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Patten G, Sipambo N, Technau KG, Euvrard J, Ford N, Davies MA. Ongoing High Prevalence of Severe Immune Suppression Among Children in South Africa. J Acquir Immune Defic Syndr 2023; 92:273-280. [PMID: 36729553 PMCID: PMC9974841 DOI: 10.1097/qai.0000000000003137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 11/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Among children in Southern Africa severe immune suppression (SIS) has declined, but most continue to initiate antiretroviral therapy (ART) with SIS. SETTING Using data from South Africa, we describe SIS at ART start and on ART between 2007 and 2020, among children <5 years with a CD4%/cell count at ART start and ≥1 subsequent measure. METHODS Gap in care was defined as >9 months without a recorded visit. We defined SIS according to age and CD4%/cell count. A multistate model was used to estimate transition probabilities between 5 states: SIS on ART; Stable, not SIS; Early Gap, commencing <9 months from ART start; Late Gap, commencing ≥9 months on ART; and Death. RESULTS Among 2536 children, 70% had SIS at ART start, and 36% experienced SIS on ART. An increasing proportion were age <1 year at ART initiation (2007-2009: 43% to 2013-2020: 55%). Increasingly, SIS on ART occurred after a gap, in those with SIS on ART for >1 year, and after a period of unknown immune status. Later year of ART initiation was associated with reduced transition from SIS on ART to Stable. Infants and those initiating ART with SIS were more likely to transition from Stable to SIS. Viremia strongly predicted death from both the on ART states. CONCLUSIONS Increasingly SIS occurred among ART-experienced children. Those starting ART with SIS and during infancy remained especially vulnerable to SIS once on treatment. Managing ART in these children may be more complex and further reducing AIDS-related mortality is likely to remain challenging.
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Affiliation(s)
- Gabriela Patten
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Nosisa Sipambo
- Harriet Shezi Children’s Clinic, Chris Hani Baragwanath Academic Hospital, Department of Paediatrics & Child Health, University of Witwatersrand, Johannesburg
| | - Karl-Günter Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
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de Waal R, Rabie H, Technau KG, Eley B, Sipambo N, Cotton M, Boulle A, Wood R, Tanser F, Fatti G, Egger M, Davies MA. Abacavir safety and effectiveness in young infants with HIV in South African observational cohorts. Antivir Ther 2023; 28:13596535231168480. [PMID: 37038365 PMCID: PMC10961679 DOI: 10.1177/13596535231168480] [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] [Indexed: 04/12/2023]
Abstract
BACKGROUND WHO guidelines recommend abacavir in first-line antiretroviral treatment for children and neonates. However, there is no approved dose <3 months of age, and data in neonates are limited. METHODS We included infants who initiated ART aged <3 months, between 2006 and 2019, in nine South African cohorts. In those who received abacavir or zidovudine, we described antiretroviral discontinuation rates; and 6- and 12-month viral suppression (<400 copies/mL). We compared infants aged <28 and ≥28 days, those weighing <3 and ≥3 kg. RESULTS Overall 837/1643 infants (51%) received abacavir and 443 (27%) received zidovudine. Median (interquartile range, IQR) age was 52 days (23-71), CD4 percentage was 27.9 (19.2-38.0), and weight was 4.0 kg (3.0-4.7) at ART initiation. In those with ≥1 month's follow-up, 100/718 (14%) infants discontinued abacavir, at a median of 17.5 months (IQR 6.5-39.5). Abacavir discontinuations did not differ by age or weight category (p = 0.4 and 0.2, respectively); and were less frequent than zidovudine discontinuations (adjusted hazard ratio 0.14, 95% confidence interval 0.10-0.20). Viral suppression at 12 months occurred in 43/79 (54%) and 130/250 (52%) of those who started abacavir aged <28 and ≥28 days, respectively (p = 0.8); 11/19 (58%) and 31/60 (52%) in those who weighed <3 and ≥3 kg, respectively (p = 0.6); and 174/329 (53%) in those on abacavir versus 77/138 (56%) in those on zidovudine (adjusted odds ratio 1.8, 95% confidence interval 1.0-3.2). CONCLUSION Our data suggest that abacavir may be used safely in infants <28 days old or who weigh <3 kg.
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Affiliation(s)
- Reneé de Waal
- Centre for Infectious Disease Epidemiology and Research, 37716University of Cape Town, Cape Town, South Africa
| | - Helena Rabie
- Department of Paediatrics and Child Health, 26697University of Stellenbosch and Tygerberg Hospital, Tygerberg, South Africa
| | - Karl-Günter Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, 37707University of the Witwatersrand, Johannesburg, South Africa
| | - Brian Eley
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, 37716University of Cape Town, Cape Town, South Africa
| | - Nosisa Sipambo
- Department of Paediatrics and Child Health, 37707University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Mark Cotton
- Department of Paediatrics and Child Health, 26697University of Stellenbosch and Tygerberg Hospital, Tygerberg, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, 37716University of Cape Town, Cape Town, South Africa
| | - Robin Wood
- The Desmond Tutu HIV Centre, 37716University of Cape Town, Cape Town, South Africa
| | - Frank Tanser
- 560159Africa Health Research Institute, Mtubatuba, South Africa
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, 26697Stellenbosch University, Stellenbosch, South Africa
| | - Matthias Egger
- Centre for Infectious Disease Epidemiology and Research, 37716University of Cape Town, Cape Town, South Africa
- Institute of Social and Preventive Medicine, 30317University of Bern, Bern, Switzerland
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, 37716University of Cape Town, Cape Town, South Africa
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Marie BT, Argaw WS, Bazezew BY. Time to death among HIV-infected under-five children after initiation of anti-retroviral therapy and its predictors in Oromiya liyu zone, Amhara region, Ethiopia: a retrospective cohort study. BMC Pediatr 2022; 22:5. [PMID: 34980032 PMCID: PMC8722209 DOI: 10.1186/s12887-021-03072-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 12/09/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Human Immunodeficiency Virus (HIV) is infection which mainly attacks immune system of an individual. Its disease progress is rapid in children and if treatment is not initiated nearly half of infected children will die by the second year of infection. In Ethiopia, nearly twenty four percent of HIV related death is happen to under-five children; however studies done in this specific age group are limited are with poor evidence of predictors. OBJECTIVES To determine time to death and identify predictors of death in HIV infected under- five children on antiretroviral therapy in Amhara regional state, Oromia 'liyu' zone, Northeast Ethiopia, from 2014 to 2019. METHODS Institution based retrospective follow up study was conducted in 376 under-five HIV- infected children on antiretroviral therapy from January 2014 to December 2019 in health institutions in Oromia Liyu Zone, Amhara region, Ethiopia. Multivariable Cox-proportional hazard regression model was used to identify independent predictors of mortality in HIV- infected under-five children on antiretroviral therapy. RESULT At the end of follow up, 304 (80.85%) of HIV-infected children were alive, 39 (10.95%) were lost to follow up, 12 (3.19%) were transferred out and 21 (5.59%) were reported dead due to HIV/AIDS. The cumulative survival probabilities of children after 3, 6, 12, 24 and 36 months were 0.99, 0.98, 0.97, 0.89 and 0.87 respectively. The overall mean time to death was 19.7 months (95%CI = 18.74-20.67) with incidence of 5.9 deaths per 100 child-months (95%CI: 3.89-9.09). Children with severe malnutrition at baseline (AHR = 4.9; 95 CI: 1.04, 23.50), advanced WHO clinical stage at enrolment (AHR = 3.9; CI: 1.37, 10.88), poor adherence to ART (AHR = 6.56; CI: 3.33, 10.14) and with no history of Isoniazide prophylaxis were significantly associated to higher mortality events (AHR = 3.6; CI: 1.24, 10.18). CONCLUSION Death of HIV-infected under-five children on ART is high within the first one year after enrolment. The risk of death increased if the child was malnourished at beginning of treatment, had poor ART adherence, with advanced WHO clinical stages and lack of Isoniazide prophylaxis during their age of infancy.
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Affiliation(s)
- Bereka Tefera Marie
- Lecturer, Midwifery Department, Kotebe Metropolitan University, Addis Ababa, Ethiopia.
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Schue JL, van Dijk JH, Hamangaba F, Hamahuwa M, Moyo N, Thuma PE, Moss WJ, Sutcliffe CG. Treatment outcomes among children younger than five years living with HIV in rural Zambia, 2008-2018: a cohort study. BMC Pediatr 2021; 21:315. [PMID: 34261465 PMCID: PMC8278691 DOI: 10.1186/s12887-021-02793-y] [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: 03/16/2021] [Accepted: 06/30/2021] [Indexed: 12/01/2022] Open
Abstract
Background HIV testing and treatment guidelines for children in sub-Saharan Africa have evolved over time, such that children are now treated at younger ages. The objective of this study was to describe the treatment experience for immunologic, virologic, and growth outcomes among HIV-infected Zambian children younger than 5 years of age from 2008 to 2018. Methods Participants enrolled in a clinical cohort study in Macha, Zambia and initiating antiretroviral treatment before 5 years of age between 2008 and 2015 were included in the analysis and followed up to the end of 2018. Outcomes, including growth, CD4+ T-cell percentage, viral suppression, and mortality, were evaluated among all children using longitudinal and survival analyses. Comparisons by age at treatment initiation (< 1, 1 to < 2, and 2 to < 5 years) were also evaluated. Results Three hundred eighty-one children initiating treatment before 5 years of age between 2008 and 2015 were included in the analysis. Growth metrics and CD4+ T-cell percentage improved over time after treatment initiation. However, 20% of children remained underweight and 40% of children remained stunted after the first 36 months of treatment. 85% of children had a viral load < 400 copies/mL after 12 months of treatment. However, children < 1 year at treatment initiation were more likely to have a detectable viral load in the first 12 months of treatment and less likely to achieve viral suppression compared to older children. Mortality was highest in the first 12 months of treatment, among underweight children, and among children initiating treatment in 2008–2010 compared to 2011–2015. Conclusions Most children initiating antiretroviral treatment from 2008 to 2015 in rural Zambia responded well to treatment. However, many children remained underweight and stunted, and experienced high mortality rates during the first few months of treatment. This supports continued efforts to improve early infant diagnosis, nutritional support, and pediatric drug formulations. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02793-y.
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Affiliation(s)
- Jessica L Schue
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, USA
| | - Janneke H van Dijk
- Erasmus University, Burgemeester Oudlaan 50, 3062, PA, Rotterdam, Netherlands
| | | | | | | | - Philip E Thuma
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, USA.,Macha Research Trust, Choma, Zambia
| | - William J Moss
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, USA
| | - Catherine G Sutcliffe
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, USA.
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Iyun V, Technau KG, Vinikoor M, Yotebieng M, Vreeman R, Abuogi L, Desmonde S, Edmonds A, Amorissani-Folquet M, Davies MA. Variations in the characteristics and outcomes of children living with HIV following universal ART in sub-Saharan Africa (2006-17): a retrospective cohort study. Lancet HIV 2021; 8:e353-e362. [PMID: 33932330 DOI: 10.1016/s2352-3018(21)00004-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 12/22/2020] [Accepted: 01/11/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The proportion of children living with HIV and receiving antiretroviral therapy (ART) in sub-Saharan Africa has increased greatly since 2006, yet the changes in their demographic characteristics and treatment outcomes have not been well described. We examine the trends in characteristics and outcomes of children living with HIV who were younger than 5 years at ART initiation, and compare outcomes over time and across country income groups. METHODS We conducted a retrospective cohort analysis of data from children living with HIV who were younger than 5 years at ART initiation from 45 paediatric sites in 16 low-income, lower-middle-income, and upper-middle-income countries in sub-Saharan Africa (Benin, Burundi, Côte d'Ivoire, Democratic Republic of the Congo, Ghana, Kenya, Lesotho, Malawi, Mali, Mozambique, Rwanda, South Africa, Togo, Uganda, Zambia, and Zimbabwe). Outcomes were trends in patient characteristics at ART initiation (age, weight, height, and CD4%), and comparisons of mortality and loss to follow-up during ART over time and in various economic settings. We identified risk factors for mortality using Cox proportional hazards models. Each participating region had relevant institutional ethics review board approvals to contribute data to the analysis. FINDINGS We included 32 221 children living with HIV and initiating ART younger than 5 years between Jan 1, 2006, and Dec 31, 2017. Median age at ART initiation was 20·4 months (IQR 9·4-36·0) in 2006-10, 19·2 months (8·3-33·6) in 2011-13, and 19·2 months (8·8-33·7) in 2014-17. Median age at ART initiation was 13·2 months (IQR 4·7-26·8) in upper-middle-income countries, 22·6 months (13·2-37·5) in lower-middle-income countries and 24·2 months (13·5-39·1) in low-income countries. The proportion of children initiating ART younger than 3 months increased from 770 (5·1%) of 14 943 children in 2006-10 to 728 (10·0%) of 7290 children in 2014-17. The proportion of children initiating ART with severe immunosuppression decreased from 5469 (74·7%) of 7314 children for whom CD4% data were available in 2006-10 to 2353 (55·2%) of 4269 children in 2014-17. Mortality at 24 months on ART decreased from 970 (6·5%) of 14 943 children in 2006-10 to 214 (2·9%) of 7290 children in 2014-17. Loss to follow-up was 20·5% (95% CI 20·1-21·0) overall, and was similar across time periods. In multivariable analysis, lower mortality was observed for more recent ART initiation cohorts (adjusted hazard ratio 0·70, 95% CI 0·63-0·79 for 2011-13; 0·53, 0·45-0·72 for 2014-17 vs 2006-10) and for those residing in an upper-middle-income country (0·42, 0·35-0·49 vs low-income countries). INTERPRETATION Mortality declined significantly after universal ART recommendations for children younger than 2 years in 2010 and children younger than 5 years in 2013. However, substantial variations persisted across country income groups, and one in five children continue to be lost to follow-up. Targeted interventions are required to improve outcomes of children living with HIV, especially in the poorest countries. FUNDING National Institute of Allergy and Infectious Disease.
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Affiliation(s)
- Victoria Iyun
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Karl-Gunter Technau
- Empilweni Service and Research Centre, Rahima Moosa Mother and Child Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Michael Vinikoor
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Marcel Yotebieng
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rachel Vreeman
- Department of Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lisa Abuogi
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Sophie Desmonde
- Inserm U1027, Université Paul Sabatier Toulouse 3, Toulouse, France
| | - Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Health Impact Assessment, Western Cape Department of Health, Cape Town, South Africa
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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.
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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
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Earlier Antiretroviral Therapy Initiation and Decreasing Mortality Among HIV-infected Infants Initiating Antiretroviral Therapy Within 3 Months of Age in South Africa, 2006-2017. Pediatr Infect Dis J 2020; 39:127-133. [PMID: 31725119 PMCID: PMC7073445 DOI: 10.1097/inf.0000000000002516] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early infant diagnosis of HIV and antiretroviral therapy (ART) has been rapidly scaled-up. We aimed to examine the effect of expanded access to early ART on the characteristics and outcomes of infants initiating ART. METHODS From 9 cohorts within the International epidemiologic Databases to Evaluate AIDS-Southern Africa collaboration, we included infants with HIV initiating ART ≤3 months of age between 2006 and 2017. We described ART initiation characteristics and the probability of mortality, loss to follow-up (LTFU) and transfer out after 6 months on ART and assessed factors associated with mortality and LTFU. RESULTS A total of 1847 infants started ART at a median age of 60 days [interquartile range: 29-77] and CD4 percentage (%) of 27% (18%-38%). Across ART initiation calendar periods 2006-2009 to 2013-2017, ART initiation age decreased from 68 (53-81) to 45 days (7-71) (P < 0.001), median CD4% improved from 22% (15%-34%) to 32% (22-43) (P < 0.001) and the proportion with World Health Organization clinical disease stage 3 or 4 declined from 81.6% to 32.7% (P < 0.001). Overall, the 6-month mortality probability was 5.0% and LTFU was 20.4%. Mortality was 10.6% (95% confidence interval: 7.8%-14.4%) in 2006-2009 and 4.6% (3.1%-6.7%) in 2013-2017 (P < 0.001), with similar LTFU across calendar periods (P = 0.274). Pretreatment weight-for-age Z score <-2 was associated with higher mortality. CONCLUSIONS Infants with HIV are starting ART younger and healthier with associated declines in mortality. However, the risk of mortality remained undesirably high in recent years. Focused interventions are needed to optimize the benefits of earlier diagnosis and treatment.
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Kawilapat S, Salvadori N, Ngo-Giang-Huong N, Decker L, Kanjanavanit S, Puangsombat A, Preedisripipat K, Lertpienthum N, Akarathum N, Mekmullica J, Srirompotong U, Lallemant M, Le Coeur S, Traisathit P, Leroi C, Jourdain G. Incidence and risk factors of loss to follow-up among HIV-infected children in an antiretroviral treatment program. PLoS One 2019; 14:e0222082. [PMID: 31527875 PMCID: PMC6748564 DOI: 10.1371/journal.pone.0222082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/21/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction The success of antiretroviral treatment (ART) programs can be compromised by high rates of patient loss to follow-up (LTFU). We assessed the incidence and risk factors of LTFU in a large cohort of HIV-infected children receiving ART in Thailand. Methods All children participating in a multicenter cohort (NCT00433030) between 1999 and 2014 were included. The date of LTFU was 9 months after the last contact date. ART interruption was defined as ART discontinuation for more than 7 days followed by resumption of treatment. Baseline and time-dependent risk factors associated with LTFU were identified using Fine and Gray competing risk regression models with death or referral to another hospital as competing events. Results Of 873 children who were followed during a median of 8.6 years (interquartile range 4.5–10.6), 196 were LTFU, 73 died, and 195 referred. The cumulative incidence of LTFU was 2.9% at 1 year, 7.3% at 5 years and 22.2% at 10 years. Children aged 13 years and more had a 3-fold higher risk (95% confidence interval 2.06–4.78) of LTFU than those younger. Children who had interrupted ART within the previous year had a 2.5-fold higher risk (1.12–5.91) than those who had not. The risk of LTFU was lower in children stunted (height-for-age Z-scores <-2 SD) (0.42–0.96) or underweight (weight-for-age Z-scores <-2 SD) (0.24–0.97). Conclusion Adolescence, ART interruption and absence of growth deficit were associated with LTFU. These may be warnings that should draw clinicians’ attention and possibly trigger specific interventions. Children with no significant growth retardation may also be at risk of LTFU.
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Affiliation(s)
- Suttipong Kawilapat
- Institut de recherche pour le développement (IRD, France), U174 –PHPT, Chiang Mai, Thailand
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Graduate Program in Applied Statistics, Department of Statistics, Faculty of Science, Chiang Mai University, Chiang Mai, Thailand
| | - Nicolas Salvadori
- Institut de recherche pour le développement (IRD, France), U174 –PHPT, Chiang Mai, Thailand
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Nicole Ngo-Giang-Huong
- Institut de recherche pour le développement (IRD, France), U174 –PHPT, Chiang Mai, Thailand
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Luc Decker
- Institut de recherche pour le développement (IRD, France), U174 –PHPT, Chiang Mai, Thailand
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | | | | | | | | | | | | | - Marc Lallemant
- Institut de recherche pour le développement (IRD, France), U174 –PHPT, Chiang Mai, Thailand
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Sophie Le Coeur
- Institut de recherche pour le développement (IRD, France), U174 –PHPT, Chiang Mai, Thailand
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Institut National d'Etudes Démographiques (INED), Paris, France
| | - Patrinee Traisathit
- Institut de recherche pour le développement (IRD, France), U174 –PHPT, Chiang Mai, Thailand
- Data Science Research Center, Department of Statistics, Faculty of Science, Chiang Mai University, Chiang Mai, Thailand
| | - Charline Leroi
- Institut de recherche pour le développement (IRD, France), U174 –PHPT, Chiang Mai, Thailand
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Gonzague Jourdain
- Institut de recherche pour le développement (IRD, France), U174 –PHPT, Chiang Mai, Thailand
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- * E-mail:
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Ahmed I, Lemma S. Mortality among pediatric patients on HIV treatment in sub-Saharan African countries: a systematic review and meta-analysis. BMC Public Health 2019; 19:149. [PMID: 30717720 PMCID: PMC6360742 DOI: 10.1186/s12889-019-6482-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/25/2019] [Indexed: 12/29/2022] Open
Abstract
Background Despite substantial improvements in accessibility of Anti-Retroviral Treatment (ART), death of children on ART remains a prevailing challenge in sub-Saharan African (SSA) countries. However, the pooled magnitude of mortality at different ART follow-up periods remains unknown for the region. We estimated the pooled proportion of all-cause mortality for pediatric patients receiving first-line ART at 3, 6, 12, and 24 months follow-up period in SSA. Methods We searched for relevant articles published between January 2014 and June 2018 on PubMed, Hinari and Google scholar databases. We searched for additional articles from reference lists and 2014–2018 abstracts archived by the Conference on Retroviruses and Opportunistic Infections (CROI) and the International AIDS Society Conference on HIV Science (IAS). Results We reviewed 29 articles reporting mortality among pediatric ART patients at different follow-up periods in countries from 2001 to 2016. Among the 51,619 pediatric ART patients in these cohorts, studies reported 4061 (7.9%) all-cause cumulative death. The cumulative pooled proportion of mortality at 3, 6, 12 and 24 months of ART were 3% (95% CI: 3.0–4.0), 5% (95% CI: 4.0–6.0), 6% (95% CI: 5.0–7.0) and 7% (95% CI: 6.0–8.0), respectively. Conclusions In SSA, significant proportion of mortality among children occurs in the first 3–6 months of ART initiation. Western Africa has a little higher estimate of mortality among pediatric ART patients at 6 and 12 months of follow-up. Strategies to prevent early mortality including thorough screening and management of opportunistic infections before ART initiation are needed. Electronic supplementary material The online version of this article (10.1186/s12889-019-6482-1) contains supplementary material, which is available to authorized users.
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Technau KG, Strehlau R, Patel F, Shiau S, Burke M, Conradie M, Sorour G, Sherman GG, Coovadia A, Murnane PM, Abrams EJ, Kuhn L. 12-month outcomes of HIV-infected infants identified at birth at one maternity site in Johannesburg, South Africa: an observational cohort study. Lancet HIV 2018; 5:e706-e714. [PMID: 30416043 DOI: 10.1016/s2352-3018(18)30251-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/20/2018] [Accepted: 09/10/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Initiation of antiretroviral therapy (ART) following diagnosis of HIV infection at birth is an emerging area of paediatric HIV care. We present outcomes of HIV-infected infants identified at birth at Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa. METHODS From September, 2013 (era 1), only high-risk HIV-exposed infants were offered diagnostic HIV PCR tests at birth. From June, 2014 (era 2), all HIV-exposed infants were offered laboratory-based diagnostic PCR tests. From October, 2014 (era 3), point of care (POC) diagnostic PCR tests were also done if staff availability allowed. We describe time to ART initiation, mortality, retention in care, and viral suppression among the HIV-infected infants identified across these eras. FINDINGS We tested 5449 HIV-exposed infants who were born between Sept 1, 2013, and June 30, 2016. 88 neonates with confirmed HIV infection were identified and included in the study, of which 86 (98%) started ART. Median age at ART initiation decreased from 9 days (IQR 6-25) in eras 1 and 2 to 2 days (1-8) in era 3. In era 3, more neonates who were co-tested with POC testing started ART within 48 h of birth (29 [83%] of 35; median 1 day [IQR 1-2]) than infants who were not co-tested (one [4%] of 29; median 6 days [5-10]). The probability of mortality by 12 months across the eras was 14% (95% CI 8-24) and did not differ by era. Of the 72 infants who survived and initiated ART at the site, 56 (78%) were retained at 12 months. Of the 56 infants retained in care, 40 (71%) had a viral load less than 400 copies per mL at 12 months, with no differences between eras (p=0·23). INTERPRETATION HIV-infected infants can be identified at birth and ART can be initiated within hours to days. Although most infants in our cohort started ART, mortality remained unacceptably high with suboptimal retention and viral suppression. Reducing mortality and improving retention and viral suppression remain urgent priorities. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institute of Allergy and Infectious Disease, National Institutes of Health, USAID/PEPfAR, and the South African National HIV Programme.
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Affiliation(s)
- Karl-Günter Technau
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Renate Strehlau
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Faeezah Patel
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Stephanie Shiau
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Megan Burke
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Martie Conradie
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Gillian Sorour
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Gayle G Sherman
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Ashraf Coovadia
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Pamela M Murnane
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Gertrude H Sergievsky Center, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, CA, USA
| | - Elaine J Abrams
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa; ICAP at Columbia, Mailman School of Public Health, and Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Louise Kuhn
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Gertrude H Sergievsky Center, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
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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: 16] [Impact Index Per Article: 2.7] [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.
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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
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Chandiwana N, Sawry S, Chersich M, Kachingwe E, Makhathini B, Fairlie L. High loss to follow-up of children on antiretroviral treatment in a primary care HIV clinic in Johannesburg, South Africa. Medicine (Baltimore) 2018; 97:e10901. [PMID: 30024494 PMCID: PMC6086461 DOI: 10.1097/md.0000000000010901] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Outcomes of HIV-infected children have improved dramatically over the past decade, but are undermined by patient loss to follow-up (LTFU). We assessed patterns of LTFU among HIV-infected children receiving antiretroviral treatment (ART) at a large inner-city HIV clinic in Johannesburg, South Africa between 2005 and 2014.Demographic and clinical data were extracted from clinic records of children under 12 years. Differences between characteristics of children retained in care and LTFU were assessed using Wilcoxon rank sum tests or Pearson χ tests. Cox proportional hazard models then identified characteristics associated with LTFU.Of 135 children, the median age at ART initiation was 21.5 months (IQR: 6.3-47.7) with a median follow-up time of 3.3 years (IQR: 1.4-5.0). The incidence rate of LTFU was 10.8 per 100 person-years (95% CI: 8.2-14.4); cumulatively 36% of children were LTFU. Almost a third (n = 39) of children missed a clinic visit, but then returned to care; 77% of these were eventually LTFU. In total, 18% of children had elevated viral loads after 6 or more months of ART. Older age at ART initiation (18-59 months: aHR 1.6, 95% CI: 3.9-14.2) and ever missing a clinic visit (aHR 7.4 95% CI: 3.9-14.2) were independent predictors of LTFU.High rates of LTFU were observed in this primary care clinic. Risks for LTFU included older age (>18 months old) and missed clinic visits. Identifying children who miss scheduled visits and developing strategies directed at retaining them in care is critical to improving long-term pediatric HIV outcomes.
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Affiliation(s)
- Nomathemba Chandiwana
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Elizabeth Kachingwe
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
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Shiau S, Abrams EJ, Arpadi SM, Kuhn L. Early antiretroviral therapy in HIV-infected infants: can it lead to HIV remission? Lancet HIV 2018; 5:e250-e258. [PMID: 29739699 PMCID: PMC7487171 DOI: 10.1016/s2352-3018(18)30012-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/19/2018] [Indexed: 12/27/2022]
Abstract
Interventions to prevent mother-to-child HIV transmission have been extremely successful, but new HIV infections continue to occur in infants. Strong evidence indicates that combination antiretroviral therapy (ART) for treatment should be started in HIV-infected infants to prevent early morbidity and mortality. In 2013, the report of the Mississippi baby, who was started on ART within 30 h of life and maintained off-treatment remission for 27 months before HIV was once again detectable, generated renewed interest in very early ART initiation. The case stimulated interest in the possibility of HIV remission, which we define as maintenance of plasma viraemia below the threshold of detection in the absence of ART, after early treatment initiation. The possibility of HIV remission elicits much hope, given that children with HIV infection currently face a lifetime of treatment. The potential for early ART to lead to HIV remission in infants can be thought of in terms of six factors: rapidity of viral suppression with very early ART; initial viral suppression rate with early ART; later virological control after early treatment; the effect of early treatment on the viral reservoir size; outcomes of randomised trials of structured treatment interruption; and the likelihood of viral rebound in neonates after ART cessation. Review of existing data suggests that achieving long-term remission off treatment remains elusive, and concentrated attention and commitment of the scientific community is needed to investigate the factors that might help to reach this goal.
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Affiliation(s)
- Stephanie Shiau
- Gertrude H. Sergievsky Center, Mailman School of Public Health, Columbia University, New York, NY, USA; College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elaine J Abrams
- Department of Pediatrics, Mailman School of Public Health, Columbia University, New York, NY, USA; College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA; Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen M Arpadi
- Gertrude H. Sergievsky Center, Mailman School of Public Health, Columbia University, New York, NY, USA; Department of Pediatrics, Mailman School of Public Health, Columbia University, New York, NY, USA; College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA; Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, Mailman School of Public Health, Columbia University, New York, NY, USA; College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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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.
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Heffron R, Pintye J, Matthews LT, Weber S, Mugo N. PrEP as Peri-conception HIV Prevention for Women and Men. Curr HIV/AIDS Rep 2017; 13:131-9. [PMID: 26993627 DOI: 10.1007/s11904-016-0312-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Daily oral tenofovir (TDF)-based pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy and recommended for men and women with substantial risk of HIV acquisition. The peri-conception period, the stage prior to pregnancy when condom use is necessarily reduced, has elevated HIV risk that can be mitigated by PrEP use. Data from a randomized trial suggest that peri-conception PrEP use by HIV-seronegative women does not increase the risk of pregnancy loss, birth defects or congenital anomalies, preterm birth, or infant growth faltering. Women considering PrEP use throughout pregnancy must weigh the known increased risk of HIV acquisition with unknown risks of drug effects on infant growth. PrEP has been used safely by HIV-seronegative men with HIV-seropositive female partners who have become pregnant. As an effective user-controlled HIV prevention strategy, PrEP offers autonomy and empowerment for HIV prevention and can be recommended alongside antiretroviral therapy, fertility screening, vaginal self-insemination, intercourse timed to peak fertility, medically assisted reproduction, and other safer conception strategies to provide multiple options. The integration of PrEP into safer conception programs is warranted and will safely reduce HIV transmission to women, men, and children during the peri-conception period.
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Affiliation(s)
- Renee Heffron
- Departments of Global Health and Epidemiology, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA.
| | - Jillian Pintye
- School of Nursing, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA
| | - Lynn T Matthews
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA
| | - Shannon Weber
- University of California San Francisco, 1001 Potrero Ave, 6D-33, San Francisco, CA, 94110, USA
| | - Nelly Mugo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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Abstract
PURPOSE OF REVIEW It is 20 years since the start of the combination antiretroviral therapy (cART) era and more than 10 years since cART scale-up began in resource-limited settings. We examined survival of vertically HIV-infected infants and children in the cART era. RECENT FINDINGS Good survival has been achieved on cART in all settings with up to 10-fold mortality reductions compared with before cART availability. Although mortality risk remains high in the first few months after cART initiation in young children with severe disease, it drops rapidly thereafter even for those who started with advanced disease, and longer term mortality risk is low. However, suboptimal retention on cART in routine programs threatens good survival outcomes and even on treatment children continue to experience high comorbidity risk; infections remain the major cause of death. Interventions to address infection risk include a cotrimoxazole prophylaxis, isoniazid preventive therapy, routine childhood and influenza immunization, and improving maternal survival. SUMMARY Pediatric survival has improved substantially with cART and HIV-infected children are aging into adulthood. It is important to ensure access to diagnosis and early cART, good program retention as well as optimal comorbidity prophylaxis and treatment to achieve the best possible long-term survival and health outcomes for vertically infected children.
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Abstract
South Africa's paediatric antiretroviral therapy (ART) programme is managed using a monitoring and evaluation tool known as TIER.Net. This electronic system has several advantages over paper-based systems, allowing profiling of the paediatric ART programme over time. We analysed anonymized TIER.Net data for HIV-infected children aged <15 years who had initiated ART in a rural district of South Africa between 2005 and 2014. We performed Kaplan–Meier survival analysis to assess outcomes over time. Records of 5461 children were available for analysis; 3593 (66%) children were retained in care. Losses from the programme were higher in children initiated on treatment in more recent years (P < 0·0001) and in children aged ≤1 year at treatment initiation (P < 0·0001). For children aged <3 years, abacavir was associated with a significantly higher rate of loss from the programme compared to stavudine (hazard ratio 1·9, P < 0·001). Viral load was suppressed in 48–52% of the cohort, with no significant change over the years (P = 0·398). Analysis of TIER.Net data over time provides enhanced insights into the performance of the paediatric ART programme and highlights interventions to improve programme performance.
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Merten S, Ntalasha H, Musheke M. Non-Uptake of HIV Testing in Children at Risk in Two Urban and Rural Settings in Zambia: A Mixed-Methods Study. PLoS One 2016; 11:e0155510. [PMID: 27280282 PMCID: PMC4900571 DOI: 10.1371/journal.pone.0155510] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 04/30/2016] [Indexed: 12/04/2022] Open
Abstract
This article investigates reasons why children who were considered at risk of HIV were not taken for HIV testing by their caregivers. Qualitative and quantitative data collected in Zambia from 2010–11 revealed that twelve percent of caregivers who stated that they had been suspecting an HIV infection in a child in their custody had not had the child tested. Fears of negative reactions from the family were the most often stated reason for not testing a child. Experience of pre-existing conflicts between the couple or within the family (aOR 1.35, 95% CI 1.00–1.82) and observed stigmatisation of seropositive children in one’s own neighbourhood (aOR 1.69, 95% CI1.20–2.39) showed significant associations for not testing a child perceived at risk of HIV. Although services for HIV testing and treatment of children have been made available through national policies and programmes, some women and children were denied access leading to delayed diagnosis and treatment–not on the side of the health system, but on the household level. Social norms, such as assigning the male household head the power to decide over the use of healthcare services by his wife and children, jeopardize women’s bargaining power to claim their rights to healthcare, especially in a conflict-affected relationship. Social norms and customary and statutory regulations that disadvantage women and their children must be addressed at every level–including the community and household–in order to effectively decrease barriers to HIV related care.
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Affiliation(s)
- Sonja Merten
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstr. 57, 4002, Basel, Switzerland
- University of Basel, Petersplatz 1, 4003, Basel, Switzerland
- * E-mail:
| | - Harriet Ntalasha
- Department of Population Studies, University of Zambia, Great East Road Campus, Lusaka, Zambia
| | - Maurice Musheke
- Population Council Zambia Office, 4 Mwaleshi Road, Olympia Park, Lusaka, Zambia
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Newell ML, Grimwood A, Cluver L, Fatti G, Sherr L. Children and HIV – a hop (hopefully), a skip (lamentably) and a jump (ideally)? AIDS Care 2016; 28 Suppl 2:1-6. [PMID: 27391992 PMCID: PMC4991223 DOI: 10.1080/09540121.2016.1176688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Contribution of Gag and Protease to HIV-1 Phenotypic Drug Resistance in Pediatric Patients Failing Protease Inhibitor-Based Therapy. Antimicrob Agents Chemother 2016; 60:2248-56. [PMID: 26833162 DOI: 10.1128/aac.02682-15] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/17/2016] [Indexed: 12/15/2022] Open
Abstract
Protease inhibitors (PIs) are used as a first-line regimen in HIV-1-infected children. Here we investigated the phenotypic consequences of amino acid changes in Gag and protease on lopinavir (LPV) and ritonavir (RTV) susceptibility among pediatric patients failing PI therapy. The Gag-protease from isolates from 20 HIV-1 subtype C-infected pediatric patients failing an LPV and/or RTV-based regimen was phenotyped using a nonreplicativein vitroassay. Changes in sensitivity to LPV and RTV relative to that of the matched baseline (pretherapy) sample were calculated. Gag and protease amino acid substitutions associated with PI failure were created in a reference clone by site-directed mutagenesis and assessed. Predicted phenotypes were determined using the Stanford drug resistance algorithm. Phenotypic resistance or reduced susceptibility to RTV and/or LPV was observed in isolates from 10 (50%) patients, all of whom had been treated with RTV. In most cases, this was associated with protease resistance mutations, but substitutions at Gag cleavage and noncleavage sites were also detected. Gag amino acid substitutions were also found in isolates from three patients with reduced drug susceptibilities who had wild-type protease. Site-directed mutagenesis confirmed that some amino acid changes in Gag contributed to PI resistance but only in the presence of major protease resistance-associated substitutions. The isolates from all patients who received LPV exclusively were phenotypically susceptible. Baseline isolates from the 20 patients showed a large (47-fold) range in the 50% effective concentration of LPV, which accounted for most of the discordance seen between the experimentally determined and the predicted phenotypes. Overall, the inclusion of thegaggene and the use of matched baseline samples provided a more comprehensive assessment of the effect of PI-induced amino acid changes on PI resistance. The lack of phenotypic resistance to LPV supports the continued use of this drug in pediatric patients.
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Davies MA. Research gaps in neonatal HIV-related care. South Afr J HIV Med 2015; 16:375. [PMID: 29568592 PMCID: PMC5843028 DOI: 10.4102/sajhivmed.v16i1.375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 03/16/2015] [Indexed: 12/19/2022] Open
Abstract
The South African prevention of mother to child transmission programme has made excellent progress in reducing vertical HIV transmission, and paediatric antiretroviral therapy programmes have demonstrated good outcomes with increasing treatment initiation in younger children and infants. However, both in South Africa and across sub-Saharan African, lack of boosted peri-partum prophylaxis for high-risk vertical transmission, loss to follow-up, and failure to initiate HIV-infected infants on antiretroviral therapy (ART) before disease progression are key remaining gaps in neonatal HIV-related care. In this issue of the Southern African Journal of HIV Medicine, experts provide valuable recommendations for addressing these gaps. The present article highlights a number of areas where evidence is lacking to inform guidelines and programme development for optimal neonatal HIV-related care.
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Affiliation(s)
- Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
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