Determinants of virological outcome and adverse events in African children treated with paediatric nevirapine fixed-dose-combination tablets

Mortality and its predictors among human immunodeficiency virus-infected children younger than 15 years receiving antiretroviral therapy in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Despite antiretroviral treatment (ART), the human immunodeficiency virus (HIV) continues to pose a considerable health burden in resource-poor countries. This systematic review and meta-analysis aimed to determine the pooled incidence density of mortality and identify potential predictors among HIV-infected children receiving ART, from studies conducted in various parts of Ethiopia.

METHODS

A comprehensive database search was made in Excerpta Medica, PubMed, Web of Science, African Journals Online, Google Scholar, and Scopus. We reported results following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020. Excel Spreadsheet and STATA Version 14 software were used for data abstraction and meta-analysis, respectively. Statistical heterogeneity among studies was assessed using I2 statistics. Meta-regression and subgroup analysis were performed to further explore the sources of statistical heterogeneity. Moreover, publication bias and a leave-out-one sensitivity analysis were performed.

RESULTS

Twenty-two articles involving 8,731 participants met inclusion criteria and were included. The pooled incidence density of mortality was 3.08 (95% confidence interval (CI), 2.52 to 3.64) per 100 child years. Predictors of mortality were living in rural areas (hazard ratio (HR), 2.18 [95% CI, 1.20 to 3.98]), poor adherence to ART (HR, 2.85 [ 95% CI, 1.39 to 5.88]), failure to initiate co-trimoxazole preventive therapy (HR, 2.16 [95% CI, 1.52 to 3.07]), anemia (HR, 2.28 [95% CI, 1.51 to 3.45]), opportunistic infections (HR, 1.52 [ 95% CI, 1.15 to 2.00]), underweight (HR, 1.74 [95% CI, 1.26 to 2.41]), wasting (HR, 2.54 [95% CI, 1.56 to 4.16]), stunting (HR, 2.02 [95% CI, 1.63 to 2.51]), World Health Organization classified HIV clinical stages III and IV (HR, 1.71 [95% CI, 1.42 to 2.05]), and Nevirapine-based regimens (HR, 3.91 [95% CI, 3.09 to 4.95]).

CONCLUSIONS

This study found that the overall mortality rate among HIV-infected children after ART initiation was high. Therefore, high-level commitment and involvement of responsible caregivers, healthcare providers, social workers, and program managers are of paramount importance to identify these risk factors and thus enhance the survival of HIV-infected children receiving ART.

Determinants of nonsuppression of HIV viral load among children receiving antiretroviral therapy in the Simiyu region: a cross-sectional study

BACKGROUND

Despite substantial antiretroviral therapy (ART) coverage among individuals with human immunodeficiency virus (HIV) infection in Tanzania, viral load suppression (VLS) among HIV-positive children receiving ART remains intolerably low. This study was conducted to determine factors affecting the nonsuppression of VL in children with HIV receiving ART in the Simiyu region; thus, an effective, sustainable intervention to address VL nonsuppression can be developed in the future.

METHODS

We conducted a cross-sectional study including children with HIV aged 2-14 years who were currently presenting to care and treatment clinics in the Simiyu region. We collected data from the children/caregivers and care and treatment center databases. We used Stata™ to perform data analysis. We used statistics, including means, standard deviations, medians, interquartile ranges (IQRs), frequencies, and percentages, to describe the data. We performed forward stepwise logistic regression, where the significance level for removal was 0.10 and that for entry was 0.05. The median age of the patients at ART initiation was 2.0 years (IQR, 1.0-5.0 years), and the mean age at HIV VL (HVL) nonsuppression was 8.8 ± 2.99 years. Of the 253 patients, 56% were female, and the mean ART duration was 64 ± 33.07 months. In multivariable analysis, independent predictors of HVL nonsuppression were older age at ART initiation (adjusted odds ratio [AOR] = 1.21; 95% confidence interval [CI] 1.012-1.443) and poor medication adherence (AOR, 0.06; 95% CI 0.004-0.867).

CONCLUSIONS

This study showed that older age at ART initiation and poor medication adherence play significant roles in HVL nonsuppression. HIV/AIDS programs should have intensive interventions targeting early identification, ART initiation, and adherence intensification.

Could pharmacogenetics aid the prediction of nevirapine pharmacokinetics and allow individualized treatment?

Tweetable abstract The large interindividual variability in nevirapine pharmacokinetics and clinical effects that remains unexplained by pharmacogenetic prediction is a major limitation for individualized nevirapine treatment.

Pharmacogenetic predictors of nevirapine pharmacokinetics in Ghanaian children living with HIV with or without TB coinfection

Nevirapine (NVP) is a non-nucleoside reverse transcriptase inhibitor that is used in the treatment of human immunodeficiency virus (HIV) infection in children younger than 3 years old. Identifying genetic predictors of NVP pharmacokinetics (PK) in young children is important because inter-individual variability in NVP concentrations contributes to variable treatment response and the information may be used to individualize dosing decisions. We examined the relationship between genetic variations in relevant drug disposition genes and NVP PK parameters in Ghanaian children living with HIV eligible to initiate NVP-based antiretroviral therapy. Participants received NVP plus zidovudine and lamivudine or abacavir and lamivudine twice daily, and those with tuberculosis (TB) coinfection received concurrent anti-TB therapy with NVP. Pharmacokinetic sampling was performed after at least 4 weeks of antiretroviral therapy. Nevirapine minimum concentration (C_min), area under the concentration-time curve from time 0 to 12 h (AUC_0-12h), and apparent clearance (CL/F) were calculated using non-compartmental analysis using Phoenix v8.0 software. Genotyping for CYP2B6, CYP2A6, CYP3A5, ABCB1, NR1I2, and NR1I3 single nucleotide polymorphism (SNPs) was performed by TaqMan® allelic discrimination method. The median (range) NVP dose received was 10 (7-14) mg/kg. Of the 53 participants, the median (range) C_min was 3.3 (0.0-14.0) mg/L and AUC_0-12h was 56.0 (16.7-202.6) mg.hr/L. Using step-wise regression, CYP2B6 rs3745274 and NR1I2 rs6785049 SNPs were independent as well as joint predictors of NVP AUC_0-12h, C_min, and CL/F. We concluded that genotyping for CYP2B6 rs3745274, and the NR1I2 rs6785049 G > A SNP (which encodes the transcriptional factor, pregnane X receptor), could improve prediction of NVP PK for individualized therapy.

Non-nucleoside reverse transcriptase inhibitor levels among HIV-exposed uninfected infants at the time of HIV PCR testing - findings from a tertiary healthcare facility in Pretoria, South Africa

INTRODUCTION

To date, very little programmatic data has been published regarding serial antiretroviral (ARV) levels in infants exposed to maternal treatment and/or infant prophylaxis during the first months of life. Such data provide the opportunity to describe the proportion of infants exposed to virologically suppressive levels of ARVs and to gauge adherence to the prevention of mother-to-child transmission of HIV (PMTCT) programme.

METHODS

From August 2014 to January 2016, HIV-exposed infants born at Kalafong Provincial Tertiary Hospital in Pretoria, South Africa were enrolled as part of an observational cohort study. Plasma samples from HIV-exposed uninfected infants were obtained at birth, 6-weeks, 10-weeks and 14-weeks of age and quantitative efavirenz (EFV) and nevirapine (NVP) drug level testing performed using liquid chromatography-mass spectrometry, irrespective of maternal ARV regimen. Descriptive analysis of EFV and NVP levels in relation to self-reported maternal and infant ARV exposure was performed. EFV levels >500 ng/mL and NVP levels >100 ng/mL were reported based on studies suggesting that trough levels above these thresholds are associated with virological suppression and PMTCT respectively.

RESULTS

Among 66 infants exposed to maternal EFVin utero, 29 (44%) had virologically suppressive plasma EFV levels at birth, with a median level of 1665 ng/mL (IQR: 1094 to 3673). Among infants who were exclusively breastfed at 6-, 10- and 14 weeks, 13/48 (27%), 5/25 (25%) and 0/21 (0%) had virologically suppressive EFV levels. Among 64 infants whose mothers reported administering daily infant NVP at time of their 6-week HIV PCR test, only 45 (70%) had NVP levels above the minimum prophylactic trough level.

CONCLUSIONS

During the first 10-weeks after delivery, a quarter of breastfed infants born to women on an EFV-containing treatment regimen maintained virologically suppressive EFV plasma levels. This finding highlights the importance of both careful monitoring of ARV side effects and repeat HIV PCR after the first few months of life among HIV-exposed uninfected infants. As 30% of infants had inadequate NVP plasma levels at 6-weeks of age, adherence counselling to caregivers regarding infant prophylaxis needs to be enhanced to further reduce mother-to-child transmission of HIV.

State-of-the-Art Review of HIV-TB Coinfection in Special Populations

Children and pregnant and postpartum women experience an undue burden of HIV-associated tuberculosis (TB), but data are lacking on key aspects of their complex management. Often excluded from clinical trials, they are left with limited options for HIV-TB cotreatment. This review will focus on pharmacologic aspects of the treatment of HIV-TB coinfection in the special populations of children and pregnant and postpartum women. Pharmacogenomic considerations, rational dosing, drug-drug interactions, safety, immune reconstitution inflammatory syndrome, and ethical and policy aspects of the inclusion of special populations in research will be surveyed. Considerations related to the treatment of both HIV-associated TB disease and HIV-associated latent TB infection will be summarized. Relevant knowledge gaps and research priorities in special populations will be outlined.