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Castro H, Sabin C, Collins IJ, Okhai H, Schou Sandgaard K, Prime K, Foster C, Le Prevost M, Crichton S, Klein N, Judd A. Evolution of CD4 T-Cell Count With Age in a Cohort of Young People Growing Up With Perinatally Acquired Human Immunodeficiency Virus. Clin Infect Dis 2024; 78:690-701. [PMID: 37820036 PMCID: PMC10954325 DOI: 10.1093/cid/ciad626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/21/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Recent studies have shown a decrease in CD4 count during adolescence in young people with perinatally acquired human immunodeficiency virus (HIV, PHIV). METHODS Young people with PHIV in the United Kingdom, followed in the Collaborative HIV Paediatric Study who started antiretroviral therapy (ART) from 2000 onward were included. Changes in CD4 count over time from age 10 to 20 years were analyzed using mixed-effects models, and were compared to published CD4 data for the gerneral population. Potential predictors were examined and included demographics, age at ART start, nadir CD4 z score (age-adjusted) in childhood, and time-updated viral load. RESULTS Of 1258 young people with PHIV included, 669 (53%) were female, median age at ART initiation was 8.3 years, and the median nadir CD4 z score was -4.0. Mean CD4 count was higher in young people with PHIV who started ART before age 10 years and had a nadir CD4 z score ≥-4; these young people with PHIV had a decline in CD4 count after age 10 that was comparable to that of the general population. Mean CD4 count was lower in young people with PHIV who had started ART before age 10 and had a nadir CD4 z score <-4; for this group, the decline in CD4 count after age 10 was steeper over time. CONCLUSIONS In children, in addition to starting ART at an early age, optimizing ART to maintain a higher CD4 z score during childhood may be important to maximizing immune reconstitution later in life.
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Affiliation(s)
- Hannah Castro
- Institute of Clinical Trials and Methodology, Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | - Caroline Sabin
- Institute for Global Health, University College London, London, United Kingdom
- National Institute for Health and Care Research, Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University Colllege London, University College London, London, United Kingdom
| | - Intira Jeannie Collins
- Institute of Clinical Trials and Methodology, Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | - Hajra Okhai
- Institute for Global Health, University College London, London, United Kingdom
| | - Katrine Schou Sandgaard
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Katia Prime
- Department of Genitourinary Medicine, St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Caroline Foster
- Department of Paediatric Infectious DIseases, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Marthe Le Prevost
- Institute of Clinical Trials and Methodology, Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | - Siobhan Crichton
- Institute of Clinical Trials and Methodology, Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | - Nigel Klein
- Infection, Immunity and Inflammation, University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Ali Judd
- Institute of Clinical Trials and Methodology, Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
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Global variations in pubertal growth spurts in adolescents living with perinatal HIV. AIDS 2023; 37:1603-1615. [PMID: 37204259 PMCID: PMC10355801 DOI: 10.1097/qad.0000000000003602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/12/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To describe pubertal growth spurts among adolescents living with perinatally acquired HIV (ALWPHIV) on antiretroviral therapy (ART). DESIGN Observational data collected from 1994 to 2015 in the CIPHER global cohort collaboration. METHODS ALWPHIV who initiated ART age less than 10 years with at least four height measurements age at least 8 years were included. Super Imposition by Translation And Rotation (SITAR) models, with parameters representing timing and intensity of the growth spurt, were used to describe growth, separately by sex. Associations between region, ART regimen, age, height-for-age (HAZ), and BMI-for-age z -scores (BMIz) at ART initiation (baseline) and age 10 years, and SITAR parameters were explored. RESULTS Four thousand seven hundred and twenty-three ALWPHIV were included: 51% from East and Southern Africa (excluding Botswana and South Africa), 17% Botswana and South Africa, 6% West and Central Africa, 11% Europe and North America, 11% Asia-Pacific, and 4% Central, South America, and Caribbean. Growth spurts were later and least intense in sub-Saharan regions. In females, older baseline age and lower BMIz at baseline were associated with later and more intense growth spurts; lower HAZ was associated with later growth spurts. In males, older baseline age and lower HAZ were associated with later and less intense growth spurts; however, associations between baseline HAZ and timing varied by age. Lower HAZ and BMIz at 10 years were associated with later and less intense growth spurts in both sexes. CONCLUSION ALWPHIV who started ART at older ages or already stunted were more likely to have delayed pubertal growth spurts. Longer-term follow-up is important to understand the impact of delayed growth.
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Belfrage E, Soeria-Atmadja S, Navér L. Growth, weight gain and BMI in virally suppressed children on antiretroviral therapy with specific reference to dolutegravir. BMC Pediatr 2023; 23:339. [PMID: 37403042 DOI: 10.1186/s12887-023-04143-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/21/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Pediatric HIV infection cause retardation in height and weight. However, effective antiretroviral therapy (ART) result in desirable weight gain. Concerns have emerged regarding excessive weight gain related to the integrase inhibitor dolutegravir in adults but knowledge about the circumstances in children/adolescents is limited. We studied if dolutegravir containing ART or switch to dolutegravir affected body mass index (BMI) and described height development in the Stockholm pediatric/adolescent HIV cohort. METHODS A retrospective cohort study of height, weight and BMI in relation to ART in 94 children/adolescents living with HIV. RESULTS At last documented visit 60/94 children/adolescents were on dolutegravir, 50 had switched from a protease inhibitor or non-nucleoside reverse transcriptase inhibitor. Height standard deviation score (SDS) increased between first and last visit from mean height SDS -0.88 (16 had SDS < -2 and 6 SDS < -3) to -0.32 (four had SDS < -2). Mean BMI SDS increased from -0.15 to 0.62 in girls, but not (-0.20 to 0.09) in boys. The number of girls ≥ 12 years with BMI SDS ≥ 2 increased significantly from 0/38 to 8/38 and totally 9/50 (18%) girls and 4/44 (9%) boys had BMI SDS ≥ 2 at last visit. There was no difference in height or weight gain between different ART regimens. BMI SDS remained stable in 22/50 children switching to dolutegravir, decreased in 13 and increased in 15. CONCLUSION Adolescent girls gained weight to a greater extent than expected but independently of ART. We found no association between dolutegravir alone or combined with tenofovir alafenamide fumarate (TAF) and excessive weight gain. Height development was within normal range.
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Affiliation(s)
- Erik Belfrage
- Department of Pediatrics, Karolinska University Hospital, Huddinge 14186, K76-78, Stockholm, Sweden
| | - Sandra Soeria-Atmadja
- Department of Pediatrics, Karolinska University Hospital, Huddinge 14186, K76-78, Stockholm, Sweden
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Lars Navér
- Department of Pediatrics, Karolinska University Hospital, Huddinge 14186, K76-78, Stockholm, Sweden.
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
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Ndiokwelu CO, Uwaezuoke SN, Iloh KK. Physical growth and sexual maturation of perinatally HIV-infected adolescent males in a southeast Nigerian tertiary hospital: a comparative cross-sectional study. BMC Pediatr 2022; 22:573. [PMID: 36199047 PMCID: PMC9533491 DOI: 10.1186/s12887-022-03626-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/05/2022] [Accepted: 09/08/2022] [Indexed: 11/26/2022] Open
Abstract
Background The advent of highly-active anti-retroviral therapy (HAART) has resulted in the survival of children with Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) into adolescence. Their prolonged survival has translated into co-morbidities like endocrine deficiencies which may manifest as growth and pubertal delay. This study aimed to determine the physical growth and sexual maturation of perinatally HIV-infected adolescent males and compare them with those of age-matched HIV-negative controls. Methods We conducted a comparative cross-sectional study of 104 perinatally HIV-infected males on HAART aged 10 to 19 years, and 104 age-matched HIV-negative males who served as controls. The subjects and controls were enrolled and assessed at a Nigerian tertiary hospital over six months. Anthropometric measurements such as weight, height, and BMI were obtained and Z scores for age were derived for weight, height, and BMI to determine physical growth using WHO AnthroPlus software. Sexual maturation was assessed using the method proposed by Marshall and Tanner. Data analysis and appropriate statistics were conducted with the Statistical Package for Social Sciences (SPSS) version 25 Chicago IL. A p-value < 0.05 was adopted as the level of statistical significance. Results The mean height, weight, and BMI Z scores of the subjects were all lower than those of the controls. The difference between the mean weight of the subjects (44.60 ± 13.32 kg) and the controls (49.97 ± 13.58 kg) was statistically significant (t = 2.88, p = 0.004). Similarly, the difference between the mean BMI Z-scores of the subjects (-0.96 ± 1.95) and the controls (-0.10 ± 0.86) was statistically significant (t = 4.10, p = < 0.001). The subjects showed a delay in pubic hair and testicular development for Stages 1, 2, and 3. Duration of HAART did not significantly affect the BMI of subjects who were in three groups: undernutrition, normal nutrition, and overnutrition (Kruskal-Wallis test, p = 0.30). Conclusion Perinatal HIV infection negatively affects physical growth and the onset of pubic-hair development (PH 2) despite the duration of HAART. We recommend that screening for weight deficit or pubertal delay should form part of the management protocol for HIV-infected male children on HAART.
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Affiliation(s)
- Chibuzo O Ndiokwelu
- Department of Pediatrics, University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla Enugu, Enugu, Nigeria
| | - Samuel N Uwaezuoke
- Department of Pediatrics, University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla Enugu, Enugu, Nigeria. .,College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria.
| | - Kenechukwu K Iloh
- Department of Pediatrics, University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla Enugu, Enugu, Nigeria.,College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
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Jesson J, Crichton S, Quartagno M, Yotebieng M, Abrams EJ, Chokephaibulkit K, Le Coeur S, Aké‐Assi M, Patel K, Pinto J, Paul M, Vreeman R, Davies M, Ben‐Farhat J, Van Dyke R, Judd A, Mofenson L, Vicari M, Seage G, Bekker L, Essajee S, Gibb D, Penazzato M, Collins IJ, Wools‐Kaloustian K, Slogrove A, Powis K, Williams P, Matshaba M, Thahane L, Nyasulu P, Lukhele B, Mwita L, Kekitiinwa‐Rukyalekere A, Wanless S, Goetghebuer T, Thorne C, Warszawski J, Galli L, van Rossum AM, Giaquinto C, Marczynska M, Marques L, Prata F, Ene L, Okhonskaya L, Navarro M, Frick A, Naver L, Kahlert C, Volokha A, Chappell E, Pape JW, Rouzier V, Marcelin A, Succi R, Sohn AH, Kariminia A, Edmonds A, Lelo P, Lyamuya R, Ogalo EA, Odhiambo FA, Haas AD, Bolton C, Muhairwe J, Tweya H, Sylla M, D'Almeida M, Renner L, Abzug MJ, Oleske J, Purswani M, Teasdale C, Nuwagaba‐Biribonwoha H, Goodall R, Leroy V. Growth and CD4 patterns of adolescents living with perinatally acquired HIV worldwide, a CIPHER cohort collaboration analysis. J Int AIDS Soc 2022; 25:e25871. [PMID: 35255197 PMCID: PMC8901148 DOI: 10.1002/jia2.25871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Adolescents living with HIV are subject to multiple co-morbidities, including growth retardation and immunodeficiency. We describe growth and CD4 evolution during adolescence using data from the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) global project. METHODS Data were collected between 1994 and 2015 from 11 CIPHER networks worldwide. Adolescents with perinatally acquired HIV infection (APH) who initiated antiretroviral therapy (ART) before age 10 years, with at least one height or CD4 count measurement while aged 10-17 years, were included. Growth was measured using height-for-age Z-scores (HAZ, stunting if <-2 SD, WHO growth charts). Linear mixed-effects models were used to study the evolution of each outcome between ages 10 and 17. For growth, sex-specific models with fractional polynomials were used to model non-linear relationships for age at ART initiation, HAZ at age 10 and time, defined as current age from 10 to 17 years of age. RESULTS A total of 20,939 and 19,557 APH were included for the growth and CD4 analyses, respectively. Half were females, two-thirds lived in East and Southern Africa, and median age at ART initiation ranged from <3 years in North America and Europe to >7 years in sub-Saharan African regions. At age 10, stunting ranged from 6% in North America and Europe to 39% in the Asia-Pacific; 19% overall had CD4 counts <500 cells/mm3 . Across adolescence, higher HAZ was observed in females and among those in high-income countries. APH with stunting at age 10 and those with late ART initiation (after age 5) had the largest HAZ gains during adolescence, but these gains were insufficient to catch-up with non-stunted, early ART-treated adolescents. From age 10 to 16 years, mean CD4 counts declined from 768 to 607 cells/mm3 . This decline was observed across all regions, in males and females. CONCLUSIONS Growth patterns during adolescence differed substantially by sex and region, while CD4 patterns were similar, with an observed CD4 decline that needs further investigation. Early diagnosis and timely initiation of treatment in early childhood to prevent growth retardation and immunodeficiency are critical to improving APH growth and CD4 outcomes by the time they reach adulthood.
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Mwambenu B, Ramoloko V, Laubscher R, Feucht U. Growth and the pubertal growth spurt in South African adolescents living with perinatally-acquired HIV infection. PLoS One 2022; 17:e0262816. [PMID: 35077489 PMCID: PMC8789101 DOI: 10.1371/journal.pone.0262816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 01/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The majority children living with HIV infection now survive into adulthood because of effective antiretroviral therapy (ART), but few data exist on their growth during adolescent years. This study investigated growth patterns and evaluated factors associated with suboptimal growth in adolescents with perinatally-acquired HIV infection. METHODS This retrospective cohort study included HIV-infected adolescents, aged 13 to 18 years, with at least 5 years of ART follow-up at a large HIV clinic in the Gauteng Province, South Africa. Weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ) and body mass index (BMI)-for-age Z-scores were calculated using World Health Organization (WHO) growth standards. Growth velocity graphs were generated utilising the mean height change calculated at 6-monthly intervals, using all available data after ART initiation, to calculate the annual change. Other collected data included WHO HIV disease staging, CD4%, HIV viral loads (VLs), ART regimens and tuberculosis co-infection. RESULTS Included were 288 children with a median age of 6.5 years (IQR 4.2;8.6 years) at ART initiation, and 51.7% were male. At baseline the majority of children had severe disease (92% WHO stages 3&4) and were started on non-nucleoside reverse transcriptase inhibitor-based regimens (79.2%). The median CD4% was 13.5% (IQR 7.9;18.9) and median HIV viral load log 5.0 (IQR 4.4;5.5). Baseline stunting (HAZ <-2) was prevalent (55.9%), with a median HAZ of -2.2 (IQR -3.1;-1.3). The median WAZ was -1.5 (IQR -2.5;-0.8), with 29.2% being underweight-for-age (WAZ <-2). The peak height velocity (PHV) in adolescents with baseline stage 3 disease was higher than for those with stage 4 disease. Being older at ART start (p<0.001) and baseline stunting (p<0.001) were associated with poorer growth, resulting in a lower HAZ at study exit, with boys more significantly affected than girls (p<0.001). CONCLUSIONS Suboptimal growth in adolescents with perinatally-acquired HIV infection is a significant health concern, especially in children who started ART later in terms of age and who had baseline stunting and is more pronounced in boys than in girls.
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Affiliation(s)
- Bilema Mwambenu
- Department of Paediatrics, Kalafong Hospital, University of Pretoria, Pretoria, South Africa
| | - Vundli Ramoloko
- Health Systems Research Unit, South Africa Medical Research Council, Cape Town, South Africa
| | - Ria Laubscher
- Biostatistics Unit, South Africa Medical Research Council, Cape Town, South Africa
| | - Ute Feucht
- Department of Paediatrics, Kalafong Hospital, University of Pretoria, Pretoria, South Africa
- Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Pretoria, South Africa
- Gauteng Department of Health, Tshwane District Health Services, Johannesburg, South Africa
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Switching to Integrase Inhibitors Unlinked to Weight Increase in Perinatally HIV-Infected Young Adults and Adolescents: A 10-Year Observational Study. Microorganisms 2020; 8:microorganisms8060864. [PMID: 32521616 PMCID: PMC7356820 DOI: 10.3390/microorganisms8060864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/26/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022] Open
Abstract
An unexpected increase in weight gain has recently been reported in the course of integrase strand transfer inhibitors (INSTI) treatment. The possibility of this effect in people who are perinatally infected with HIV (PHIV) and thus exposed to lifelong therapy needs to be explored. This is a retrospective multicenter case-control study. Adults with PHIV followed between 2010 and 2019 in two outpatient services in Northern Italy were included if they had at least two weight measures in two successive years of observation. Patients were considered as cases if they were switched to INSTI (INSTI group), or controls if they were never exposed to INSTI (non-INSTI group). The date of the switch in cases was considered to be the baseline (T0), while it was randomly selected in controls. Mixed effect models were used to assess the weight changes in INSTI and non-INSTI groups. A total of 66 participants, 50.0% women, 92.4% Caucasian, were included. Median follow-up was 9 years (range 2–10): 4 years (range 1–8) before and 3 (range 1–9) after-T0. Mean age at the last study visit was 27.3 (±4.8) years, and mean CD4+ T-cells were 820.8 (±323.6) cells/mm3. Forty-five patients were switched to INSTI during the study, while 21 remained in the non-INSTI group. The INSTI group experienced a mean increase (pre-post T0) in bodyweight of 0.28 kg/year (95% CI − 0.29; 0.85, p = 0.338), while in the non-INSTI group, the mean increase was 0.36 kg/year (95% CI − 0.47; 1.20, p = 0.391), without a significant difference between groups (p for interaction between time and treatment regimen = 0.868). Among patients on INSTI, the weight gain after T0 was higher than pre-T0, amounting to +0.28 kg/year (95% CI − 0.29; 0.85), although this difference did not reach significance (p = 0.337). PHIV switched to an INSTI-based regimen did not experience an excessive weight gain compared to those who were treated with a non-INSTI based regimen in our cohort.
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Frigati LJ, Ameyan W, Cotton MF, Gregson CL, Hoare J, Jao J, Majonga ED, Myer L, Penazzato M, Rukuni R, Rowland-Jones S, Zar HJ, Ferrand RA. Chronic comorbidities in children and adolescents with perinatally acquired HIV infection in sub-Saharan Africa in the era of antiretroviral therapy. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:688-698. [PMID: 32359507 DOI: 10.1016/s2352-4642(20)30037-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/27/2020] [Accepted: 01/31/2020] [Indexed: 12/13/2022]
Abstract
Globally, 1·7 million children are living with HIV, of which 90% are in sub-Saharan Africa. The remarkable scale-up of combination antiretroviral therapy has resulted in increasing numbers of children with HIV surviving to adolescence. Unfortunately, in sub-Saharan Africa, HIV diagnosis is often delayed with children starting antiretroviral therapy late in childhood. There have been increasing reports from low-income settings of children with HIV who have multisystem chronic comorbidities despite antiretroviral therapy. Many of these chronic conditions show clinical phenotypes distinct from those in adults with HIV, and result in disability and reduced quality of life. In this Review, we discuss the spectrum and pathogenesis of comorbidities in children with HIV in sub-Saharan Africa. Prompt diagnosis and treatment of perinatally acquired HIV infection is a priority. Additionally, there is a need for increased awareness of the burden of chronic comorbidities. Diagnostic and therapeutic strategies need to be collectively developed if children with HIV are to achieve their full potential.
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Affiliation(s)
- Lisa J Frigati
- SA-MRC Unit on Child and Adolescent Health, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa; Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Wole Ameyan
- Department of HIV, Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Mark F Cotton
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Celia L Gregson
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Jacqueline Hoare
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Jennifer Jao
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Edith D Majonga
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Martina Penazzato
- Department of HIV, Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Ruramayi Rukuni
- Biomedical Research and Training Institute, Harare, Zimbabwe; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Heather J Zar
- SA-MRC Unit on Child and Adolescent Health, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Rashida A Ferrand
- Biomedical Research and Training Institute, Harare, Zimbabwe; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK.
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