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Chinsembu KC. Chemical diversity and activity profiles of HIV-1 reverse transcriptase inhibitors from plants. REVISTA BRASILEIRA DE FARMACOGNOSIA-BRAZILIAN JOURNAL OF PHARMACOGNOSY 2019. [DOI: 10.1016/j.bjp.2018.10.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Tadesse BT, Kinloch NN, Baraki B, Lapointe HR, Cobarrubias KD, Brockman MA, Brumme CJ, Foster BA, Jerene D, Makonnen E, Aklillu E, Brumme ZL. High Levels of Dual-Class Drug Resistance in HIV-Infected Children Failing First-Line Antiretroviral Therapy in Southern Ethiopia. Viruses 2018; 10:E60. [PMID: 29389912 PMCID: PMC5850367 DOI: 10.3390/v10020060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 01/30/2018] [Accepted: 01/30/2018] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
| | - Natalie N Kinloch
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada.
| | - Bemuluyigza Baraki
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada.
| | - Hope R Lapointe
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC V6Z 1Y6, Canada.
| | - Kyle D Cobarrubias
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada.
| | - Mark A Brockman
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada.
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC V6Z 1Y6, Canada.
| | - Chanson J Brumme
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC V6Z 1Y6, Canada.
| | - Byron A Foster
- Departments of Dermatology and Pediatrics, Oregon Health Sciences University, Portland, OR 97239, USA.
| | - Degu Jerene
- Management Sciences for Health, Addis Ababa 1250, Ethiopia.
| | - Eyasu Makonnen
- Department of Pharmacology, College of Health Sciences, Addis Ababa University, Addis Ababa 9086, Ethiopia.
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital Huddinge C1:68, Stockholm 141 86, Sweden.
| | - Zabrina L Brumme
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada.
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC V6Z 1Y6, Canada.
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Where do HIV-infected adolescents go after transfer? - Tracking transition/transfer of HIV-infected adolescents using linkage of cohort data to a health information system platform. J Int AIDS Soc 2017; 20:21668. [PMID: 28530037 PMCID: PMC5577779 DOI: 10.7448/ias.20.4.21668] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION To evaluate long-term outcomes in HIV-infected adolescents, it is important to identify ways of tracking outcomes after transfer to a different health facility. The Department of Health (DoH) in the Western Cape Province (WCP) of South Africa uses a single unique identifier for all patients across the health service platform. We examined adolescent outcomes after transfer by linking data from four International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) cohorts in the WCP with DoH data. METHODS We included adolescents on antiretroviral therapy who transferred out of their original cohort from 10 to 19 years of age between 2004 and 2014. The DoH conducted the linkage separately for each cohort and linked anonymized data were then combined. The primary outcome was successful transfer defined as having a patient record at a facility other than the original facility after the transfer date. Secondary outcomes included the proportion of patients retained, with HIV-RNA <400 copies/ml and CD4 > 500 cells/µl at 1, 2 and 3 years post-transfer. RESULTS Of 460 adolescents transferred out (53% female), 72% transferred at 10-14 years old, and 79% transferred out of tertiary facilities. Overall, 81% of patients transferred successfully at a median (interquartile range) of 56 (27-134) days following transfer date; 95% reached the transfer site <18 months after transfer out. Among those transferring successfully, the proportion retained decreased from 1 to 3 years post-transfer (90-84%). There was no significant difference between transfer and 1-3 years post-transfer in the proportion of retained adolescents with HIV-RNA <400 copies/ml and CD4 > 500 cells/µl except for HIV-RNA <400 copies/ml at 3 years (86% vs. 75%; p = 0.007). The proportion virologically suppressed and with CD4 > 500 cells/µl was significantly lower at 1 and 2 years post-transfer in those transferring at 15-19 vs. 10-14 years of age. Using laboratory data alone over-estimated time to successful transfer. CONCLUSIONS Linking cohort data to health information system data allowed efficient assessment of post-transfer outcomes. Although >80% of adolescents transferred successfully with nearly 85% of them retained for 3 years post-transfer, the decline in the proportion virologically suppressed and poorer outcomes in older adolescents are concerns..
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Challenges and perspectives of compliance with pediatric antiretroviral therapy in Sub-Saharan Africa. Med Mal Infect 2017; 47:511-518. [PMID: 28943171 DOI: 10.1016/j.medmal.2017.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/17/2016] [Accepted: 07/20/2017] [Indexed: 11/22/2022]
Abstract
More than 3 million children aged less than 15years are infected with HIV worldwide, mainly in Sub-Saharan Africa. The survival of HIV-infected children depends on their access to antiretroviral therapy whose success mainly depends on a good life-long compliance with antiretroviral therapy. Given its complexity and specificity, assessment and monitoring of pediatric compliance with antiretroviral therapy is a major challenge. There is no consensus on a gold standard for monitoring compliance with antiretroviral therapy. Compliance is also influenced by many factors related to the child, the caregiver, the healthcare staff, the healthcare system, and antiretroviral drugs. This review aimed to assess scientific knowledge on pediatric compliance with antiretroviral therapy in Sub-Saharan Africa, and to identify areas for future interventions to improve compliance. Good compliance is essential to achieve the "90% coverage of children on antiretroviral therapy" gold standard of the World Health Organization, and to eliminate HIV infection by 2030.
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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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Ateba Ndongo F, Warszawski J, Texier G, Penda I, Tetang Ndiang S, Ndongo JA, Guemkam G, Sofeu CL, Kfutwah A, Faye A, Msellati P, Tejiokem MC. Could caregiver reporting adherence help detect virological failure in Cameroonian early treated HIV-infected infants? BMC Pediatr 2015; 15:132. [PMID: 26391474 PMCID: PMC4578260 DOI: 10.1186/s12887-015-0451-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 09/14/2015] [Indexed: 11/24/2022] Open
Abstract
Background Viral load is still the marker of choice for monitoring adherence to combined antiretroviral therapy (cART) and confirming the success of HIV treatment. Unfortunately it is difficult to access in many resource-poor settings. We aimed to measure the performance of caregiver reporting adherence for detecting virological failure in routine practice during the first 2 years after cART initiation in infants. Methods PEDIACAM is an ongoing prospective cohort study including HIV1-infected infants diagnosed before 7 months of age between November 2007 and October 2011 in Cameroon. Adherence was assessed using a questionnaire administered every 3 months from cART initiation; the HIV-RNA viral load was determined at the same visits. Virological failure was defined as having a viral load ≥ 1000 cp/mL at 3 and 12 months after cART initiation or having a viral load ≥ 400 cp/mL at 24 months after cART initiation. The performance of each current missed and cumulative missed dose defined according to adherence as reported by caregiver was assessed using the viral load as the gold standard. Results cART was initiated at a median age of 4 months (IQR: 3–6) in the 167 infants included. The cumulative missed dose showed the best overall performance for detecting virological failure after 12 months of cART (AUC test, p = 0.005, LR + =4.4 and LR− = 0.4). Whatever the adherence reporting criterion, the negative predictive value was high (NPV ≥ 75 %) 12 and 24 months after cART initiation, whereas the positive predictive value was low (PPV ≤ 50 %). Conclusions The adherence questionnaire administered by the health care provider to the infants’ caregivers is not reliable for detecting virological failure in routine practice: its positive predictive value is low. However, the cumulative missed dose measurement may be a reliable predictor of virological success, particularly after 12 months of cART, given its high negative predictive value.
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Affiliation(s)
- Francis Ateba Ndongo
- Université Paris-Sud; Centre Mère et Enfant de la Fondation Chantal Biya, POB 1936, Yaounde, Cameroon.
| | - 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.
| | - Gaetan Texier
- SESSTIM (UMR 912) Aix-Marseille Université, Marseille, France.
| | - Ida Penda
- Université Douala; Hôpital Laquintinie, POB 4035, Douala, Cameroon.
| | | | - Jean-Audrey Ndongo
- Centre Mère et Enfant de la Fondation Chantal Biya, POB 1936, Yaounde, Cameroon.
| | - Georgette Guemkam
- Centre Mère et Enfant de la Fondation Chantal Biya, POB 1936, Yaounde, Cameroon.
| | - Casimir Ledoux Sofeu
- Université Yaoundé I; Centre Pasteur du Cameroun, Service d'Epidémiologie et de Santé Publique, POB 1274, Yaounde, Cameroon.
| | - Anfumbom Kfutwah
- Centre Pasteur du Cameroun, Service de Virologie, POB 1274, Yaounde, Cameroon.
| | - Albert Faye
- Université Paris Diderot, Sorbonne Paris Cité; Assistance Publique des Hôpitaux de Paris, Pédiatrie Générale, Hôpital Robert Debré, Paris, France.
| | - Philippe Msellati
- UMI 233, IRD, Université Montpellier, POB 64501, 34394, Montpellier, France.
| | - Mathurin Cyrille Tejiokem
- Centre Pasteur du Cameroun, Service d'Epidémiologie et de Santé Publique, POB 1274, Yaounde, Cameroon.
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Davies MA, May M, Bolton-Moore C, Chimbetete C, Eley B, Garone D, Giddy J, Moultrie H, Ndirangu J, Phiri S, Rabie H, Technau K, Wood R, Boulle A, Egger M, Keiser O. Prognosis of children with HIV-1 infection starting antiretroviral therapy in Southern Africa: a collaborative analysis of treatment programs. Pediatr Infect Dis J 2014; 33:608-16. [PMID: 24378936 PMCID: PMC4349941 DOI: 10.1097/inf.0000000000000214] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prognostic models for children starting antiretroviral therapy (ART) in Africa are lacking. We developed models to estimate the probability of death during the first year receiving ART in Southern Africa. METHODS We analyzed data from children ≤10 years of age who started ART in Malawi, South Africa, Zambia or Zimbabwe from 2004 to 2010. Children lost to follow up or transferred were excluded. The primary outcome was all-cause mortality in the first year of ART. We used Weibull survival models to construct 2 prognostic models: 1 with CD4%, age, World Health Organization clinical stage, weight-for-age z-score (WAZ) and anemia and the other without CD4%, because it is not routinely measured in many programs. We used multiple imputation to account for missing data. RESULTS Among 12,655 children, 877 (6.9%) died in the first year of ART. We excluded 1780 children who were lost to follow up/transferred from main analyses; 10,875 children were therefore included. With the CD4% model probability of death at 1 year ranged from 1.8% [95% confidence interval (CI): 1.5-2.3] in children 5-10 years with CD4% ≥10%, World Health Organization stage I/II, WAZ ≥ -2 and without severe anemia to 46.3% (95% CI: 38.2-55.2) in children <1 year with CD4% < 5%, stage III/IV, WAZ< -3 and severe anemia. The corresponding range for the model without CD4% was 2.2% (95% CI: 1.8-2.7) to 33.4% (95% CI: 28.2-39.3). Agreement between predicted and observed mortality was good (C-statistics = 0.753 and 0.745 for models with and without CD4%, respectively). CONCLUSIONS These models may be useful to counsel children/caregivers, for program planning and to assess program outcomes after allowing for differences in patient disease severity characteristics.
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Affiliation(s)
- Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Margaret May
- School of Social and Community Medicine, University of Bristol, UK
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia and University of North Caroline at Chapel Hill, USA
| | | | - Brian Eley
- Red Cross Children’s Hospital and School of Child and Adolescent Health, University of Cape Town, South Africa
| | - Daniela Garone
- Médecins Sans Frontières (MSF) South Africa and Khayelitsha ART Programme, Cape Town, South Africa
| | - Janet Giddy
- Sinikithemba Clinic, McCord Hospital, Durban, South Africa
| | - Harry Moultrie
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg and Harriet Shezi Children’s Clinic, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - James Ndirangu
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Sam Phiri
- Lighthouse Trust Clinic, Kamuzu Central Hospital, Lilongwe, Malawi and Liverpool School of Tropical Medicine Liverpool, UK
| | - Helena Rabie
- Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch, South Africa
| | - Karl Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, and University of Witwatersrand, Johannesburg, South Africa
| | - Robin Wood
- Gugulethu ART Programme and Desmond Tutu HIV Centre, University of Cape Town, South Africa
| | - Andrew Boulle
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Matthias Egger
- School of Public Health and Family Medicine, University of Cape Town, South Africa
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
| | - Olivia Keiser
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
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Luyirika E, Towle MS, Achan J, Muhangi J, Senyimba C, Lule F, Muhe L. Scaling up paediatric HIV care with an integrated, family-centred approach: an observational case study from Uganda. PLoS One 2013; 8:e69548. [PMID: 23936337 PMCID: PMC3735564 DOI: 10.1371/journal.pone.0069548] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/10/2013] [Indexed: 11/19/2022] Open
Abstract
Family-centred HIV care models have emerged as an approach to better target children and their caregivers for HIV testing and care, and further provide integrated health services for the family unit's range of care needs. While there is significant international interest in family-centred approaches, there is a dearth of research on operational experiences in implementation and scale-up. Our retrospective case study examined best practices and enabling factors during scale-up of family-centred care in ten health facilities and ten community clinics supported by a non-governmental organization, Mildmay, in Central Uganda. Methods included key informant interviews with programme management and families, and a desk review of hospital management information systems (HMIS) uptake data. In the 84 months following the scale-up of the family-centred approach in HIV care, Mildmay experienced a 50-fold increase of family units registered in HIV care, a 40-fold increase of children enrolled in HIV care, and nearly universal coverage of paediatric cotrimoxazole prophylaxis. The Mildmay experience emphasizes the importance of streamlining care to maximize paediatric capture. This includes integrated service provision, incentivizing care-seeking as a family, creating child-friendly service environments, and minimizing missed paediatric testing opportunities by institutionalizing early infant diagnosis and provider-initiated testing and counselling. Task-shifting towards nurse-led clinics with community outreach support enabled rapid scale-up, as did an active management structure that allowed for real-time review and corrective action. The Mildmay experience suggests that family-centred approaches are operationally feasible, produce strong coverage outcomes, and can be well-managed during rapid scale-up.
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Affiliation(s)
| | | | | | | | | | - Frank Lule
- World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo
| | - Lulu Muhe
- World Health Organization Headquarters, Geneva, Switzerland
- * E-mail:
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Mutanga JN, Raymond J, Towle MS, Mutembo S, Fubisha RC, Lule F, Muhe L. Institutionalizing provider-initiated HIV testing and counselling for children: an observational case study from Zambia. PLoS One 2012; 7:e29656. [PMID: 22536311 PMCID: PMC3335043 DOI: 10.1371/journal.pone.0029656] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 12/01/2011] [Indexed: 01/07/2023] Open
Abstract
Background Provider-initiated testing and counselling (PITC) is a priority strategy for increasing access for HIV-exposed children to prevention measures, and infected children to treatment and care interventions. This article examines efforts to scale-up paediatric PITC at a second-level hospital located in Zambia’s Southern Province, and serving a catchment area of 1.2 million people. Methods and Principal Findings Our retrospective case study examined best practices and enabling factors for rapid institutionalization of PITC in Livingstone General Hospital. Methods included clinical observations, key informant interviews with programme management, and a desk review of hospital management information systems (HMIS) uptake data following the introduction of PITC. After PITC roll-out, the hospital experienced considerably higher testing uptake. In a 36-month period following PITC institutionalization, of total inpatient children eligible for PITC (n = 5074), 98.5% of children were counselled, and 98.2% were tested. Of children tested (n = 4983), 15.5% were determined HIV-infected; 77.6% of these results were determined by DNA polymerase chain reaction (PCR) testing in children under the age of 18 months. Of children identified as HIV-infected in the hospital’s inpatient and outpatient departments (n = 1342), 99.3% were enrolled in HIV care, including initiation on co-trimoxazole prophylaxis. A number of good operational practices and enabling factors in the Livingstone General Hospital experience can inform rapid PITC institutionalization for inpatient and outpatient children. These include the placement of full-time nurse counsellors at key areas of paediatric intake, who interface with patients immediately and conduct testing and counselling. They are reinforced through task-shifting to peer counsellors in the wards. Nurse counsellor capacity to draw specimen for DNA PCR for children under 18 months has significantly enhanced early infant diagnosis. The hospital’s bolstered antiretroviral supply chain, package of on-site HIV services, and follow-up care for children and families improved the continuum of service uptake. Conclusions and Significance The clinical impact and operational experience emphasizes that institutional PITC is a feasible strategy for increasing access to paediatric HIV care, particularly in generalized epidemic settings.
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Affiliation(s)
| | | | | | - Simon Mutembo
- Southern Provincial Medical Office, Livingstone, Zambia
| | - Robert Captain Fubisha
- Department of Paediatrics and Child Health, Livingstone Paediatric Centre of Excellence, Livingstone, Zambia
| | - Frank Lule
- World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Lulu Muhe
- World Health Organization Headquarters, Geneva, Switzerland
- * E-mail:
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Early mortality and loss to follow-up in HIV-infected children starting antiretroviral therapy in Southern Africa. J Acquir Immune Defic Syndr 2010; 54:524-32. [PMID: 20588185 DOI: 10.1097/qai.0b013e3181e0c4cf] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many HIV-infected children in Southern Africa have been started on antiretroviral therapy (ART), but loss to follow up (LTFU) can be substantial. We analyzed mortality in children retained in care and in all children starting ART, taking LTFU into account. PATIENTS AND METHODS Children who started ART before the age of 16 years in 10 ART programs in South Africa, Malawi, Mozambique, and Zimbabwe were included. Risk factors for death in the first year of ART were identified in Weibull models. A meta-analytic approach was used to estimate cumulative mortality at 1 year. RESULTS Eight thousand two hundred twenty-five children (median age 49 months, median CD4 cell percent 11.6%) were included; 391 (4.8%) died and 523 (7.0%) were LTFU in the first year. Mortality at 1 year was 4.5% [95% confidence interval (CI): 2.8% to 7.4%] in children remaining in care, but 8.7% (5.4% to 12.1%) at the program level, after taking mortality in children and LTFU into account. Factors associated with mortality in children remaining in care included age [adjusted hazard ratio (HR) 0.37; 95% CI: 0.25 to 0.54 comparing > or =120 months with <18 months], CD4 cell percent (HR: 0.56; 95% CI: 0.39 to 0.78 comparing > or =20% with <10%), and clinical stage (HR: 0.12; 95% CI: 0.03 to 0.45 comparing World Health Organization stage I with III/IV). CONCLUSIONS In children starting ART and remaining in care in Southern Africa mortality at 1 year is <5% but almost twice as high at the program level, when taking LTFU into account. Age, CD4 percentage, and clinical stage are important predictors of mortality at the individual level.
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Mangtani P, Mulholland K, Madhi SA, Edmond K, O’Loughlin R, Hajjeh R. Haemophilus influenzae type b disease in HIV-infected children: A review of the disease epidemiology and effectiveness of Hib conjugate vaccines. Vaccine 2010; 28:1677-83. [DOI: 10.1016/j.vaccine.2009.12.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 07/23/2009] [Accepted: 12/08/2009] [Indexed: 10/20/2022]
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Effect of provider-initiated testing and counselling and integration of ART services on access to HIV diagnosis and treatment for children in Lilongwe, Malawi: a pre- post comparison. BMC Pediatr 2009; 9:80. [PMID: 20021641 PMCID: PMC2803160 DOI: 10.1186/1471-2431-9-80] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Accepted: 12/18/2009] [Indexed: 11/27/2022] Open
Abstract
Background The HIV prevalence in Malawi is 12% and Kamuzu Central Hospital (KCH), in the capital Lilongwe, is the main provider of adult and paediatric HIV services in the central region. The Lighthouse at KCH offers opt-in HIV testing and counselling (HTC) for adults and children. In June 2004, Lighthouse was the first clinic to provide free antiretroviral treatment (ART) in the public sector, but few children accessed the services. In response, provider-initiated HIV testing and counselling (PITC) and an ART clinic were introduced at the paediatric department at KCH in Quarter 4 (Q4) 2004. Methods We analysed prospectively collected, aggregated data of quarterly reports from Q1 2003 to Q4 2006 from HTC centre registers, ART registers and clinic registrations at the ART clinics of both Lighthouse and the paediatric department. By comparing data of both facilities before (Q1 2003 to Q3 2004), and after the introduction of the services at the paediatric department (Q4 2004 to Q4 2006), we assessed the effect of this intervention on the uptake of HIV services for children at KCH. Results Overall, 3971 children were tested for HIV, 2428 HIV-infected children were registered for care and 1218 started ART. Between the two periods, the median (IQR) number of children being tested, registered and starting ART per quarter rose from 101 (53-109) to 358 (318-440), 56 (50-82) to 226 (192-234) and 18 (8-23) to 139 (115-150), respectively. The median proportion of tested clients per quarter that were children rose from 3.8% (2.7-4.3) to 9.6% (8.8 to 10.0) (p = 0.0009) and the proportion of ART starters that were children rose from 6.9% (4.9-9.3) to 21.1% (19.2-24.2) (p = 0.0036). The proportion of registered children and adults starting ART each quarter increased similarly, from 26% to 53%, and 20% to 52%, respectively. Conclusions Implementation of PITC and integration of ART services within the paediatric ward are likely to be the main reasons for improved access to HTC and ART for children at KCH, and can be recommended to other hospitals with paediatric inpatients in resource limited settings with high HIV prevalence.
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Davies MA, Egger M, Keiser O, Boulle A. Paediatric antiretroviral treatment programmes in sub-Saharan Africa: a review of published clinical studies. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2009; 8:329-338. [PMID: 21124759 DOI: 10.2989/ajar.2009.8.3.9.930] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Knowledge of the experience and outcomes of current paediatric antiretroviral treatment (ART) programmes in sub-Saharan Africa can inform new programmes in the region as well as enhance existing ones. This is urgently needed to facilitate the scale-up of treatment, which is needed to address the burden of paediatric HIV cases on the continent. We reviewed the characteristics and outcomes of programmes with clinical paediatric ART studies published prior to 1 January 2008. The outcomes of the studies were comparable to similar ones from developed countries; however, the duration of follow-up was relatively limited in almost all the studies reviewed. One-year survival probability was between 84% and 91%, and considerable improvement in the clinical, immunologic and viral status of the paediatric patients was generally recorded. Loss to follow-up was less than 10% in all but two studies. Adherence to treatment was good and few adverse events were reported. This is despite the fact that many programmes were subject to enormous constraints in terms of health services, and despite widespread use of adult fixed-dose combinations for paediatric patients, including young infants. While the majority of children commencing ART were severely ill, most children were old (median age > 5 years for almost all studies) with relatively few infants and young children (age < 2 years) receiving treatment. This is in contrast to knowledge of rapid disease progression in the majority of HIV-infected infants and despite the World Health Organization's recent recommendations to commence ART in all HIV-infected infants less than one year old. There is an urgent need to address barriers to ART for infants. Studies of the outcomes of programmes treating infants as well as those with longer-term follow-up are also needed.
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Affiliation(s)
- Mary-Ann Davies
- Infectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
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Kankasa C, Carter RJ, Briggs N, Bulterys M, Chama E, Cooper ER, Costa C, Spielman E, Katepa-Bwalya M, M'soka T, Ou CY, Abrams EJ. Routine offering of HIV testing to hospitalized pediatric patients at university teaching hospital, Lusaka, Zambia: acceptability and feasibility. J Acquir Immune Defic Syndr 2009; 51:202-8. [PMID: 19504732 PMCID: PMC5117627 DOI: 10.1097/qai.0b013e31819c173f] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The difficulties diagnosing infants and children with HIV infection have been cited as barriers to increasing the number of children receiving antiretroviral therapy worldwide. DESIGN We implemented routine HIV antibody counseling and testing for pediatric patients hospitalized at the University Teaching Hospital, a national reference center, in Lusaka, Zambia. We also introduced HIV DNA polymerase chain reaction (PCR) testing for early infant diagnosis. METHODS Caregivers/parents of children admitted to the hospital wards were routinely offered HIV counseling and testing for their children. HIV antibody positive (HIV+) children <18 months of age were tested with PCR for HIV DNA. RESULTS From January 1, 2006, to June 30, 2007, among 15,670 children with unknown HIV status, 13,239 (84.5%) received counseling and 11,571 (87.4%) of those counseled were tested. Overall, 3373 (29.2%) of those tested were seropositive. Seropositivity was associated with younger age: 69.6% of those testing HIV antibody positive were <18 months of age. The proportion of counseled children who were tested increased each quarter from 76.0% in January to March 2006 to 88.2% in April to June 2007 (P < 0.001). From April 2006 to June 2007, 1276 PCR tests were done; 806 (63.2%) were positive. The rate of PCR positivity increased with age from 22% in children <6 weeks of age to 61% at 3-6 months and to 85% at 12-18 months (P < 0.001). CONCLUSIONS Routine counseling and antibody testing of pediatric inpatients can identify large numbers of HIV-seropositive children in high prevalence settings. The high rate of HIV infection in hospitalized infants and young children also underscores the urgent need for early infant diagnostic capacity in high prevalence settings.
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Affiliation(s)
- Chipepo Kankasa
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
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Clinical practice treatment of HIV infection in children. Eur J Pediatr 2009; 168:387-92. [PMID: 19152000 DOI: 10.1007/s00431-008-0914-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 12/15/2008] [Indexed: 10/21/2022]
Abstract
Perinatal transmission remains the main cause of HIV infection in the pediatric population. Treatment of HIV-infected children has become less of a problem in resource-rich countries with a remarkable decrease of perinatal infections, resulting in an effective prevention of mother-to-child transmission and antiretroviral treatment of HIV infection in pediatrics because of differences in drug pharmacokinetics, the lack of available licensed drugs, the use of different immunologic markers and age-related adherence issues. This review, for the general pediatrician, summarizes the most recent pediatric data and guidelines for treatment of HIV. Recommendations for when to initiate therapy are more aggressive in children than in adults, particularly in infants because disease progression in children is more rapid. The indications to start therapy differ by age and are based on international immunologic and clinical classification system for HIV infection. At present, combination regimens of at least three drugs are recommended. Moreover, therapies must also consider the potential complications in these children currently treated for a long time.
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Differences in Factors Associated With Initial Growth, CD4, and Viral Load Responses to ART in HIV-Infected Children in Kampala, Uganda, and the United Kingdom/Ireland. J Acquir Immune Defic Syndr 2008; 49:384-92. [DOI: 10.1097/qai.0b013e31818cdef5] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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CD4 cell response before and after HAART initiation according to viral load and growth indicators in HIV-1-infected children in Abidjan, Côte d'Ivoire. J Acquir Immune Defic Syndr 2008; 49:70-6. [PMID: 18667922 DOI: 10.1097/qai.0b013e3181831847] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze the determinants of CD4 change in children during 3 periods: before highly active antiretroviral therapy (HAART), during the first year after HAART initiation, and past 1 year after HAART initiation. METHODS One hundred seventy-seven children enrolled in a prospective cohort in Abidjan received HAART during a mean follow-up of 30 months. A linear mixed-effects model was used for the first period, a mixed-effects piecewise model for the second period, and an asymptotic mixed-effects model for long-term CD4 dynamics. RESULTS Before HAART initiation, CD4 percentage decreased along time [beta = -0.59 (-0.92 to -0.26)] was positively associated with body mass index for age [beta = 0.47 (0.22 to 0.72)] and negatively associated with viral load [beta = -1.01 (-1.90 to -0.13)]. During the first year of treatment, the CD4 decrease reverted to a steep increase that was negatively associated with age at HAART initiation [beta = -0.24 (-0.4 to -0.07)] and with the mean viral load under HAART [beta = -1.51 (-2.21 to -0.81)]. The long-term CD4 percentage was also negatively associated with the mean viral load under HAART [beta = -4.97 (-6.22 to -3.72)] and age at HAART initiation [beta = -0.82 (-1.12 to -0.51)]. CONCLUSIONS Before HAART initiation, the CD4 cell percentage was associated with growth indicators whereas, after HAART, an early increase and a long-term plateau were negatively associated with the viral load and age at HAART initiation.
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Davies MA, Boulle A, Fakir T, Nuttall J, Eley B. Adherence to antiretroviral therapy in young children in Cape Town, South Africa, measured by medication return and caregiver self-report: a prospective cohort study. BMC Pediatr 2008; 8:34. [PMID: 18771599 PMCID: PMC2533648 DOI: 10.1186/1471-2431-8-34] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Accepted: 09/04/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) dramatically improves outcomes for children in Africa; however excellent adherence is required for treatment success. This study describes the utility of different measures of adherence in detecting lapses in infants and young children in Cape Town, South Africa. METHODS In a prospective cohort of 122 HIV-infected children commenced on ART, adherence was measured monthly during the first year of treatment by medication return (MR) for both syrups and tablets/capsules. A questionnaire was administered to caregivers after 3 months of treatment to assess experience with giving medication and self-reported adherence. Viral and immune response to treatment were assessed at the end of one year and associations with measured adherence determined. RESULTS Medication was returned for 115/122 (94%) children with median age (IQR) of 37 (16-61) months. Ninety-one (79%) children achieved annual average MR adherence > or = 90%. This was an important covariate associated with viral suppression after adjustment for disease severity (OR = 5.5 [95%CI: 0.8-35.6], p = 0.075), however was not associated with immunological response to ART. By 3 months on ART, 13 (10%) children had deceased and 11 (10%) were lost to follow-up. Questionnaires were completed by 87/98 (90%) of caregivers of those who remained in care. Sensitivity of poor reported adherence (missing > or = 1 dose in the previous 3 days) for MR adherence <90% was only 31.8% (95% CI: 10.7%-53.0%). Caregivers of 33/87 (38.4%) children reported difficulties with giving medication, most commonly poor palatability (21.8%). Independent socio-demographic predictors of MR adherence > or = 90% were secondary education of caregivers (OR = 4.49; 95%CI: 1.10-18.24) and access to water and electricity (OR = 2.65; 95%CI: 0.93-7.55). Taking ritonavir was negatively associated with MR adherence > or = 90% (OR = 0.37; 95%CI: 0.13-1.02). CONCLUSION Excellent adherence to ART is possible in African infants and young children and the relatively simple low technology measure of adherence by MR strongly predicts viral response. Better socio-economic status and more palatable regimens are associated with better adherence.
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Affiliation(s)
- Mary-Ann Davies
- Red Cross War Memorial Children's Hospital and the School of Child and Adolescent Health, University of Cape Town, Cape Town, The Republic of South Africa.
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Effectiveness of antiretroviral therapy among HIV-infected children in sub-Saharan Africa. THE LANCET. INFECTIOUS DISEASES 2008; 8:477-89. [PMID: 18652994 DOI: 10.1016/s1473-3099(08)70180-4] [Citation(s) in RCA: 210] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Assessment of antiretroviral treatment programmes for HIV-infected children in sub-Saharan Africa is important to enable the development of effective care and improve treatment outcomes. We review the effectiveness of paediatric antiretroviral treatment programmes in sub-Saharan Africa and discuss the implications of these findings for the care and treatment of HIV-infected children in this region. Available reports indicate that programmes in sub-Saharan Africa achieve treatment outcomes similar to those in North America and Europe. However, progress in several areas is required to improve the care of HIV-infected children in sub-Saharan Africa. The findings emphasise the need for low-cost diagnostic tests that allow for earlier identification of HIV infection in infants living in sub-Saharan Africa, improved access to antiretroviral treatment programmes, including expansion of care into rural areas, and the integration of antiretroviral treatment programmes with other health-care services, such as nutritional support.
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Bundred P, Gibbs T. Medical migration and Africa: an unwanted legacy of educational change. MEDICAL TEACHER 2007; 29:893-896. [PMID: 18158660 DOI: 10.1080/01421590701814278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The opportunities given for medical staff to travel, work and remain in countries other than that of their domicile or graduation have led to the phenomenon of medical migration. This has been supported by ease of travel, improved technology and a drive to share good examples of medical education through improved communication. Whilst these opportunities create positive advantages to the individuals and countries involved, through the transfer of knowledge and medical management, the situation does not always lead to long term benefits, and clear disadvantages begin to emerge. The gulf between the developed and developing countries becomes pronounced, leading to a general drift of resources away from the areas where they are most needed and subsequent profound effects upon the indigenous population. This paper suggests that it is a responsibility of medical educators throughout the world to recognize this effect and create opportunities whereby the specialty of medical education positively effects medical migration to the benefit of the less fortunate areas of the world.
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Affiliation(s)
- Peter Bundred
- Department of Primary Care, University of Liverpool, UK.
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Clinical management of HIV infection in children. Curr Opin HIV AIDS 2007; 2:410-5. [PMID: 19372920 DOI: 10.1097/coh.0b013e3282ddedf5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to review recent advances in the clinical care of HIV-infected children. RECENT FINDINGS Obstacles to diagnosing HIV in children and providing clinical care to those HIV infected relate to a number of technical and operational factors. Most countries now have antiretroviral treatment guidelines and have incorporated co-trimoxazole prophylaxis for infected and exposed infants and children. Implementation lags behind policy and technical recommendations. Optimal early infant feeding remains difficult and, while breastfeeding remains the safest feeding option for child survival, it carries with it the risk of HIV acquisition. Recent data suggest HIV-free survival at 18 months is comparable in infants who are replacement-fed or exclusively breastfed for the first 6 months of life. Antiretroviral treatment efficacy in children is now well documented. Optimal timing of initiation of antiretroviral treatment remains uncertain; in general it is started earlier, especially in infants. Children starting treatment in infancy are surviving and reaching adulthood; new problems of managing the highly treatment-experienced and adolescents are emerging. SUMMARY New antiretroviral drugs and classes will be needed for the future; research is urgently required to characterize optimal nutritional interventions, interpretation of immunological and virological parameters, and develop diagnostic tools for use in health services with limited infrastructure and capacity.
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