health, Columbia University, New York, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Elaine J Abrams
- ICAP, Mailman School of Public Health, Columbia University, New York, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Ashraf Coovadia
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Renate Strehlau
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Leigh Martens
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Louise Kuhn
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA,Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University, NY
| |
Collapse
|
38
|
Mutwa PR, Van Nuil JI, Asiimwe-Kateera B, Kestelyn E, Vyankandondera J, Pool R, Ruhirimbura J, Kanakuze C, Reiss P, Geelen S, van de Wijgert J, Boer KR. Living situation affects adherence to combination antiretroviral therapy in HIV-infected adolescents in Rwanda: a qualitative study. PLoS One 2013; 8:e60073. [PMID: 23573232 PMCID: PMC3616046 DOI: 10.1371/journal.pone.0060073] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 02/21/2013] [Indexed: 12/22/2022] Open
Abstract
Introduction Adherence to combination antiretroviral therapy (cART) is vital for HIV-infected adolescents for survival and quality of life. However, this age group faces many challenges to remain adherent. We used multiple data sources (role-play, focus group discussions (FGD), and in-depth interviews (IDI)) to better understand adherence barriers for Rwandan adolescents. Forty-two HIV positive adolescents (ages 12–21) and a selection of their primary caregivers were interviewed. All were perinatally-infected and received (cART) for ≥12 months. Topics discussed during FGDs and IDIs included learning HIV status, disclosure and stigma, care and treatment issues, cART adherence barriers. Results Median age was 17 years, 45% female, 45% orphaned, and 48% in boarding schools. We identified three overarching but inter-related themes that appeared to influence adherence. Stigma, perceived and experienced, and inadvertent disclosure of HIV status hampered adolescents from obtaining and taking their drugs, attending clinic visits, carrying their cARTs with them in public. The second major theme was the need for better support, in particular for adolescents with different living situations, (orphanages, foster-care, and boarding schools). Lack of privacy to keep and take medication came out as major barrier for adolescents living in congested households, as well the institutionalization of boarding schools where privacy is almost non-existent. The third important theme was the desire to be ‘normal’ and not be recognized as an HIV-infected individual, and to have a normal life not perturbed by taking a regimen of medications or being forced to disclose where others would treat them differently. Conclusions We propose better management of HIV-infected adolescents integrated into boarding school, orphanages, and foster care; training of school-faculty on how to support students and allow them privacy for taking their medications. To provide better care and support, HIV programs should stimulate caregivers of HIV-infected adolescents to join them for their clinic visits.
Collapse
Affiliation(s)
- Philippe R Mutwa
- Kigali University Teaching Hospital/Department of Pediatrics, Kigali, Rwanda.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Tukei VJ, Murungi M, Asiimwe AR, Migisha D, Maganda A, Bakeera-Kitaka S, Kalyesubula I, Musoke P, Kekitiinwa A. Virologic, immunologic and clinical response of infants to antiretroviral therapy in Kampala, Uganda. BMC Pediatr 2013; 13:42. [PMID: 23536976 PMCID: PMC3616823 DOI: 10.1186/1471-2431-13-42] [Citation(s) in RCA: 13] [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: 12/14/2012] [Accepted: 03/22/2013] [Indexed: 11/23/2022] Open
Abstract
Background Antiretroviral therapy (ART) is known to save lives. Among HIV-infected infants living in resource constrained settings, the short and long term benefits of ART are only partially known. This study was designed to determine the virologic, immunologic and clinical outcomes of antiretroviral therapy in a cohort of HIV-infected infants receiving care from an outpatient clinic in Kampala, Uganda. Methods A prospective cohort of HIV-infected infants receiving treatment at the Baylor-Uganda clinic was analyzed. Patients were diagnosed, enrolled and followed up at the clinic. HIV viral load, CD4 cell counts and clinical progress were assessed during follow-up. Descriptive statistical analysis and logistic regression modeling to determine predictors of treatment success were conducted. Results Of 91 HIV-infected infants enrolled into the cohort, 53 (58.2%) infants were female; 43 (47.3%) were 6 months of age or younger, and 50 (55.6%) had advanced HIV/AIDS disease (Clinical stage 3 or 4). Eighty four infants started ART and 78 (92.9%) completed 6 months of treatments. Fifty six (71.8%) infants attained virologic suppression by month-6 of ART, and at month-12 of ART, the cumulative probability of attaining viral suppression was 83.1%. None of the baseline infant factors (age, sex, WHO stage, CD4 cell percent, weight for age, or height for age z-score) predicted treatment success. There was an increase in CD4 cells from a baseline mean of 23% to 30% at month-6 of treatment (p<0.001) and by month-24 of ART, the mean CD4 percent was 36%. A total of 7 patients died while on ART and another 7 experienced adverse events that were related to treatment. Conclusion Our results show that, even among very young patients from resource constrained settings, ART dramatically suppresses HIV replication, allows immune recovery and clinical improvement, and is safe. However, baseline characteristics do not predict recovery in this age group.
Collapse
Affiliation(s)
- Vincent J Tukei
- Baylor College of Medicine-Bristol Myers Squibb Children's Clinical Center of Excellence at Mulago Hospital, Kampala, Uganda.
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
van Dijk JH, Sutcliffe CG, Hamangaba F, Bositis C, Watson DC, Moss WJ. Effectiveness of efavirenz-based regimens in young HIV-infected children treated for tuberculosis: a treatment option for resource-limited settings. PLoS One 2013; 8:e55111. [PMID: 23372824 PMCID: PMC3555823 DOI: 10.1371/journal.pone.0055111] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 12/19/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Antiretroviral treatment (ART) options for young children co-infected with HIV and tuberculosis are limited in resource-poor settings due to limited data on the use of efavirenz (EFV). Using available pharmacokinetic data, an EFV dosing schedule was developed for young co-infected children and implemented as the standard of care at Macha Hospital in Southern Province, Zambia. Treatment outcomes in children younger than 3 years of age or weighing less than 10 kg receiving either EFV-based ART plus anti-tuberculous treatment or nevirapine-based (NVP) ART were compared. METHODS Treatment outcomes were measured in a cohort of HIV-infected children seeking care at Macha Hospital in rural Zambia from 2007 to 2010. Information on the diagnosis and treatment of tuberculosis was abstracted from medical records. RESULTS Forty-five children treated for tuberculosis initiated an EFV-based regimen and 69 children initiated a NVP-based regimen, 7 of whom also were treated for tuberculosis. Children receiving both regimens were comparable in age, but children receiving EFV started ART with a lower CD4(+) T-cell percentage and weight-for-age z-score. Children receiving EFV experienced increases in both CD4(+) T-cell percentage and weight-for-age z-score during follow-up, such that levels were comparable to children receiving NVP after two years of ART. Cumulative survival after 12 months of ART did not differ between groups (NVP:87%;EFV:80%;p = 0.25). Eleven children experienced virologic failure during follow-up.The adjusted hazard ratio of virologic failure comparing EFV to NVP was 0.25 (95% CI:0.05,1.24) and 0.13 (95% CI:0.03,0.62) using thresholds of 5000 and 400 copies/mL, respectively.Five children receiving EFV were reported to have had convulsions after ART initiation compared to only one child receiving NVP (p = 0.04). CONCLUSIONS Despite poorer health at ART initiation, children treated for tuberculosis and receiving EFV-based regimens showed significant improvements comparable to children receiving NVP-based regimens. EFV-based regimens should be considered for young HIV-infected children co-infected with tuberculosis in resource-limited settings.
Collapse
Affiliation(s)
- Janneke H. van Dijk
- Macha Research Trust, Macha Hospital, Choma, Zambia
- Department of Immunology and Infectious Diseases, Erasmus University, Rotterdam, The Netherlands
| | - Catherine G. Sutcliffe
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Christopher Bositis
- Greater Lawrence Family Health Center, Lawrence, Massachusetts, United States of America
| | - Douglas C. Watson
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - William J. Moss
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| |
Collapse
|
41
|
Sengayi M, Dwane N, Marinda E, Sipambo N, Fairlie L, Moultrie H. Predictors of loss to follow-up among children in the first and second years of antiretroviral treatment in Johannesburg, South Africa. Glob Health Action 2013; 6:19248. [PMID: 23364098 PMCID: PMC3556704 DOI: 10.3402/gha.v6i0.19248] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 11/13/2012] [Accepted: 11/13/2012] [Indexed: 01/03/2023] Open
Abstract
Background Ninety percent of the world's 2.1 million HIV-infected children live in sub-Saharan Africa, and 2.5% of South African children live with HIV. As HIV care and treatment programmes are scaled-up, a rise in loss to follow-up (LTFU) has been observed. Objective The aim of the study was to determine the rate of LTFU in children receiving antiretroviral treatment (ART) and to identify baseline characteristics associated with LTFU in the first year of treatment. We also explored the effect of patient characteristics at 12 months treatment on LTFU in the second year. Methods The study is an analysis of prospectively collected routine data of HIV-infected children at the Harriet Shezi Children's Clinic (HSCC) in Soweto, Johannesburg. Cox proportional hazards models were fitted to investigate associations between baseline characteristics and 12-month characteristics with LTFU in the first and second year on ART, respectively. Results The cumulative probability of LTFU at 12 months was 7.3% (95% CI 7.1–8.8). In the first 12 months on ART, independent predictors of LTFU were age <1 year at initiation, recent year of ART start, mother as a primary caregiver, and being underweight (WAZ ≤ −2). Among children still on treatment at 1 year from ART initiation, characteristics that predicted LTFU within the second year were recent year of ART start, mother as a primary caregiver, being underweight (WAZ ≤ −2), and low CD4 cell percentage. Conclusions There are similarities between the known predictors of death and the predictors of LTFU in the first and second years of ART. Knowing the vital status of children is important to determine LTFU. Although HIV-positive children cared for by their mothers appear to be at greater risk of becoming LTFU, further research is needed to explore the challenges faced by mothers and other caregivers and their impact on long-term HIV care. There is also a need to investigate the effects of differential access to ART between mothers and children and its impact on ART outcomes in children.
Collapse
Affiliation(s)
- Mazvita Sengayi
- Wits Reproductive Health and HIV Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | | | | | | | | | | |
Collapse
|
42
|
Abstract
OBJECTIVE Little is known about the cost of paediatric antiretroviral treatment (ART) in low-income and middle-income countries. We analysed the average cost of providing paediatric ART in South Africa during the first 2 years after ART initiation, stratified by patient outcomes. METHODS We collected data on outpatient resource use and treatment outcomes of 288 children in two Johannesburg public clinics, Empilweni Services and Research Unit (ESRU) and Harriet Shezi Children's Clinic (HSCC) from 2005 to 2009. Patient-level resource use was estimated from patient records. Unit cost data came from site accounts and public-sector sources. Patient outcomes at month 12 and 24 after initiation were defined based on patients' weight CD4 cell counts/percentages, viral loads, and the presence of new WHO stage 3/4 conditions. RESULTS Median age/CD4 percentage at initiation was 4.03 years/12.40% in ESRU and 5.84 years/14.05% in HSCC, respectively. Sixty-two and 91% of patients remained in care and responding to treatment at month 12 in ESRU and HSCC, respectively, and 68 and 80% at month 24. The average cost per patient in care and responding was US$ 830 in year 1 and US$ 717 in year 2 in ESRU and US$ 678 and US$ 782 in HSCC. Antiretroviral drugs comprised 33-52% of total cost, clinic visits 23-31%, lab tests 12-16%, and fixed costs 8-18%. CONCLUSIONS Costs varied between the two clinics but were comparable with those of adult ART. Few very young children accessed ART in either clinic and those who did were already very ill, emphasizing the importance of early infant treatment.
Collapse
|
43
|
Zhao Y, Li C, Sun X, Mu W, McGoogan JM, He Y, Cheng Y, Tang Z, Li H, Ni M, Ma Y, Chen RY, Liu Z, Zhang F. Mortality and treatment outcomes of China's National Pediatric antiretroviral therapy program. Clin Infect Dis 2012; 56:735-44. [PMID: 23175558 DOI: 10.1093/cid/cis941] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The aim of this study was to describe 3-year mortality rates, associated risk factors, and long-term clinical outcomes of children enrolled in China's national free pediatric antiretroviral therapy (ART) program. METHODS Records were abstracted from the national human immunodeficiency virus (HIV)/AIDS case reporting and national pediatric ART databases for all HIV-positive children ≤15 years old who initiated ART prior to December 2010. Mortality risk factors over 3 years of follow-up were examined using Cox proportional hazards regression models. Life tables were used to determine survival rate over time. Longitudinal plots of CD4(+) T-cell percentage (CD4%), hemoglobin level, weight-for-age z (WAZ) score, and height-for-age z (HAZ) score were created using generalized estimating equation models. RESULTS Among the 1818 children included in our cohort, 93 deaths were recorded in 4022 child-years (CY) of observed time for an overall mortality rate of 2.31 per 100 CY (95% confidence interval [CI], 1.75-2.78). The strongest factor associated with mortality was baseline WAZ score <-2 (adjusted hazard ratio [HR] = 9.1; 95% CI, 2.5-33.2), followed by World Health Organization stage III or IV disease (adjusted HR = 2.4; 95% CI, 1.1-5.2), and hemoglobin <90 g/L (adjusted HR = 2.2; 95% CI, 1.2-3.9). CD4%, hemoglobin level, WAZ score, and HAZ score increased over time. CONCLUSIONS Our finding that 94% of children engaged in this program are still alive and of improved health after 3 years of treatment demonstrates that China's national pediatric ART program is effective. This program needs to be expanded to better meet treatment demands, and efforts to identify HIV-positive children earlier must be prioritized.
Collapse
Affiliation(s)
- Yan Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, PR China
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Changes in pediatric HIV-related hospital admissions and mortality in Soweto, South Africa, 1996-2011: light at the end of the tunnel? J Acquir Immune Defic Syndr 2012; 60:503-10. [PMID: 22487588 DOI: 10.1097/qai.0b013e318256b4f8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND With widespread availability of pediatric antiretroviral therapy and improved access to prevention of mother-to-child transmission (PMTCT), it is important to monitor the impact on pediatric HIV-related hospital admissions and in-hospital mortality in South Africa. METHODS Over a 15-year period, 4 independent surveillance studies were conducted in the pediatric wards at Chris Hani Baragwanath Hospital in Soweto, South Africa (1996, 2005, 2007, and late 2010 to early 2011). Trends in HIV prevalence and HIV-related mortality were evaluated. RESULTS HIV prevalence was similar during the first 3 periods: 26.2% (1996), 31.7% (2005), and 29.5% (2007) P > 0.10, but was lower in 2010-2011 (19.3%; P = 0.0005). Median age of the children admitted with HIV increased in the latter periods from 9.13 (interquartile range 3.6-28.8) months to 10.0 (3.0-44.5) months (P > 0.10) and 18.0 (6.2-69.8) months (P = 0.048). Median admission weight-for-age z-scores were similar (< -3 SD) for the latter 3 periods. Admission CD4 percentage increased from 0.0% (0.0-9.4) in 2005 to 15.0% (8.2-22.8) in 2007 (P < 0.0001) and was 18.7% (9.6-24.7) in 2010-2011 (P > 0.10). Mortality among all vs. HIV-infected admissions was 63 of 565 (11.2%) and 43 of 179 (24.0%) in 2005, 91 of 1510 (6.0%) and 53 of 440 (12.0%) in 2007, and 18 of 429 (4.2%) and 9 of 73 (12.3%) in 2010-2011. CONCLUSIONS HIV prevalence and mortality among pediatric admissions is decreasing. This is likely a result of improved PMTCT and wider antiretroviral therapy coverage. Continued effort to improve PMTCT coverage and identify and treat younger and older HIV-infected children is required to further reduce HIV-related morbidity and mortality.
Collapse
|
45
|
Effect of Baseline Immune Suppression on Growth Recovery in HIV Positive South African Children Receiving Antiretroviral Treatment. J Acquir Immune Defic Syndr 2012; 61:235-42. [DOI: 10.1097/qai.0b013e3182634e09] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|