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Kyobe S, Kisitu G, Mwesigwa S, Farirai J, Katagirya E, Retshabile G, Williams L, Mirembe A, Ketumile L, Wayengera M, Mukisa J, Sebetso G, Diphoko T, Amujal M, Kigozi E, Katabazi F, Oceng R, Mlotshwa B, Morapedi K, Nsangi B, Wampande E, Tsimako M, Brown C, Kasvosve I, Joloba M, Anabwani G, Mpoloka S, Mardon G, Kekitiinwa A, Hanchard NA, Kyosiimire-Lugemwa J, Matshaba M, Kiragga D. Long-term non-progression and risk factors for disease progression among children living with HIV in Botswana and Uganda: A retrospective cohort study. Int J Infect Dis 2024; 139:132-140. [PMID: 38036259 PMCID: PMC10843817 DOI: 10.1016/j.ijid.2023.11.030] [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: 08/25/2023] [Revised: 11/08/2023] [Accepted: 11/22/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES We utilize a large retrospective study cohort derived from electronic medical records to estimate the prevalence of long-term non-progression (LTNP) and determine the factors associated with progression among children infected with HIV in Botswana and Uganda. METHODS Electronic medical records from large tertiary HIV clinical centers in Botswana and Uganda were queried to identify LTNP children 0-18 years enrolled between June 2003 and May 2014 and extract demographic and nutritional parameters. Multivariate subdistribution hazard analyses were used to examine demographic factors and nutritional status in progression in the pre-antiretroviral therapy era. RESULTS Between the two countries, 14,246 antiretroviral therapy-naïve children infected with HIV were enrolled into clinical care. The overall proportion of LTNP was 6.3% (9.5% in Botswana vs 5.9% in Uganda). The median progression-free survival for the cohort was 6.3 years, although this was lower in Botswana than in Uganda (6.6 vs 8.8 years; P <0.001). At baseline, the adjusted subdistribution hazard ratio (aHRsd) of progression was increased among underweight children (aHRsd 1.42; 95% confidence interval [CI]: 1.32-1.53), enrolled after 2010 (aHRsd 1.32; 95% CI 1.22-1.42), and those from Botswana (aHRsd 2; 95% CI 1.91-2.10). CONCLUSIONS In our study, the prevalence of pediatric LTNP was lower than that observed among adult populations, but progression-free survival was higher than expected. Underweight, year of enrollment into care, and country of origin are independent predictors of progression among children.
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Affiliation(s)
- Samuel Kyobe
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Grace Kisitu
- Baylor College of Medicine Children's Foundation Uganda, Kampala, Uganda
| | - Savannah Mwesigwa
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Farirai
- Botswana-Baylor Children's Clinical Centre of Excellence, Gaborone, Botswana
| | - Eric Katagirya
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Gaone Retshabile
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Lesedi Williams
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Angela Mirembe
- Baylor College of Medicine Children's Foundation Uganda, Kampala, Uganda
| | - Lesego Ketumile
- Botswana-Baylor Children's Clinical Centre of Excellence, Gaborone, Botswana
| | - Misaki Wayengera
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Mukisa
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Gaseene Sebetso
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Thabo Diphoko
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Marion Amujal
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edgar Kigozi
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fred Katabazi
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ronald Oceng
- Baylor College of Medicine Children's Foundation Uganda, Kampala, Uganda
| | - Busisiwe Mlotshwa
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Koketso Morapedi
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Betty Nsangi
- Baylor College of Medicine Children's Foundation Uganda, Kampala, Uganda
| | - Edward Wampande
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Chester Brown
- University of Tennessee Health Science Center, Memphis, USA
| | - Ishmael Kasvosve
- School of Allied Health Professionals, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Moses Joloba
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Gabriel Anabwani
- Baylor College of Medicine Children's Foundation Uganda, Kampala, Uganda
| | - Sununguko Mpoloka
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Graeme Mardon
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, USA; Department of Pathology and Immunology, Baylor College of Medicine, Houston, USA
| | - Adeodata Kekitiinwa
- Baylor College of Medicine Children's Foundation Uganda, Kampala, Uganda; Pediatric Retrovirology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Neil A Hanchard
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, USA; USDA/ARS/Children's Nutrition Research Center, Baylor College of Medicine, Houston, USA; Childhood Complex Disease Genomics Section, Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, USA
| | | | - Mogomotsi Matshaba
- Botswana-Baylor Children's Clinical Centre of Excellence, Gaborone, Botswana; Pediatric Retrovirology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Dithan Kiragga
- Baylor College of Medicine Children's Foundation Uganda, Kampala, Uganda; Pediatric Retrovirology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
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Banerjee T, Grover G, Pensi T, Banerjee D. Estimation of hazard of death in vertically transmitted HIV-1-infected children for doubly censored failure times and fixed covariates. J Appl Stat 2011. [DOI: 10.1080/02664760903406454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Penazzato M, Donà D, Wool PS, Rampon O, Giaquinto C. Update on antiretroviral therapy in paediatrics. Antiviral Res 2009; 85:266-75. [PMID: 19879898 DOI: 10.1016/j.antiviral.2009.10.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 10/19/2009] [Accepted: 10/21/2009] [Indexed: 11/27/2022]
Abstract
This review provides an update on the most relevant issues concerning the current management of HIV infection in infants and children. Tremendous progress has been made over the last few years to diagnose and treat infants and children with HIV infection, yet much remains to be done. Every day there are nearly 1150 new infections in children under 15 years of age, more than 90% of them occurring in the developing world and most being the result of transmission from mother-to-child (WHO 2008). The comprehensive approach to preventing mother-to-child transmission (MTCT) has clearly reduced the number of children acquiring the infection in Western countries; while a further reduction of mother-to-child transmission should be aimed for personalized setting, specific intervention needs to be put in place and new efforts are now required in order to optimise treatment and care in HIV-infected children. The prompt initiation of treatment and a careful selection of first-line regimen, which considers potency as well as tolerability remain central. In addition, occurrence and prevention of opportunistic infections, adherence as well as long-term psychosocial consequences are becoming more and more relevant in the era of effective antiretroviral therapy. This article forms part of a special issue of Antiviral Research marking the 25th anniversary of Antiretroviral Drug Discovery and Development, vol. 85, issue 1, 2010.
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Affiliation(s)
- Martina Penazzato
- Department of Paediatrics, University of Padua, Via Giustiniani 3, 35128 Padova, Italy
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Ananworanich J, Kosalaraksa P, Siangphoe U, Engchanil C, Pancharoen C, Lumbiganon P, Intasan J, Apateerapong W, Chuenyam T, Ubolyam S, Bunupuradah T, Lange J, Cooper DA, Phanuphak P. A feasibility study of immediate versus deferred antiretroviral therapy in children with HIV infection. AIDS Res Ther 2008; 5:24. [PMID: 18957095 PMCID: PMC2584102 DOI: 10.1186/1742-6405-5-24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Accepted: 10/28/2008] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the feasibility of a large immediate versus deferred antiretroviral therapy (ART) study in children. METHODS We conducted an open-label pilot randomized clinical trial study in 43 Thai children with CD4 15 to 24% of starting generic AZT/3TC/NVP immediately (Arm 1) or deferring until CD4 < 15% or CDC C (Arm 2). Primary endpoints were recruitment rate, adherence to randomized treatment and retention in trial. Secondary endpoints were % with CDC C or CD4 < 15%. Children were in the trial until the last child reached 108 weeks. Intention to treat and on treatment analyses were performed. RESULTS Recruitment took 15 months. Twenty-six of 69 (37.7%) were not eligible due mainly to low CD4%. Twenty four and 19 were randomized to arms 1 and 2 respectively. All accepted the randomized arm; however, 3 in arm 1 stopped ART and 1 in arm 2 refused to start ART. Ten/19 (53%) in arm 2 started ART. At baseline, median age was 4.8 yrs, CDC A:B were 36:7, median CD4 was 19% and viral load was 4.8 log. All in arm 1 and 17/19 in arm 2 completed the study (median of 134 weeks). No one had AIDS or death. Four in immediate arm had tuberculosis. Once started on ART, deferred arm children achieved similar CD4 and viral load response as the immediate arm. Adverse events were similar between arms. The deferred arm had a 26% ART saving. CONCLUSION Almost 40% of children were not eligible due mainly to low CD4% but adherence to randomized treatment and retention in trial were excellent. A larger study to evaluate when to start ART is feasible.
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Affiliation(s)
- Jintanat Ananworanich
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), the Thai Red Cross AIDS Research Center, Bangkok, Thailand
- The South East Asia Research Collaboration with Hawaii (SEARCH), Bangkok, Thailand
| | | | - Umaporn Siangphoe
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), the Thai Red Cross AIDS Research Center, Bangkok, Thailand
- The South East Asia Research Collaboration with Hawaii (SEARCH), Bangkok, Thailand
| | | | | | | | - Jintana Intasan
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), the Thai Red Cross AIDS Research Center, Bangkok, Thailand
| | - Wichitra Apateerapong
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), the Thai Red Cross AIDS Research Center, Bangkok, Thailand
- The South East Asia Research Collaboration with Hawaii (SEARCH), Bangkok, Thailand
| | - Theshinee Chuenyam
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), the Thai Red Cross AIDS Research Center, Bangkok, Thailand
| | - Sasiwimol Ubolyam
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), the Thai Red Cross AIDS Research Center, Bangkok, Thailand
| | - Torsak Bunupuradah
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), the Thai Red Cross AIDS Research Center, Bangkok, Thailand
| | - Joep Lange
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), the Thai Red Cross AIDS Research Center, Bangkok, Thailand
- The International Antiviral Evaluation Center (IATEC), Amsterdam, the Netherlands
| | - David A Cooper
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), the Thai Red Cross AIDS Research Center, Bangkok, Thailand
- The National Center for HIV Epidemiology and Clinical Research (NCHECR), University of New South Wales, Sydney, Australia
| | - Praphan Phanuphak
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), the Thai Red Cross AIDS Research Center, Bangkok, Thailand
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Vignoles M, Barboni G, Agosti MR, Quarleri J, García MK, Giraudi V, Ayala SG, Salomón H. High frequency of primary mutations associated with antiretroviral drug resistance in recently diagnosed HIV-infected children. Antivir Ther 2007. [DOI: 10.1177/135965350701200716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The aim of our study was to analyse the frequency of primary mutations associated with HIV drug resistance in a population of children born to HIV-infected mothers. Design A prospective study included newly HIV-diagnosed children treated at two public paediatric hospitals. Patients and methods Clinical and antiretroviral therapy (ART) data were collected in mother-child pairs. HIV-1 subtyping and ART resistance mutations were assayed in children by sequencing a region of HIV pol gene. Results: A total of 67 children were enrolled 22 less than 12 months of age, 20 between 1 and 5 years and 25 between 6 and 14 years. Six (9.0%) children had viral strains with at least one primary mutation associated with resistance to reverse transcriptase and protease inhibitors. A significantly ( P=0.019) higher frequency of resistance (22.7%, n=5/22) was found among children aged <12 months. Fourteen children (20.9%) had a subtype B HIV-1 strain and 53 (79.1%) had an inter-subtype B/F recombinant variant. Discussion A high percentage of recently diagnosed infants were found to carry primary ART resistance mutations. Limited options for ART of HIV-infected children might lead to increased HIV-associated morbidity and mortality. Thus, consideration should be given to mandatory screening for primary ART resistance before initiating therapy for infants aged <12 months in countries where HIV mother-to-child transmission is still present, such as in Argentina. This will allow for the rationalized and individualized use of drugs and will contribute to the increased cost-effectiveness of local health systems.
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Affiliation(s)
- Moira Vignoles
- National Reference Centre for AIDS, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Graciela Barboni
- Clinical Immunology Division, ‘Dr Pedro de Elizalde’ General Children's Hospital, Buenos Aires, Argentina
| | | | - Jorge Quarleri
- National Reference Centre for AIDS, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Vera Giraudi
- Clinical Immunology Division, ‘Dr Pedro de Elizalde’ General Children's Hospital, Buenos Aires, Argentina
| | | | - Horacio Salomón
- National Reference Centre for AIDS, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
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Warszawski J, Lechenadec J, Faye A, Dollfus C, Firtion G, Meyer L, Douard D, Monpoux F, Tricoire J, Benmebarek Y, Rouzioux C, Blanche S. Long-term nonprogression of HIV infection in children: evaluation of the ANRS prospective French Pediatric Cohort. Clin Infect Dis 2007; 45:785-94. [PMID: 17712765 DOI: 10.1086/521165] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Accepted: 05/11/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Some children who are infected with human immunodeficiency virus type 1 (HIV-1) during the perinatal period remain asymptomatic for very long periods in the absence of antiretroviral treatment, as is the case for some adults. Our objective was to estimate the proportion of children who developed neither symptoms nor major immunological perturbations to the age of > or = 10 years in a prospective cohort of infected children who had been observed since birth. METHODS The ongoing prospective French Pediatric Cohort includes 568 HIV-1-infected children. Here, we report the follow-up data for all 348 HIV-1-infected children who were born before 1 January 1994. Children with long-term nonprogression of infection (LTNPs) were defined as HIV-1-infected children who had been observed for at least 10 years, never received antiretroviral treatment other than zidovudine monotherapy, never developed symptoms of Centers for Disease Control and Prevention clinical category C or B, and had a CD4+ cell percentage of < 25% no more than once during follow-up. Other definitions were compared. RESULTS The Kaplan-Meier estimate of long-term nonprogression was 2.4% (95% confidence interval, 1.1%-4.6%) at 10 years of age, and 7 children were classified as LTNPs. The Kaplan-Meier estimates decreased slightly with age, to 1.8% at 12 years of age and 1.4% at 14 years of age. Plasma HIV-1 replication rates were low (< 1000 copies RNA/mL) for 2 of the 7 LTNPs at the age of 10 years (0.6% of the total denominator). None of the routinely measured maternal or perinatal markers were significantly linked to long-term nonprogression, with the exception of the mother's Centers for Disease Control and Prevention clinical category at the time of delivery. CONCLUSIONS Approximately 2% of children who were infected during the perinatal period displayed no immunological or clinical progression by the age of 10 years. This figure is close to that reported for adults in studies that have used similar definitions.
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Prendergast A, Tudor-Williams G, Jeena P, Burchett S, Goulder P. International perspectives, progress, and future challenges of paediatric HIV infection. Lancet 2007; 370:68-80. [PMID: 17617274 DOI: 10.1016/s0140-6736(07)61051-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Paediatric HIV infection is a growing health challenge worldwide, with an estimated 1500 new infections every day. In developed countries, well established prevention programmes keep mother-to-child transmission rates at less than 2%. However, in developing countries, where transmission rates are 25-40%, interventions are available to only 5-10% of women. Children with untreated natural infection progress rapidly to disease, especially in resource-poor settings where mortality is greater than 50% by 2 years of age. As in adult infection, antiretroviral therapy has the potential to rewrite the natural history of HIV, but is accessible only to a small number of children needing therapy. We focus on the clinical and immunological features of HIV that are specific to paediatric infection, and the formidable challenges ahead to ensure that all children worldwide have access to interventions that have proved successful in developed countries.
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Affiliation(s)
- Andrew Prendergast
- Department of Paediatrics, University of Oxford, Peter Medawar Building for Pathogen Research, Oxford OX1 3SY, UK
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Saavedra-Lozano J, Ramos JT, Sanz F, Navarro ML, de José MI, Martín-Fontelos P, Mellado MJ, Leal JAL, Rodriguez C, Luque I, Madison SJ, Irlbeck D, Lanier ER, Ramilo O. Salvage therapy with abacavir and other reverse transcriptase inhibitors for human immunodeficiency-associated encephalopathy. Pediatr Infect Dis J 2006; 25:1142-52. [PMID: 17133160 DOI: 10.1097/01.inf.0000246976.40494.af] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND HIV-associated encephalopathy (HIV-AE) is a severe neurologic condition that affects HIV-infected children. The potential benefit of antiretroviral (ARV) agents with good cerebrospinal fluid (CSF) penetration remains to be defined. Abacavir (ABC) achieves good CSF concentrations and studies of high-dose ABC showed benefit in adults with HIV dementia. The present study evaluated the safety and virologic, immunologic and neuropsychological responses of an ARV regimen including high-dose ABC in children with HIV-AE. METHODS Children between 3 months and 18 years old and abacavir-naive with HIV-AE and virologic failure were eligible. RESULTS : Seventeen children (16 ARV-experienced) were enrolled and 14 children completed 48 weeks of therapy. The overall tolerability was good; 2 children had a possible hypersensitivity reaction. At week 48, 53% and 59% of the children achieved HIV RNA levels below the limit of quantitation in plasma and CSF, respectively. The median (25%-75% range) change of HIV RNA from baseline to week 48 was -2.29 (-0.81 to -2.47) log10 copies/mL in plasma and -0.94 (0 to -1.13) log10 copies/mL in CSF. The mean increases in CD4 (+/-standard error of mean) cell count and CD4% were 427 (+/-169) cells/mm and 8% (+/-2), respectively. Concentrations of soluble tumor necrosis factor receptor II were reduced in plasma and CSF. Children less than 6 years of age demonstrated significant neuropsychological improvement at week 48. CONCLUSIONS In the present study with a limited number of children, highly active ARV therapy including high-dose ABC showed a safety profile similar to standard dose ABC and provided clinical, immunologic and virologic response in children with HIV-AE at week 48. Children less than 6 years of age also demonstrated significant neuropsychological improvement.
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Verweel G, Saavedra-Lozano J, van Rossum AMC, Ramilo O, de Groot R. Initiating highly active antiretroviral therapy in human immunodeficiency virus type 1-infected children in Europe and the United States: comparing clinical practice to guidelines and literature evidence. Pediatr Infect Dis J 2006; 25:987-94. [PMID: 17072119 DOI: 10.1097/01.inf.0000242670.11693.56] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Several guidelines are available to guide the initiation of highly active antiretroviral therapy (HAART) in human immunodeficiency virus (HIV)-infected children. The recommendations in these guidelines show significant variability. Because there is no well-established evidence on when to start HAART, it is left to the discretion of the pediatrician which guidelines to follow. We conducted a survey concerning the indications for starting antiretroviral therapy among pediatricians involved in the treatment of HIV-infected patients in Europe and the United States. We compared the results of this survey with the guidelines available at the time, the recently adapted guidelines and literature evidence. Our results indicate that in clinical practice HAART was initiated at higher viral loads and lower CD4 counts than recommended by the guidelines. American guidelines recommended and still recommend more aggressive treatment than the European guidelines, and this is reflected in clinical practice. Until recently all guidelines were based on long term risk analyses of progression to acquired immunodeficiency syndrome (AIDS) and death performed in cohort data. A recent short term risk analysis makes it possible to calculate the 6 or 12-month risk for progression to AIDS or death for an individual child. Because viral load and CD4 count are typically measured every 3 months, one can argue that it is clinically more relevant to base the decision of when to start HAART on the short term probability of disease progression. Guidelines in Europe are now based on this type of analysis. The American guidelines only adopted the thresholds for CD4 and viral load. The short term risk analysis also shows that the risk for developing AIDS varies markedly with age. This should be reflected in all guidelines. Determining the acceptable risk of disease progression is difficult and influenced by patient-, doctor- and culture-related factors. The controversy over whether or not to treat asymptomatic infants is unresolved as well. All infants have a very high risk of disease progression regardless of their viral load or CD4 count, but lifelong treatment with a potential for significant toxicities and risk of developing resistance is also not an appealing option. We recommend an attempt to achieve a consensus among the different working groups to reduce the number of different guidelines, which should be based on the literature evidence. Because all risk analyses are based on information from the pre-HAART era, a head-to-head trial comparing early versus deferred HAART would be useful. This may be difficult to accomplish. The first step could be an analysis of retrospective data from collaborative cohort data.
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Affiliation(s)
- Gwenda Verweel
- Department of Pediatrics, Division of Pediatric Infectious Diseases, ErasmusMC-Sophia Children's Hospital, Rotterdam, the Netherlands
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Abstract
OBJECTIVES To describe the relationship between absolute CD4 cell count and the short-term risk of disease progression in HIV-1-infected children. DESIGN A meta-analysis of individual longitudinal data on HIV-1-infected children enrolled in trials and cohort studies in Europe and the USA. METHODS The risks of progression to death and AIDS (or death) within 12 months, in terms of age and the most recent CD4 cell count, were estimated using parametric survival models. The analysis was restricted to measurements before the start of antiretroviral therapy except zidovudine monotherapy. The values of the absolute CD4 cell count and percentage predicting selected levels of disease progression risk were determined from this and previous models. RESULTS A total of 566 deaths was observed over 9128 person-years of follow-up, and 992 children progressed to AIDS or death over 7309 person-years of follow-up. In children older than 4 or 5 years, the estimated risk of disease progression increased sharply when the CD4 cell count fell below 200-300 cells/microl. As with other immunological markers, CD4 cell count was less prognostic in younger children. The CD4 cell count values predicting a 12-month risk of death of 2-5% and of AIDS of 5-10% were much more strongly influenced by age than equivalent CD4 cell percentage values. CONCLUSION This study suggests it may be appropriate to extend CD4 cell count criteria for initiating antiretroviral therapy in HIV-1-infected adults to children as young as 4 or 5 years. Monitoring by CD4 cell count in younger children is problematical because age is a highly influential variable.
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Use of total lymphocyte count for informing when to start antiretroviral therapy in HIV-infected children: a meta-analysis of longitudinal data. Lancet 2005; 366:1868-74. [PMID: 16310553 DOI: 10.1016/s0140-6736(05)67757-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Total lymphocyte count has been proposed as an alternative to the percentage of CD4+ T-cells to indicate when antiretroviral therapy should be started in children with HIV in resource-poor settings. We aimed to assess thresholds of total lymphocyte count at which antiretroviral therapy should be considered, and compared monitoring of total lymphocyte count with monitoring of CD4-cell percentage. METHODS Longitudinal data on 3917 children with HIV infection were pooled from observational and randomised studies in Europe and the USA. The 12-month risks of death and AIDS by most recent total lymphocyte count and age were estimated by parametric survival models, based on measurements before antiretroviral therapy or during zidovudine monotherapy. Risks were derived and compared at thresholds of total lymphocyte count and CD4-cell percentage for starting antiretroviral therapy recommended in WHO 2003 guidelines. FINDINGS Total lymphocyte count was a powerful predictor of the risk of disease progression despite a weak correlation with CD4-cell percentage (r=0.08-0.19 dependent on age). For children older than 2 years, the 12-month risk of death and AIDS increased sharply at values less than 1500-2000 cells per muL, with little trend at higher values. Younger children had higher risks and total lymphocyte count was less prognostic. Mortality risk was substantially higher at thresholds of total lymphocyte count recommended by WHO than at corresponding thresholds of CD4-cell percentage. When the markers were compared at the threshold values at which mortality risks were about equal, total lymphocyte count was as effective as CD4-cell percentage for identifying children before death, but resulted in an earlier start of antiretroviral therapy. INTERPRETATION In this population, total lymphocyte count was a strong predictor of short-term disease progression, being only marginally less predictive than CD4-cell percentage. Confirmatory studies in resource-poor settings are needed to identify the most cost-effective markers to guide initiation of antiretroviral therapy.
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Abstract
Much of the success attributed to HIV therapy in the last few years has resulted from improved ways of using existing drugs in combination therapy regimens. The availability of new, more potent drugs such as protease inhibitors and more accurate viral load tests to aid decisions to start or change treatment has also contributed to the success. Published recommendations for pediatric HIV therapy, generated by a panel of experts and specialists, are readily available and regularly updated. Preferred regimens of 'potent' therapy (referred to as highly active antiretroviral therapy, or HAART) currently consist of two nucleoside reverse transcriptase inhibitors (NRTIs) combined with either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor. More intense four-drug regimens using an NNRTI or a second protease inhibitor as a fourth drug are being evaluated. Problems with HAART include: unpalatable drug formulations and adverse effects, coupled with lack of data on the pharmacokinetics, efficacy, and safety of various drug combinations. Adherence is a major factor influencing the efficacy and outcome of antiretroviral therapy. Many children cannot adhere to complex multidrug regimens, which cause virologic failure, despite excellent CD4+ cell count responses. This means a rapid progression through the limited number of treatment regimens available. Simpler regimens such as those containing three NRTIs have been proposed as a method of treatment that will allow suppression of the virus, yet circumvent many of the problems previously mentioned. An additional benefit would be the preservation of antiretroviral drugs from other classes for future treatment options if required. The major advantages of triple NRTI regimens are the simplicity of the regimen, good tolerability, few drug-drug interactions, and infrequent adverse effects coupled with a low pill burden. However, abacavir hypersensitivity remains a major problem. Up to 3% of patients may develop an early idiosyncratic hypersensitivity reaction - fever, malaise, and mucositis with or without rash, which can progress to more advanced stages of shock and death. A major concern is the apparently inferior virologic control of triple NRTI therapy as demonstrated in the AIDS Clinical Trials Group A5095 study with zidovudine/lamivudine/abacavir (Trizivir) combination in adults. Such a combination should only be considered in special situations. Examples cited include informed patient choice based on anticipated poor adherence on other treatment regimens, or if concomitant drugs such as tuberculosis medication are prescribed. The low pill burden of triple NRTI regimens (especially if combined in a single pill such as Trizivir), offers hope that regimen simplification may still be possible in the future.
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Affiliation(s)
- Jennifer Handforth
- Paediatric Infectious Diseases Unit, St George's Hospital, Tooting, London, UK
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Sharland M, Blanche S, Castelli G, Ramos J, Gibb DM. PENTA guidelines for the use of antiretroviral therapy, 2004. HIV Med 2004; 5 Suppl 2:61-86. [PMID: 15239717 DOI: 10.1111/j.1468-1293.2004.00227.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
There have been few major advances in paediatric HIV management over the last 2 years. Decisions about starting antiretroviral therapy can now be based on a recent large meta-analysis of the predictive value of CD4 and HIV RNA viral load (VL) in nearly 4000 untreated children, which is discussed in these updated guidelines. Risk estimates for progression to AIDS and death using surrogate markers can now be broken down by age, allowing more accurate discussion with families. In addition, there is increasing recognition of the problems of long-term adherence, drug resistance and cumulative toxicity in adults and children. The controversy over whether to treat asymptomatic infants continues. For older children more data on the efficacy of ritonavir boosted protease inhibitor (PI) regimens suggests that these may be the PI option of first choice. There is still no adult or paediatric trial evidence on which to base decisions about whether to start with PI- or non-nucleoside reverse transcriptase inhibitor (NNRTI)- based regimens, but the PENPACT 1 trial, which is addressing this question, is ongoing. There are increasing moves to provide simpler antiretroviral therapy (ART) regimens, including once daily dosing, but these lag behind adult regimens because of the paucity of pharmacokinetic data. Resistance assays should now be performed in all HIV-infected infants exposed to ART in pregnancy. Therapeutic drug monitoring may be very important in children because of high between- and within-child variability in drug absorption and metabolism. A trial to evaluate this should start shortly in Europe (PENTA 14 trial). The value of resistance tests for choice of second-line and subsequent choices of ART regimens remain unproven (the PERA trial will report late in 2004), but resistance assays are increasingly being used. The issue of when to switch therapy also remains unanswered and is being addressed within the PENPACT 1 trial. Regular formal assessment of adherence is now the standard of care, and routine monitoring in the clinic for lipodystrophy syndrome (LDS) and other ART toxicities is increasingly important. These guidelines will be updated again in 2006.
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Affiliation(s)
- M Sharland
- Paediatric Infectious Diseases Unit, St George's Hospital, London, UK.
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14
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Havens PL. Principles of antiretroviral treatment of children and adolescents with human immunodeficiency virus infection. ACTA ACUST UNITED AC 2004; 14:269-85. [PMID: 14724792 DOI: 10.1053/j.spid.2003.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Human immunodeficiency virus (HIV) infection requires life-long therapy to attain durable suppression of HIV replication and prevent or reverse HIV-related symptoms or immune system dysfunction. Combination therapy with 3 or more antiretroviral medications is currently widely recommended for treatment of children and adolescents with HIV infection. While potent regimens can initially reduce virus load to below assay quantitation limits in the majority of persons with HIV infection, 30% to 80% of children will have regimen failure and return of detectable plasma virus within 1 year. Adherence to therapy is critical to regimen success. Optimal treatment requires careful use of potent combinations of drugs, with attention to adherence, palatability, toxicity, and pharmacokinetics. Practitioners with experience caring for children and adolescents with HIV infection should be involved.
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Dunn D. Short-term risk of disease progression in HIV-1-infected children receiving no antiretroviral therapy or zidovudine monotherapy: a meta-analysis. Lancet 2003; 362:1605-11. [PMID: 14630440 DOI: 10.1016/s0140-6736(03)14793-9] [Citation(s) in RCA: 177] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Data on the short-term risk of disease progression in HIV-1-infected children are needed to address the question of when to begin combination antiretroviral therapy. We estimated 12-month risks of progression to AIDS and death, by age and most recent measurement of CD4 T-cell percentage (CD4%) or viral load, in children receiving no antiretroviral therapy or zidovudine monotherapy only. METHODS We undertook a meta-analysis of individual longitudinal data for 3941 children from eight cohort studies and nine randomised trials in Europe and the USA. Estimates of risk were derived from parametric survival models. FINDINGS 997 AIDS-defining events were recorded over 7297 person-years of follow-up in the analysis of CD4%, and 284 events over 2282 person-years in the viral load analysis, corresponding to 568 deaths (9087 person-years) and 129 deaths (2816 person-years), respectively. In children older than 2 years, risk of death increased sharply when CD4% was less than about 10%, or 15% for risk of AIDS, with a low and fairly stable risk at greater CD4%. Children younger than 2 years had worse outlook than older children with the same CD4%. Risk of progression increased when viral load exceeded about 10(5) copies per mL, although this association was more gradual compared with CD4%. Both markers had independent predictive value for disease progression; CD4% was the stronger predictor. INTERPRETATION This information is important for paediatricians making decisions, and for researchers designing trials, about when to initiate or restart antiretroviral therapy.
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Affiliation(s)
- David Dunn
- MRC Clinical Trials Unit, 222 Euston Road, , London NW1 2DA, UK.
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16
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Gibb DM, Duong T, Tookey PA, Sharland M, Tudor-Williams G, Novelli V, Butler K, Riordan A, Farrelly L, Masters J, Peckham CS, Dunn DT. Decline in mortality, AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland. BMJ 2003; 327:1019. [PMID: 14593035 PMCID: PMC261655 DOI: 10.1136/bmj.327.7422.1019] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe changes in demographic factors, disease progression, hospital admissions, and use of antiretroviral therapy in children with HIV. DESIGN Active surveillance through the national study of HIV in pregnancy and childhood (NSHPC) and additional data from a subset of children in the collaborative HIV paediatric study (CHIPS). SETTING United Kingdom and Ireland. PARTICIPANTS 944 children with perinatally acquired HIV-1 under clinical care. MAIN OUTCOME MEASURES Changes over time in progression to AIDS and death, hospital admission rates, and use of antiretroviral therapy. RESULTS 944 children with perinatally acquired HIV were reported in the United Kingdom and Ireland by October 2002; 628 (67%) were black African, 205 (22%) were aged > or = 10 years at last follow up, 193 (20%) are known to have died. The proportion of children presenting who were born abroad increased from 20% in 1994-5 to 60% during 2000-2. Mortality was stable before 1997 at 9.3 per 100 child years at risk but fell to 2.0 in 2001-2 (trend P < 0.001). Progression to AIDS also declined (P < 0.001). From 1997 onwards the proportion of children on three or four drug antiretroviral therapy increased. Hospital admission rates declined by 80%, but with more children in follow up the absolute number of admissions fell by only 26%. CONCLUSION In children with HIV infection, mortality, AIDS, and hospital admission rates have declined substantially since the introduction of three or four drug antiretroviral therapy in 1997. As infected children in the United Kingdom and Ireland are living longer, there is an increasing need to address their medical, social, and psychological needs as they enter adolescence and adult life.
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Affiliation(s)
- D M Gibb
- Medical Research Council Clinical Trials Unit, London NW1 2DA.
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17
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Sharland M, di Zub GCG, Ramos JT, Blanche S, Gibb DM. PENTA guidelines for the use of antiretroviral therapy in paediatric HIV infection. Pediatric European Network for Treatment of AIDS. HIV Med 2002; 3:215-26. [PMID: 12139662 DOI: 10.1046/j.1468-1293.2002.00120.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To produce European Guidelines for the use of antiretroviral therapy (ART) in HIV-infected children. DESIGN Systematic literature review using Medline, the major antiretroviral conference reports, and IDSA recommendations on guideline production. SETTING Pediatric European Network for Treatment of AIDS (PENTA) Steering Committee. OUTCOME MEASURE Guidelines have been produced for the use of antiretroviral therapy in HIV-infected children in Europe. Recommendations on when to start ART and which ART to start, with dosages and a summary of the relevant literature, have been produced. CONCLUSIONS These guidelines are aimed at assisting paediatricians in Europe with ART prescribing, and provide a more cautious approach to starting therapy than current paediatric USA guidelines.
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Affiliation(s)
- M Sharland
- Paediatric Infectious Diseases Unit, St George's Hospital, London, UK.
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18
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Thorne C, Newell ML, Botet FA, Bohlin AB, Ferrazin A, Giaquinto C, de José Gomez I, Mok JYQ, Mur A, Peltier A. Older children and adolescents surviving with vertically acquired HIV infection. J Acquir Immune Defic Syndr 2002; 29:396-401. [PMID: 11917245 DOI: 10.1097/00126334-200204010-00011] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article describes the characteristics of children infected vertically with HIV surviving 10 years or more who were enrolled in the prospective European Collaborative Study. Thirty-four of 187 infected children were identified with a median age of 11.4 years (range, 10.1-15.9 years). Factors examined included clinical status, immunologic and virologic characteristics, type of antiretroviral therapy, and psychosocial characteristics. By 10 years of age, 6 (18%) children had progressed to Class A as determined by the system of the U.S. Centers for Disease Control and Prevention (CDC), 17 (52%) to class B, 7 (21%) to class C, and 3 (9%) had remained asymptomatic. At 73% (904 of 1234) of scheduled clinic visits, these children had no symptoms of HIV disease. Most children were in CDC immune categories 1 (18, 56%) or 2 (11, 34%) at their last visit. Three quarters (24 patients) were on combination therapy with three or more drugs, although 3 children had never received any antiretroviral therapy. Nineteen (56%) children were living with at least 1 parent and the mothers of 13 (38%) children had died. Most (77%) children had been told about their HIV infection. Children infected vertically with HIV who have survived their first 10 years are mainly free of serious symptoms. As they enter adolescence, additional services are needed including support with disclosure to others, therapy, and sexual health.
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Affiliation(s)
- Claire Thorne
- Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, London, UK
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Abstract
OBJECTIVES To audit clinical and surrogate marker outcome data following the introduction of combination antiretroviral therapy to HIV-infected children in South London. METHODS We performed a retrospective cohort study of 110 HIV-infected children under the care of the Paediatric HIV in South London Network (PHILS-NET) from January 1996 to September 1999. The following were identified: type of antiretroviral therapy used; duration of therapy; toxicity; impact on viral load and CD4 count; reasons for changing therapy; and clinical progression. RESULTS Ninety-one (83%) of the 110 children (55 females; median age 6.3 years) received 166 antiretroviral therapy regimens. Sixty per cent of the regimens were triple therapy: either two nucleoside reverse transcriptase inhibitors (NRTIs) and one protease inhibitor (58; 34.9%) or two NRTIs and one non-nucleoside reverse transcriptase inhibitor (39; 23.5%). The mean duration of completed therapy was 46 weeks for first line therapy with a standard deviation (SD) of 38 weeks and 40 weeks in third line therapy with an SD of 22 weeks. Changes in antiretroviral regimens were owing to virological failure in 60% and toxicity in 10%. Overall, 46% of children on first line and 37% on second line antiretroviral therapy achieved an undetectable viral load of < 400 HIV-1 RNA copies/mL. Clinical progression for the whole cohort fell from 3.7% per year for children on dual therapy to 0.7% per year for children on highly active antiretroviral therapy. CONCLUSIONS This audit shows the clinical benefit of antiretroviral therapy use in a cohort of children with moderately advanced HIV disease. The surrogate outcome data seen for the viral load and CD4 count are similar to those of reports from clinical trials. Antiretroviral therapy regimens were sequenced rapidly, mainly owing to virological failure.
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Affiliation(s)
- K Doerholt
- Paediatric Infectious Diseases Unit, St George's Hospital, London, UK
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20
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Abstract
Over one million children world-wide are living with HIV infection and respiratory disease is the commonest cause of morbidity and mortality in these children. The initial presentation of respiratory infection is usually in infancy or early childhood. There is enormous potential to prevent childhood HIV infection that is being realised in industrialised countries but not yet elsewhere. Increasingly, therefore, the burden of HIV disease is in children living in or from non-industrialised countries. This review describes and contrasts the pattern of respiratory infection from both regions. This pattern has changed with the implementation of PCP prophylaxis and the availability of potent antiretroviral therapy for children in resource-rich countries, such as the UK. More data are required from resource-poor regions such as tropical Africa, but it is clear that the major differences reflect greater background risk for respiratory infection and very limited management options rather than specific aetiology.
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Affiliation(s)
- Stephen M Graham
- Wellcome Trust Research Laboratory and Department of Paediatrics, College of Medicine, University of Malawi, Malawi.
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