Cohort profile: improving treatment of HIV-infected Ethiopian children through better detection of treatment failure in southern Ethiopia

Treatment failure among Sub-Sahara African children living with HIV: a systematic review and meta-analysis

BACKGROUND

Antiretroviral treatment failure is a global issue, particularly in developing countries such as Sub-Saharan Africa. Prior research findings were highly variable and inconsistent across areas. As a result, the goal of this systematic review and meta-analysis was to determine the pooled prevalence of treatment failure among children receiving antiretroviral medication in Sub-Saharan Africa.

METHODS

To find qualifying papers, we searched databases (such as PubMed, Google Scholar, African Journals Online, Scopus, and the Cochrane Library). The data were retrieved using Microsoft Excel and exported to STATA Version 14 for analysis. To check for publication bias, we employed Egger and Begg's regression tests. A random-effects model was used to assess the pooled prevalence of treatment failure due to high levels of variability.

RESULTS

Following the removal of duplicated articles and quality screening, a total of 33 primary articles were determined to be appropriate for inclusion in the final analysis for this study. Overall, the pooled prevalence of treatment failure among HIV-infected children was 25.86% (95% CI: 21.46, 30.26). There is great variety across the included studies, with the majority of them being conducted in Ethiopia. Cameroon had the greatest pooled prevalence of treatment failure among HIV-infected children, at 39.41% (95% CI: 21.54, 57.28), while Ethiopia had the lowest, at 13.77% (95% CI: 10.08, 17.47).

CONCLUSIONS

The pooled estimate prevalence of treatment failure among HIV-infected children in Sub-Saharan Africa was high. The implementation of national and international policies and strategies on ART clinic care services should be given special focus in order to reduce treatment failure in children living with HIV/AIDS.

TRIAL REGISTRATION

The protocol has been registered in the PROSPERO database under the registration number CRD-429011.

Incidence and predictors of treatment failure among children with HIV on first-line antiretroviral therapy in Wolaita zone, Southern Ethiopia: A multicenter retrospective cohort study

Background

Antiretroviral therapy has improved the life expectancy of HIV-positive children. Treatment failure and drug resistance among children with HIV remain major public health concerns despite the rise in ART use. A dearth of evidence exists regarding treatment failure among Ethiopian children from multicenter settings. Therefore, this study sought to assess the incidence and predictors of treatment failure among children with HIV on first-line antiretroviral therapy at health facilities in Wolaita zone, Southern Ethiopia.

Methods

A facility-based retrospective cohort study was conducted from January 1, 2017, to December 30, 2021, at health facilities providing ART in Wolaita zone, Southern Ethiopia. A total of 425 children with HIV on first-line ART were selected using a simple random sampling technique. Data were extracted by reviewing the patient's medical record. The data were entered using epi-data version 4.6 and exported to STATA version 15 for analysis. Both bi-variable and multivariable Cox regression analysis were employed. A p-value of less than 0.05 and a hazard ratio with 95 % CI was used to estimate the association between the predictor factors and treatment failure.

Results

The overall incidence density rate of treatment failure was 3.2 per 1000 person-months of observation (95 % CI: 2.4-4.6). The factors significantly associated with antiretroviral treatment failure were caregiver marital status, single (AHR = 4.86, 95 % CI: 1.52, 15.60), and widowed (AHR = 3.75, 95 % CI: 1.16, 12.11), duration of follow-up (AHR = 4.95, 95 % CI: 1.81, 13.54), and baseline CD4 count (AHR = 4.70, 95 % CI: 1.68, 13.14).

Conclusion

The incidence rate of ART failure among children with HIV was found to be significant. Low baseline CD4 count, short follow-up duration on ART, and having a single or widowed caregiver were significantly associated with antiretroviral treatment failure. Early identification of children with low CD4 count and subsequent initiation of ART should be emphasized by stakeholders working in HIV care programs. Healthcare professionals should pay special attention to and regularly monitor the treatment progress of children who have single or widowed caregivers, and those with shorter duration of follow-ups.

Antiretroviral therapy regimen modification rates and associated factors in a cohort of HIV/AIDS patients in Asmara, Eritrea: a 16-year retrospective analysis

Combined antiretroviral therapy (cART) durability and time to modification are important quality indicators in HIV/AIDs treatment programs. This analysis describes the incidence, patterns, and factors associated with cART modifications in HIV patients enrolled in four treatment centers in Asmara, Eritrea from 2005 to 2021. Retrospective cohort study combining data from 5020 [males, 1943 (38.7%) vs. females, 3077 (61.3%)] patients were utilized. Data on multiple demographic and clinical variables were abstracted from patient's charts and cART program registry. Independent predictors of modification and time to specified events were evaluated using a multi-variable Cox-proportional hazards model and Kaplan-Meier analysis. The median (±IQR) age, CD4⁺ T-cell count, and proportion of patients with WHO Clinical stage III/IV were 48 (IQR 41-55) years; 160 (IQR 80-271) cells/µL; and 2667 (53.25%), respectively. The cumulative frequency of all cause cART modification was 3223 (64%): 2956 (58.8%) substitutions; 37 (0.7%) switches; and both, 230 (4.5%). Following 241,194 person-months (PMFU) of follow-up, incidence rate of cART substitution and switch were 12.3 (95% CI 11.9-12.8) per 1000 PMFU and 3.9 (95% CI 3.2-4.8) per 10,000 PMFU, respectively. Prominent reasons for cART substitution included toxicity/intolerance, drug-shortage, new drug availability, treatment failure, tuberculosis and pregnancy. The most common adverse event (AEs) associated with cART modification included lipodystrophy, anemia and peripheral neuropathy, among others. In the adjusted multivariate Cox regression model, Organisation (Hospital B: aHR = 1.293, 95% CI 1.162-1.439, p value < 0.001) (Hospital D: aHR = 1.799, 95% CI 1.571-2.060, p value < 0.001); Initial WHO clinical stage (Stage III: aHR = 1.116, 95% CI 1.116-1.220, p value < 0.001); NRTI backbone (D4T-based: aHR = 1.849, 95% CI 1.449-2.360, p value < 0.001) were associated with increased cumulative hazard of treatment modification. Baseline weight (aHR = 0.996, 95% CI 0.993-0.999, p value = 0.013); address within Maekel (aHR = 0.854, 95% CI 0.774-0.942, p value = 0.002); AZT-based backbones (aHR = 0.654, 95% CI 0.515-0.830, p value < 0.001); TDF-based backbones: aHR = 0.068, 95% CI 0.051-0.091, p value < 0.001), NVP-based anchors (aHR = 0.889, 95% CI 0.806-0.980, p value = 0.018) were associated with lower cumulative hazards of attrition. The minimal number of switching suggests inadequate VL testing. However, the large number of toxicity/intolerance and drug-shortage driven substitutions highlight important problems in this setting. Consequently, the need to advocate for both sustainable access to safer ARVs in SSA and improvements in local supply chains is warranted.

Predictors of first-line antiretroviral treatment failure among children on antiretroviral therapy at the University of Gondar comprehensive specialised hospital, North-west, Ethiopia: a 14-year long-term follow-up study

OBJECTIVE

To determine the incidence and predictors of first-line human immune deficiency virus treatment failure among human immune deficiency virus-infected children at the University of Gondar comprehensive specialised hospital in Ethiopia.

DESIGN

A retrospective follow-up study.

SETTING

University of Gondar comprehensive specialised hospital, North-west, Ethiopia.

PARTICIPANTS

Children were among the HIV infected from January 2005 to December 2018. There were 336 children included in the study. The data were entered into EPi Info V.7.2 and then exported to STATA V.14.0 Software for analysis. Both bivariable and multivariable analyses with Cox proportional hazards models were used to identify the predictors of treatment failure.

PRIMARY OUTCOME MEASURES

Predictors of first-line antiretroviral treatment failure among children on antiretroviral therapy (ART) during 14 years long-term follow-up study.

RESULT

A total of 336 human immunodeficiency virus-infected children participated in this study with 27 058 child years of observation. The overall incidence rate was 2.1 (95% CI 1.57 to 2.78) per 100 child years. Poor adherence (adjusted HR (AHR); 6.5 (95% CI 2.03 to 21.39)), fair adherence (AHR; 6.55 (95% CI 2.64 to 16.53), the presence of opportunistic infection (AHR; 4.22 (95% CI 1.44 to 12.30), clinical staging of III/IV (AHR; 3.08 (95% CI 1.17 to 8.08) and a baseline CD4 count less than 200 cells/mm³ (AHR; 3.61 (95% CI 1.12 to 11.54)).

CONCLUSION

The incidence of first-line ART failure was found to be high. Baseline opportunistic infection, poor and fair adherence, advanced WHO clinical staging III/IV and a CD4 count less than 200 cells/mm³ were all predictors of first-line treatment failure. Early identification of associated factors and monitoring treatment failure has to be important for the optimal management of HIV-infected children who are receiving ART and to prevent further complications.

Prevalence and associated factors of treatment failure among children on ART in Ethiopia: A systematic review and meta-analysis

BACKGROUND

As the use of antiretroviral therapy (ART) increases, the issue of treatment failure is still a global challenge, particularly in a resource limited settings including Ethiopia. The results of former studies in Ethiopia were highly variable and inconsistent across studies. Thus, this systematic review and meta-analysis intended to provide the pooled estimation of treatment failure and associated factors among children on antiretroviral therapy.

METHODS

We searched international databases (i.e., PubMed, Google Scholar, Web of Science, Ethiopian Universities' online repository library, Scopus, and the Cochrane Library) during the period of February 30 to April 7, 2021. All identified observational studies reporting the proportion of treatment failure among HIV positive children in Ethiopia were included. Heterogeneity of the studies was checked using I2 test and Cochrane Q test statistics. We run Begg's regression test to assess publication bias. A random-effects meta-analysis model was performed to estimate the pooled prevalence of treatment failure.

RESULTS

The estimated pooled prevalence of treatment failure among children in Ethiopia was 12.34 (95%CI: 8.59, 16.10). Subgroup analysis of this review showed that the highest prevalence was observed in Addis Ababa (15.92%), followed by Oromia region (14.47%). Poor ART adherence (AOR = 2.53, CI: 2.03, 4.97), advanced WHO clinical staging (AOR = 1.66, CI: 1.24, 3.21), and opportunistic infections (AOR = 2.64 CI: 2.19, 4.31 were found to be significantly associated factors with childhood treatment failure.

CONCLUSIONS

This study revealed that treatment failure among children on ART was high in Ethiopia. Poor ART adherence, advanced WHO clinical staging, opportunistic infections, and low level of CD4 cell counts increased the risk of treatment failure.

Time to First-Line Antiretroviral Treatment Failure and Its Predictors among HIV-Positive Children in Shashemene Town Health Facilities, Oromia Region, Ethiopia, 2019

With expanding pediatric antiretroviral therapy access, children will begin to experience treatment failure and require second-line therapy. In resource-limited settings, treatment failure is often diagnosed based on the clinical or immunological criteria which occur way after the occurrence of virological failure. Previous limited studies have evaluated immunological and clinical failure without considering virological failure in Ethiopia. The aim of this study was to investigate time to first-line antiretroviral treatment failure and its predictors in Shashamene town health facilities with a focus on virological criteria. Methods. A retrospective cohort study was conducted in three health facilities of Shashamene town, Oromia Regional State, from March 1 to 26, 2019. Children aged less than 15 years living with HIV/AIDS that were enrolled on ART between January 1, 2011, and December 30, 2015, in Shashamene town health facilities were the study population. Data were extracted using a checklist, entered into EpiData version 3.1, and exported to SPSS version 20 for data analysis. Cox proportional hazard regression was used to determine the predictors of time to first-line treatment failure. Result. The median survival time to virological failure was 30 months with IQR of 24.42 to 44.25. Baseline WHO stages 3 and 4 with AHR = 5.69 (95% CI: 2.07–15.66) and NVP-based NNRT at initial treatment with AHR = 2.72 (1.13–6.54) were the independent predictors of time to treatment failure. Conclusion. The median survival time of first-line antiretroviral treatment failure was moderate in the study area as compared to other studies. The incidence density of treatment failure in this study was low as compared to other studies. The finding also demonstrated that children treated with nevirapine-based nonnucleoside reverse transcriptase inhibitors at initial and advanced WHO clinical stages at baseline were at higher risk of treatment failure.

Predictors of Virologic Failure Among a Cohort of HIV-infected Children in Southern Ethiopia

BACKGROUND

Optimal care for children with HIV infection includes timely assessment of treatment failure. Using HIV viral load to define treatment failure remains a challenge in resource-limited settings.

METHODS

Children with HIV infection who were already on or starting first-line antiretroviral therapy were enrolled and followed over time. We examined clinical and immunologic predictors of virologic failure (VF), defined as consecutive viral load measurements > 1000 copies/mL (VF). Children were followed every 6 months with clinical assessments, immunologic assays and viral load testing until treatment failure or up to 18 months.

RESULTS

Of the 484 children with complete data, we observed a prevalence of 15% who had VF at enrollment, and 18 who developed VF over 10.5 person-years of follow-up for an incidence of 4.97 [95% CI: 3.04-7.70) per 100 person-years. Lower adherence, lower CD4 T-cell count, lower white blood cells count, lower platelets and a lower glomerular filtration rate were all associated with increased VF. However, in a multivariable analysis, renal function (estimated glomerular filtration rate < 90 mL/min), odds ratio: 11.5 (95% CI: 1.5-63.7), and lower adherence, odds ratio: 3.9 (95% CI: 1.1-13.4), were the only factors associated with development of VF.

CONCLUSIONS

We identified a significant risk of VF in children with HIV infection in a prospective cohort study in southern Ethiopia and limited predictive value of clinical variables for VF. This provides further evidence that rapid and reliable viral load testing is needed to adequately address the HIV epidemic, along with implementation of adherence interventions in sub-Saharan Africa.

HIV/AIDS treatment failure and associated factors in Ethiopia: meta-analysis

Background

The national burden of human immunodeficiency virus treatment failure and associated factors in the Ethiopian context is required to provide evidence towards a renewed ambitious future goal.

Methods

We accessed Ethiopian Universities’ online repository library, Google Scholar, PubMed, Web of Science, and Scopus to get the research articles. We run I-squared statistics to see heterogeneity. Publication bias was checked by using Egger’s regression test. The pooled prevalence was estimated using the DerSimonian-Laird random-effects model. We employed the sensitivity analysis to see the presence of outlier result in the included studies.

Results

The overall human immunodeficiency treatment failure was 15.9% (95% confidence interval: 11.6–20.1%). Using immunological, virological, and clinical definition, human immunodeficiency treatment failure was 10.2% (95% confidence interval: 6.9–13.6%), 5.6% (95% confidence interval: 2.9–8.3%), and 6.3% (95% confidence interval: 4.6–8.0%), respectively. The pooled effects of World Health Organization clinical stage III/IV (Adjusted Odd Ratio = 1.9; 95% CI: 1.3–2.6), presence of opportunistic infections (Adjusted Odd Ratio = 1.8; 95% CI: 1.2–2.4), and poor adherence to highly active antiretroviral therapy (Adjusted Odd Ratio = 8.1; 95% CI: 4.3–11.8) on HIV treatment failure were estimated.

Conclusions

Human immunodeficiency virus treatment failure in Ethiopia found to be high. Being on advanced clinical stage, presence of opportunistic infections, and poor adherence to highly active antiretroviral therapy were the contributing factors of human immunodeficiency virus treatment failure. Human immunodeficiency virus intervention programs need to address the specified contributing factors of human immunodeficiency virus treatment failure. Behavioral intervention to prevent treatment interruption is required to sustain human immunodeficiency virus treatment adherence.

Protocol registration

It has been registered in the PROSPERO database with a registration number of CRD42018100254.

Magnitude and causes of first-line antiretroviral therapy regimen changes among HIV patients in Ethiopia: a systematic review and meta-analysis

Background

Antiretroviral therapy (ART) has markedly decreased the morbidity and mortality due to HIV/AIDS. ART regimen change is a major challenge for the sustainability of human immunodeficiency virus (HIV) treatment program. This is found to be a major concern among HIV/AIDS patients in a resource-limited setting, where treatment options are limited.

Objectives

The aim of this review is to generate the best available evidence regarding the magnitude of first-line antiretroviral therapy regimen change and the causes for regimen change among HIV patients on ART in Ethiopia.

Methods

The reviewed studies were accessed through electronic web-based search strategy from PubMed Medline, EMBASE, Hinari, Springer link and Google Scholar. Data were extracted using Microsoft Excel and exported to Stata software version 13 for analyses. The overall pooled estimation of outcomes was calculated using a random-effect model of DerSimonian–Laird method at 95% confidence level. Heterogeneity of studies was determined using I² statistics. For the magnitude of regimen change, the presence of publication bias was evaluated using the Begg’s and Egger’s tests. The protocol of this systematic review and meta-analysis was registered in the Prospero database with reference number ID: CRD42018099742. The published methodology is available from: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=99742.

Results

A total of 22 studies published between the years 2012 and 2018 were included. Out of 22 articles, 14 articles reported the magnitude of regimen change and consisted of 13,668 HIV patients. The estimated national pooled magnitude of regimen change was 37% (95% CI: 34, 44%; Range: 15.1–63.8%) with degree of heterogeneity (I²), 98.7%; p-value < 0.001. Seventeen articles were used to identify the causes for first-line antiretroviral therapy regimen change. The major causes identified were toxicity, 58% (95% CI: 46, 69%; Range: 14.4–88.5%); TB co-morbidity, 12% (95% CI: 8, 16%; Range: 0.8–31.7%); treatment failure, 7% (95% CI: 5, 9%; Range: 0.4–24.4%); and pregnancy, 5% (95% CI: 4, 7%; Range: 0.6–11.9%).

Conclusions

The original first-line regimen was changed in one-third of HIV patients on ART in Ethiopia. Toxicity of the drugs, TB co-morbidity, treatment failure, and pregnancy were the main causes for the change of the first-line regimen among HIV patients on antiretroviral therapy.

HIV and cART-Associated Dyslipidemia Among HIV-Infected Children

BACKGROUND

Persistent dyslipidemia in children is associated with risks of cardiovascular accidents and poor combination antiretroviral therapy (cART) outcome. We report on the first evaluation of prevalence and associations with dyslipidemia due to HIV and cART among HIV-infected Ethiopian children.

METHODS

105 cART naïve and 215 treatment experienced HIV-infected children were enrolled from nine HIV centers. Demographic and clinical data, lipid profile, cART type, adherence to and duration on cART were recorded. Total, low density (LDLc) and high density (HDLc) cholesterol values >200 mg/dL, >130 mg/dL, <40 mg/dL, respectively; and/or, triglyceride values >150 mg/dL defined cases of dyslipidemia. Prevalence and predictors of dyslipidemia were compared between the two groups.

RESULTS

prevalence of dyslipidemia was significantly higher among cART experienced (70.2%) than treatment naïve (58.1%) children (p = 0.03). Prevalence of low HDLc (40.2% versus 23.4%, p = 0.006) and hypertriglyceridemia (47.2% versus 35.8%, p = 0.02) was higher among cART experienced than naïve children. There was no difference in total hypercholesterolemia and high LDLc levels. Nutrition state was associated with dyslipidemia among cART naïve children (p = 0.01).

CONCLUSION

high prevalence of cART-associated dyslipidemia, particularly low HDLc and hypertriglyceridemia was observed among treatment experienced HIV-infected children. The findings underscore the need for regular follow up of children on cART for lipid abnormalities.

Hepatic and renal toxicity and associated factors among HIV-infected children on antiretroviral therapy: a prospective cohort study

OBJECTIVES

The aim of the study was to investigate the prevalence of renal function and liver enzyme abnormalities among HIV-infected children, changes in prevalence with time on combination antiretroviral therapy (cART), and the factors associated with these abnormalities.

METHODS

A prospective cohort study was conducted among HIV-infected children < 18 years old (n = 705) who were on first-line cART. Liver enzymes, renal function, haematology, immunology and virological response were assessed at enrolment and followed bi-annually for 18 months. Liver fibrosis and cirrhosis were assessed using noninvasive markers including the aspartate aminotransferase (AST) to platelet ratio index (APRI) and fibrosis score (FIB-4).

RESULTS

The median age was 12 [interquartile range (IQR) 8-14] years; 53.3% of patients were male. At enrolment, the median cART duration was 3.3 (IQR 1.1-6.1) years; 177 (25.1%) and 83 (11.8%) patients had elevated AST and alanine aminotransferase (ALT), respectively. A tenth of the children had an APRI score > 0.5, suggesting liver fibrosis. Being on a zidovudine (ZDV)- or nevirapine (NVP)-based regimen and having a viral load > 1000 HIV-1 RNA copies/mL were significantly associated with elevated ALT. Twenty-four (3.4%) and 84 (12.1%) patients had elevated creatinine and blood urea nitrogen (BUN), respectively. As cART duration increased by 6 months, median BUN increased by 1.6 [95% confidence interval (CI) 0.4-2.7] mg/dL (P = 0.01); the glomerular filtration rate (GFR) decreased by 35.6 (95% CI 17.7-53.4) mL/min/1.73 m² (P < 0.0001); and AST and ALT decreased by 1.4 (95% CI 0.4-2.5) IU/L (P = 0.01) and 1.4 (95% CI 0.2-2.6) IU/L (P = 0.01), respectively.

CONCLUSIONS

A high prevalence of liver enzyme and renal function abnormalities was observed at enrolment. Decreasing liver enzyme levels during follow-up are possibly reassuring, while the progressive reduction in GFR and the increase in BUN are worrisome and require further study.

High Levels of Dual-Class Drug Resistance in HIV-Infected Children Failing First-Line Antiretroviral Therapy in Southern Ethiopia

Clinical monitoring of pediatric HIV treatment remains a major challenge in settings where drug resistance genotyping is not routinely available. As a result, our understanding of drug resistance, and its impact on subsequent therapeutic regimens available in these settings, remains limited. We investigate the prevalence and correlates of HIV-1 drug resistance among 94 participants of the Ethiopia Pediatric HIV Cohort failing first-line combination antiretroviral therapy (cART) using dried blood spot-based genotyping. Overall, 81% (73/90) of successfully genotyped participants harbored resistance mutations, including 69% (62/90) who harbored resistance to both Nucleoside Reverse Transcriptase Inhibitors (NRTIs) and Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs). Strikingly, 42% of resistant participants harbored resistance to all four NRTIs recommended for second-line use in this setting, meaning that there are effectively no remaining cART options for these children. Longer cART duration and prior regimen changes were significantly associated with detection of drug resistance mutations. Replicate genotyping increased the breadth of drug resistance detected in 34% of cases, and thus is recommended for consideration when typing from blood spots. Implementation of timely drug resistance testing and access to newer antiretrovirals and drug classes are urgently needed to guide clinical decision-making and improve outcomes for HIV-infected children on first-line cART in Ethiopia.