Computed CD4 percentage as a low-cost method for determining pediatric antiretroviral treatment eligibility

Implementation of antiretroviral therapy guidelines for under-five children in Tanzania: translating recommendations into practice

INTRODUCTION

Paediatric antiretroviral therapy (ART) guidelines have been updated several times in recent years. We assessed implementation of ART guidelines among under-five children to inform the transition to universal paediatric ART in Tanzania.

METHODS

We conducted a retrospective cohort analysis of infants (0 to 11 months) and children (12 to 59 months) enrolled between 2010 and 2012 using routinely collected data. Infants and children were initiated on ART according to the 2008 World Health Organization (WHO) recommendations/2009 Tanzania guidelines (universal ART for infants). Cumulative ART initiation incidence and correlates of ART initiation were examined using competing risk methods accounting for attrition (death or loss to follow-up). Kaplan-Meier methods and Cox regression models were used to examine attrition on ART and its correlates.

RESULTS

A total of 1679 children were enrolled at 69 clinics: 469 (28%) infants and 1210 (74%) children. Infant cumulative ART initiation incidence was 59.6, 71.3 and 78.0% at one, three and six months of follow-up. Infants were more likely to start ART if enrolled in 2012 [adjusted sub-hazard ratio (AsHR)=2.2, 95% confidence interval (CI): 1.7 to 2.8] or 2011 (AsHR=1.8, 95% CI: 1.4 to 2.3) compared to 2010; they were more likely to start ART from prevention of mother-to-child HIV transmission (AsHR=1.6, 95% CI: 1.3 to 2.1) and inpatient wards (AsHR=1.5, 95% CI: 1.2 to 2.0) versus being enrolled from voluntary counselling and testing centres. Attrition at 12 months on ART was 33.9% and was more likely among infants with WHO Stage 4 [adjusted hazard ratio (AHR)=3.1. 95% CI: 1.8 to 5.2] and severe malnutrition (AHR=1.4, 95% CI: 1.0 to 1.9).Among 599 children eligible for ART at enrollment, cumulative ART initiation incidence was 51.8, 68.6 and 76.1% at one, three, and six months. Children were more likely to start ART if enrolled in 2012 (AsHR=1.8, 95% CI: 1.4 to 2.3) or 2011 (AsHR=1.5, 95% CI: 1.2 to 1.8) compared to 2010; they were more likely to start ART at primary health facilities (AsHR=1.5, 95% CI: 1.1 to 2.0) and less likely at urban facilities (AsHR=0.6, 95% CI: 0.5 to 0.9) and facilities without CD4 testing on site (AsHR=0.7, 95% CI: 0.5 to 0.9). Attrition at 12 months on ART was 23.1% and was more likely with severe malnutrition (AHR=1.8, 95% CI: 1.1 to 3.0), WHO Stage 4 (AHR=3.0, 95% CI: 1.0 to 8.5) and outpatient enrolees (AHR=1.7, 95% CI: 1.1 to 2.7).

CONCLUSIONS

Our findings suggest the gradual adoption of guidelines over calendar time. Interventions to expedite ART initiation and support retention on ART are needed.

Discordance between clinical and immunological ART eligibility criteria for children in Malawi

Background

Since May 2014, all HIV positive children aged less than five years in Malawi are eligible for ART. For children older than five years they are eligible if they are in WHO stage III/IV, if stage I/II, if their CD4 < 500 cells/mm³. Our goal was to compare the WHO clinical classification criteria (WHO stage + CD4/age) to CD4 count (CD4/age) on all children. Prior to 2014, children aged 2–5 years in stage I and II were eligible for ART if their CD4 was < 750 cells/mm³. We were interested in the increase in numbers of children in this age group who now meet the eligibility criteria and their average CD4 count.

Methods

Data including age, stage and CD4 count were used. We examined the effect of using two different criteria; WHO staging and checking CD4 count if stage I or II versus CD4 count on all, on the numbers of children eligibility for ART in a cohort of 969 children aged 0 to 14 years in Blantyre, Malawi.

Results

Using WHO stage + CD4/age, 786 patients out of 969 would have been treated and 183 would not. Using CD4/age, 745 patients out of 969 would have been treated and 224 would not. Within the 224 patients not treated by CD4 classification, 41 were clinical stage III or IV. The most common staging condition in these 41 children was low weight for age (i.e. underweight). 41% of children age2-5 years have a CD4 count >750.

Conclusion

Most children are correctly started on treatment using recent guidelines. 41% more children <5 years will be started on ART.

HIV in the tropics: staging in the resource-limited setting

PURPOSE OF REVIEW

In 2010, the WHO updated HIV treatment guidelines for adults and children, expanding the eligibility of HIV-infected individuals for antiretroviral therapy (ART) on the basis of immunological staging. We discuss the barriers to HIV staging in under-resourced settings.

RECENT FINDINGS

In industrialized countries, HIV-infected patients are immunologically staged using CD4 lymphocyte counts measured using flow cytometry, but reliable and timely CD4 testing is still not readily available for all patients in many poorly resourced countries. Often CD4 testing is only available in central hospitals and clinics and depends upon availability of reagents. This leaves clinical staging as the standard of care in many places. Significant discrepancies exist between clinical and immunologic staging. Lack of immunologic staging can lead to delayed or inappropriate initiation of ART, increased attrition before ART, and overall poorer outcomes as patients often initiate ART at lower CD4 cell count baselines. This has led to intensive efforts to develop cost-effective laboratory testing, particularly for accurate low-cost CD4 testing.

SUMMARY

Simplified, low-cost alternatives for immunologic staging are vital to continued scale up of ART programs globally. Point-of-care CD4 testing in particular has shown promise in decreasing attrition rates before ART and improving overall mortality in resource-limited settings.

Engaging with research ethics in central Francophone Africa: reflections on a workshop about ancillary care

Research ethics is predominantly taught and practiced in Anglophone countries, particularly those in North America and Western Europe. Initiatives to build research ethics capacity in developing countries must attempt to avoid imposing foreign frameworks and engage with ethical issues in research that are locally relevant. This article describes the process and outcomes of a capacity-building workshop that took place in Kinshasa, Democratic Republic of Congo in the summer of 2011. Although the workshop focused on a specific ethical theme - the responsibilities of researchers to provide health-related care to their research participants - we argue that the structure of the workshop offers a useful method for engaging with research ethics in general, and the theme of ancillary care encourages a broad perspective on research ethics that is highly pertinent in low-income countries. The workshop follows an interactive, locally driven model that could be fruitfully replicated in similar settings.

HIV infection and the incidence of malaria among HIV-exposed children from Tanzania

OBJECTIVE

To determine whether human immunodeficiency virus (HIV) infection is associated with increased risk of malaria incidence and recurrence in children.

METHODS

Newborn infants of HIV-infected mothers were enrolled at 6 weeks and followed for 2 years. HIV status was assessed by enzyme-linked immunosorbant assay and confirmed by HIV DNA polymerase chain reaction. Malaria was defined as (1) physician-diagnosed clinical malaria; (2) probable malaria, in which laboratory testing is requested for parasitemia; and (3) blood smear-confirmed malaria. Cox proportional hazards models estimated hazard ratios (HRs) for development of first and second malaria episodes, and generalized estimating equation models estimated malaria rate differences per 100-child-years in relation to time-updated HIV status.

RESULTS

Child HIV infection was associated with clinical (HR, 1.34; 95% confidence interval [CI], 1.12-1.61), probable (HR, 1.47; 95% CI, 1.19-1.81), and confirmed (HR, 1.67; 95% CI, 1.18-2.36) malaria episodes. Per 100 child-years, HIV-infected children experienced 88 (95% CI, 65-113), 36 (95% CI, 19-53), and 20 (95% CI, 9-31) more episodes of clinical, probable, and confirmed malaria episodes, respectively, than HIV-uninfected children. Among children with ≥1 malaria episodes, those with HIV infection developed second clinical (HR, 1.28; 95% CI, 1.04-1.57), probable (HR, 1.60; 95% CI, 1.26-2.14), and confirmed (HR, 2.27; 95% CI, 1.06-3.89) malaria sooner than HIV-uninfected children.

CONCLUSIONS

HIV infection is a risk factor for the development of malaria. Proactive malaria disease prevention and treatment is warranted for all children, particularly those with HIV infection in settings of coendemicity.

Kaposi sarcoma in South African children

BACKGROUND

The incidence of Kaposi's sarcoma (KS) in sub-Saharan Africa, increased tens of times since the onset of the AIDS epidemic. There is, however, very little literature concerning the clinical features of this disease, its management and outcome in HIV-positive children in Africa. This study describes retrospectively the clinical presentation of the malignancy, its management and outcome, in a series of HIV-positive children.

PATIENTS AND METHODS

Seventy children with KS and HIV infection were admitted consecutively from January 1998 to December 2009 in South African hospitals. Clinical data were extracted from tumor registries and patient records and analyzed.

RESULTS

The average age in this series was 73 months. The males/females ratio was 1.59:1. Skin lesions were present in 36 out of 63 cases (57.14%), followed by lymph node lesions (28 cases, 44.44%). The mean CD4+ lymphocyte count was 440 (SD = 385). The average CD4+ percentage was 12.20% (SD = 9.13). Only 14 patients (20%) were taking combined antiretrovirals at the time of diagnosis; a further 35 were given HIV treatment after diagnosis. Thirty-two patients (45.71%) survived only 4 months on average; 10 were lost to follow-up; and 28 (40%) were alive, with an average follow-up of 16 months. Antiretrovirals improved survival (P = 0.001).

CONCLUSIONS

The often present skin lesions facilitated the diagnosis; lymphadenopathy was less frequently seen than skin lesions. Antiretroviral drugs were associated with higher survival rate. The mortality remains high in spite of antiretrovirals and cytostatics.

Cost-effectiveness of routine and low-cost CD4 T-cell count compared with WHO clinical staging of HIV to guide initiation of antiretroviral therapy in resource-limited settings

BACKGROUND

HIV is a major cause of disease and death in sub-Saharan Africa. Provision and scale-up of antiretroviral therapy (ART) in resource-limited settings is feasible and cost-effective. Initiation of ART is guided by WHO stage or CD4 cell count; the latter may not be available and up to 70% of eligible individuals are not identified. Low-cost CD4 cell count tests are comparable to conventional methods. We compared the direct healthcare costs and benefits using routine and low-cost CD4 cell count versus WHO staging to initiate ART.

METHODS

Using a Markov state transition model, we incorporated costs, survival and quality of life. We compared the direct healthcare costs and benefits in quality-adjusted life years gained using routine and low-cost CD4 cell count versus WHO staging to initiate ART. We estimated an incremental cost-effectiveness ratio in US$ per quality-adjusted life year gained and compared with threshold of gross domestic product per capita. Uncertainty was assessed by sensitivity analysis.

RESULTS

Routine and low-cost CD4 cell counts compared to WHO staging to guide initiation of ART improved quantity and quality of life and appears to be very cost-effective. The base case estimated an incremental cost-effectiveness ratio of US$939 and US$85 per quality-adjusted life years gained, respectively, and well below the cost effectiveness thresholds of gross domestic product per capita.

CONCLUSION

Routine or low-cost CD4 cell count compared to WHO staging, to guide initiation of ART, is a very cost-effective intervention for sub-Saharan Africa and should be an integral part of the scale-up of ART programs.

Role of the CD4 count in HIV management

As a result of successful antiretroviral treatment over the last 20 years, HIV has become more of a chronic disease for practitioners to manage, requiring careful, but routine, clinical monitoring. Laboratory markers, such as the HIV-1 RNA viral load and CD4 cell count, are regularly used for patient management in addition to predicting disease progression and/or treatment outcomes. The HIV viral load is considered to be the gold standard for evaluating treatment success, although it is often limited by the cost. Furthermore, in certain cases, there is a mismatch between an undetectable viral load (<50 copies/ml) and the absence of immune reconstitution, which can be confusing to both the treatment provider and patient. In this review, the utility of the CD4 count as a predictor for HIV disease progression in patients not on therapy is evaluated, as well as a method for monitoring a patient’s response to therapy. Its use in predicting immune reconstitution in patients initiating antiretrovirals is also identified. We hope to aid the clinician by examining the most recent literature and discussing the added value of the CD4 count in the management of a person with HIV infection.