Risk factors associated with increased mortality among HIV infected children initiating antiretroviral therapy (ART) in South Africa

Mortality and its predictors among human immunodeficiency virus-infected children younger than 15 years receiving antiretroviral therapy in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Despite antiretroviral treatment (ART), the human immunodeficiency virus (HIV) continues to pose a considerable health burden in resource-poor countries. This systematic review and meta-analysis aimed to determine the pooled incidence density of mortality and identify potential predictors among HIV-infected children receiving ART, from studies conducted in various parts of Ethiopia.

METHODS

A comprehensive database search was made in Excerpta Medica, PubMed, Web of Science, African Journals Online, Google Scholar, and Scopus. We reported results following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020. Excel Spreadsheet and STATA Version 14 software were used for data abstraction and meta-analysis, respectively. Statistical heterogeneity among studies was assessed using I2 statistics. Meta-regression and subgroup analysis were performed to further explore the sources of statistical heterogeneity. Moreover, publication bias and a leave-out-one sensitivity analysis were performed.

RESULTS

Twenty-two articles involving 8,731 participants met inclusion criteria and were included. The pooled incidence density of mortality was 3.08 (95% confidence interval (CI), 2.52 to 3.64) per 100 child years. Predictors of mortality were living in rural areas (hazard ratio (HR), 2.18 [95% CI, 1.20 to 3.98]), poor adherence to ART (HR, 2.85 [ 95% CI, 1.39 to 5.88]), failure to initiate co-trimoxazole preventive therapy (HR, 2.16 [95% CI, 1.52 to 3.07]), anemia (HR, 2.28 [95% CI, 1.51 to 3.45]), opportunistic infections (HR, 1.52 [ 95% CI, 1.15 to 2.00]), underweight (HR, 1.74 [95% CI, 1.26 to 2.41]), wasting (HR, 2.54 [95% CI, 1.56 to 4.16]), stunting (HR, 2.02 [95% CI, 1.63 to 2.51]), World Health Organization classified HIV clinical stages III and IV (HR, 1.71 [95% CI, 1.42 to 2.05]), and Nevirapine-based regimens (HR, 3.91 [95% CI, 3.09 to 4.95]).

CONCLUSIONS

This study found that the overall mortality rate among HIV-infected children after ART initiation was high. Therefore, high-level commitment and involvement of responsible caregivers, healthcare providers, social workers, and program managers are of paramount importance to identify these risk factors and thus enhance the survival of HIV-infected children receiving ART.

Machine learning outperformed logistic regression classification even with limit sample size: A model to predict pediatric HIV mortality and clinical progression to AIDS

Logistic regression (LR) is the most common prediction model in medicine. In recent years, supervised machine learning (ML) methods have gained popularity. However, there are many concerns about ML utility for small sample sizes. In this study, we aim to compare the performance of 7 algorithms in the prediction of 1-year mortality and clinical progression to AIDS in a small cohort of infants living with HIV from South Africa and Mozambique. The data set (n = 100) was randomly split into 70% training and 30% validation set. Seven algorithms (LR, Random Forest (RF), Support Vector Machine (SVM), K-Nearest Neighbor (KNN), Naïve Bayes (NB), Artificial Neural Network (ANN), and Elastic Net) were compared. The variables included as predictors were the same across the models including sociodemographic, virologic, immunologic, and maternal status features. For each of the models, a parameter tuning was performed to select the best-performing hyperparameters using 5 times repeated 10-fold cross-validation. A confusion-matrix was built to assess their accuracy, sensitivity, and specificity. RF ranked as the best algorithm in terms of accuracy (82,8%), sensitivity (78%), and AUC (0,73). Regarding specificity and sensitivity, RF showed better performance than the other algorithms in the external validation and the highest AUC. LR showed lower performance compared with RF, SVM, or KNN. The outcome of children living with perinatally acquired HIV can be predicted with considerable accuracy using ML algorithms. Better models would benefit less specialized staff in limited resources countries to improve prompt referral in case of high-risk clinical progression.

Survival and predictors of mortality among HIV-positive children on antiretroviral therapy in public hospitals

Background

Human immunodeficiency virus and acquired immunodeficiency syndrome had created enormous challenges worldwide, and continues to be the world’s serious health and development challenges. Globally, at the end 2017, there were 1.8 million children (< 15 years) living with HIV. The survival of HIV-positive children treated with ART depends on a variety of factors, which might vary greatly with economic, socio-demographic, behavioral risk, and health factors. This study aimed to assess survival status and predictors of mortality among HIV-positive children on antiretroviral therapy at East Gojjam Zone Public hospitals, Northwest Ethiopia.

Methods

An institution-based retrospective cohort study was conducted in selected hospitals of the East Gojjam zone, Northwest Ethiopia, among < 15-year-old children who were newly enrolled in HIV care clinic from January 1st, 2014 to December 31, 2018. Data were collected from patient charts from March 1 to 22, 2019 using a standardized checklist. Data were analyzed by SPSS version 24. A Kaplan–Meier curve and log-rank test were used to estimate the survival time and compare survival curves between variables. Multivariable Cox proportional-hazards model was fitted to identify predictors of survival status taking p-value < 0.05 as statistically significant.

Result

In this study, a total of 251 HIV-positive children on ART were followed up for a total of 60 months, with a mean survival time of 55.54 (± 0.83) (95% CI: 53.90–57.17) months. The overall mortality incidence rate in the cohort during the 626 Child-Year-Observation (CYO) was 2.56/100 CYO. The overall estimated survival probability after starting ART was 0.90 at 60 months of follow-up. In this study age < 5 years, Hgb < 10 gm/dl, CD4 count below threshold, cotrimoxazole preventive therapy, and subnormal weight for height were statistically significant predictors of survival status (P < 0.05).

Conclusion and recommendation

Age, hemoglobin level, CD4 count, weight for height, and not taking cotrimoxazole preventive therapy were independent predictors of mortality. Therefore, concerned stakeholders should focus on the above-mentioned predictors of mortality and nutritional interventions to enhance the survival of HIV-infected children on antiretroviral therapy.

Attrition and associated factors among children living with HIV at a tertiary hospital in Eritrea: a retrospective cohort analysis

BACKGROUND

Reducing attrition in paediatric HIV-positive patients using combined antiretroviral therapy (cART) programmes in sub-Saharan Africa is a challenge. This study explored the rates and predictors of attrition in children started on cART in Asmara, Eritrea.

METHODS

This was a retrospective cohort study using data from all paediatric patients on cART between 2005 and 2020, conducted at the Orotta National Referral and Teaching Hospital. Kaplan-Meier estimates of the likelihood of attrition and multivariate Cox proportional hazards models were used to assess the factors associated with attrition. All p values were two sided and p<0.05 was considered statistically significant.

RESULTS

The study enrolled 710 participants with 374 boys (52.7%) and 336 girls (47.3%). After 5364 person-years' (PY) follow-up, attrition occurred in 172 (24.2%) patients: 65 (9.2%) died and 107 (15.1%) were lost to follow-up (LTFU). The crude incidence rate of attrition was 3.2 events/100 PY, mortality rate was 2.7/100 PY and LTFU was 1.2/100 PY. The independent predictors of attrition included male sex (adjusted HR (AHR)=1.6, 95% CI: 1 to 2.4), residence outside Zoba Maekel (AHR=1.5, 95% CI: 1 to 2.3), later enrolment years (2010-2015: AHR=3.2, 95% CI: 1.9 to 5.3; >2015: AHR=6.1, 95% CI: 3 to 12.2), WHO body mass index-for-age z-score <-2 (AHR=1.4, 95% CI: 0.9 to 2.1), advanced HIV disease (WHO III or IV) at enrolment (AHR=2.2, 95% CI: 1.2 to 3.9), and initiation of zidovudine+lamivudine or other cART backbones (unadjusted HR (UHR)=2, 95% CI: 1.2 to 3.2). In contrast, a reduced likelihood of attrition was observed in children with a record of cART changes (UHR=0.2, 95% CI: 0.15 to 0.4).

CONCLUSION

A low incidence of attrition was observed in this study. However, the high mortality rate in the first 24 months of treatment and late presentation are concerning. Therefore, data-driven interventions for improving programme quality and outcomes should be prioritised.

Development of a transition readiness score for adolescents living with perinatally-acquired HIV and transitioning to adult care

We created a transition readiness score for adolescents with perinatally-acquired HIV as they transition from pediatric to adult care. Of the 199 adolescents who transitioned to adult care, 84 (42%) had viral suppression (< 200 copies/ml) one year after transition. Adolescents on first-line ART, with documented HIV status disclosure, and higher rating on the HIV Adolescent Readiness to Transition Scale had significantly higher odds of viral suppression after transition. Conversely, females, those with older age at ART initiation, and those with prior alcohol use had significantly lower odds of viral suppression after transition. Using these data, we created a transition readiness score organized into low, intermediate, and high levels of transition readiness. This transition readiness score can be used to identify adolescents who are likely ready to transition to adult care and identify additional areas for intervention to improve the likelihood of successful transition for those with lower transition readiness scores.

Survival status and predictors of mortality among HIV-positive children initiated antiretroviral therapy in Bahir Dar town public health facilities Amhara region, Ethiopia, 2020

BACKGROUND

Although there is a presence of governmental and non-governmental organizations running to provide quality HIV care services to reduce HIV-related mortality, there is rapid disease progression and death among children in developing countries including Ethiopia. Thus, this study was aimed to assess the mortality predictors of children living with HIV at Bahir Dar town public health facilities.

METHOD

A facility-based retrospective follow-up study was conducted among 588 children who were enrolled in the HIV care clinic from 1 September 2010 to 30 August 2019. Data were entered into the Epi-Data entry 3.1 and then exported to STATA version 14 for analysis. Multiple imputation models were employed to handle missing data using the multivariate imputation Chained Equations technique. The Kaplan-Meier survival curve and log-rank test were used to estimate and compare the survival time of categorical variables.

RESULT

About 27 (4.6%) (95% confidence interval: 2.9-6.5) deaths were observed from the 30,062.3 person-months follow-up period, and the overall incidence density rate of 0.9 per 1000 child-months (95% confidence interval: 0.6-1.3). Advanced WHO clinical stage (adjusted hazard ratio = 3.18; 95% confidence interval: 1.07-9.43), hemoglobin level less than 8 g/dL (adjusted hazard ratio = 3.54; 95% confidence interval: 1.27-8.85), children having a weight for age of <-2z (adjusted hazard ratio = 2.81; 95% confidence interval: 1.19-6.6), children with poor adherence (adjusted hazard ratio = 3.91; 95% confidence interval: 1.41-10.8), and starting the treatment beyond 1 week of being eligible (adjusted hazard ratio = 3.22; 95% confidence interval: 1.21-8.53) were predictors of HIV-related mortality among children initiated antiretroviral therapy.

CONCLUSION

The hazard of mortality was higher among HIV-infected children in the early period of initiation. Enhancing antiretroviral therapy drug adherence, monitoring Hgb level, and timely initiation of antiretroviral therapy reduce HIV-related mortality.

Level of Attrition from Antiretroviral Therapy Among Human Immune Deficiency Virus-Infected Children: The Cases of Sidama Zone, Southern Ethiopia

Background

Human immune deficiency virus (HIV) remains one of the leading causes of infectious disease mortality and morbidity in Sub-Saharan Africa. Although remarkable progress has been made in prevention and treatment of HIV, there is a higher rate of loss to follow-up in HIV-infected children than in adults, once they enter care.

Objective

To determine the incidence and identify predictors of loss to follow-up among HIV-infected children on anti-retroviral treatment in Sidama Zone, Ethiopia.

Methods

A retrospective cohort study was done among children that were enrolled in ART care in Sidama Zone from September 2014 to August 2018. A total of 143 eligible children were included in this study. A structured checklist was used to extract data from patients’ medical records such as patient intake forms, electronic database, and registers. Data were entered, cleaned, coded, and analyzed by STATA version 12. Cox proportional hazards models were fitted to investigate predictors of loss to follow-up.

Results

Of the 143 participants, 76 (53.15%) were female children with a median age of 7 years and interquartile range of 4–9. The incidence rate was 5 per 100 person-years and the cumulative incidence 12.59%. The median follow-up time was 2.46 years and the total time at risk was 356.06 person-years. Furthermore, 55.56% and 72.22% of those lost to follow-up were within the first and the second years of follow-up, respectively. In multivariable Cox proportional model, only the TB status of the children was significantly associated with loss to follow-up with hazard ratio 3.348 [1.174831, 9.543494] and p-value of 0.024.

Conclusion

In this study, TB status of children was the significant determinant of loss to follow-up. However, the overall retention was 87.4% and a substantially higher proportion of loss was observed within the first and second years of follow-up.

Clinical Features of HIV Arthropathy in Children: A Case Series and Literature Review

Background

HIV infection has been associated with a non-erosive inflammatory arthritis in children, although few published reports exist. This study describes the clinical, laboratory and imaging features of this noncommunicable disease in a series of HIV-infected children in South Africa.

Methods

A database search was conducted to identify HIV-infected children enrolled in a Paediatric Rheumatology service in Cape Town, South Africa between 1 January 2010 and 31 December 2020. Retrospective data were collected from individuals classified with HIV arthropathy, based on a predefined checklist. Demographic, clinical, laboratory, sonographic, therapeutic, and outcomes data were extracted by chart review. Descriptive statistical analysis was performed using R (v4.0.3).

Results

Eleven cases of HIV arthropathy were included in the analysis. Cases predominantly presented in older boys with low CD4+ counts. Median age at arthritis onset was 10.3 years (IQR 6.9 – 11.6) and the male-female ratio was 3.0. The median absolute CD4+ count was 389 cells/uL (IQR 322 – 449). The clinical presentation was variable, with both oligoarthritis and polyarthritis being common. Elevated acute phase reactants were the most consistent laboratory feature, with a median ESR of 126 mL/h (IQR 67 – 136) and median CRP of 36 mg/L (IQR 25 – 68). Ultrasonography demonstrated joint effusions and synovial hypertrophy. Response to therapy was slower than has generally been described in adults, with almost all cases requiring more than one immunosuppressive agent. Five children were discharged in established remission after discontinuing immunotherapy, however outcomes data were incomplete for the remaining six cases.

Conclusions

In this case series, HIV arthropathy was associated with advanced immunosuppression. Therapeutic modalities included immunomodulators and antiretroviral therapy, which consistently induced disease remission although data were limited by a high rate of attrition. Prospective studies are needed to define and understand this HIV-associated noncommunicable disease.

Assessing the Effectiveness of a Telemedicine Initiative in Clinical Management of Children Living with HIV/AIDS in Maharashtra, India

AIMS

To evaluate the effectiveness of telemedicine in the clinical management of children living with HIV/AIDS in resource-limited settings ; Background: Telemedicine is an important mechanism for service delivery in health care settings, both in resource-rich and resource-poor settings. Such service delivery mechanisms have shown to be associated with virologic suppression and higher CD4 counts. These services are also associated with improved access, shorter visiting times, and higher patient satisfaction. ; Objective: We designed the present two-group comparison study to compare the clinical evaluation and management of children in the anti-retroviral therapy (ART) centres linked to telemedicine facility with those who are not linked to this facility in Maharashtra, India. ; Methods: We analysed clinical records from six ART centres in Maharashtra; of these, 250 children were in the linked ART centres and 301 were in the non-linked ART centres. The outcomes were classified according to investigations, management, and monitoring. For management, we evaluated: 1) Initiation of cotrimoxazole prophylaxis; 2) Children not initiated on ART when required; 3) ART regime after appropriate investigations; and 4) Change of regime (if immunologically indicated). For monitoring, we assessed the haematological monitoring of children on ART. ; Results: The mean (SD) ages of children in linked and non-linked ART centres were 10.8 (4.6) and 10.9 (4.6) years, respectively (p=0.80). After adjusting for individual and structural level variables, physical examination (OR: 2.0, 95% CI; 1.2, 3.2), screening for tuberculosis (OR: 12.9, 95% CI: 2.0, 82.9) and cotrimoxazole prophylaxis were significantly more likely in the linked centres compared with non-linked centres (OR: 1.8, 95% CI: 1.4, 2.2). A higher proportion of children eligible for ART were not initiated on treatment in the non-linked centres compared with linked centres (26% vs. 8%, p=0.06). Children were less likely to be initiated on zidovudine-based regimens without baseline haemoglobin or with baseline haemoglobin of less than 9 gm% in linked centres (OR: 0.7, 95% CI: 0.6, 0.8). Similarly, children in the linked centres were less likely to have been started on nevirapine-based regimens without baseline liver enzymes (OR: 0.8, 95% CI: 0.7, 0.9). ; Conclusion: Thus, the overall clinical management of Children Living with HIV/ AIDS (CLHA) was better in ART centres linked with the telemedicine initiative compared with those who were not linked. Children in the linked ART centres were more likely to have a complete baseline assessment (physical, hematological, radiological, and screening for TB); the presence of a pediatrician in the centres was helpful.

Long-Term Outcomes and Risk Factors for Mortality in a Cohort of HIV-Infected Children Receiving Antiretroviral Therapy in Vietnam

Background

Management of HIV-infected children on a long-term basis is a challenge in resource-limited countries. The aim of this study is to evaluate the long-term outcome and identify the risk factors for mortality in a cohort of children with antiretroviral therapy (ART) in Vietnam.

Patients and Methods

A retrospective cohort study was conducted in children aged 0-15 years, seen at the outpatient clinic of the Women and Children Hospital of An Giang, Vietnam, from August 2006 to May 2019. Cox proportional-hazard models were used to determine factors associated with mortality.

Results

A total of 266 HIV-infected children were on ART. During 1545 child-years of follow-up (median follow-up was 5.8 years), 28 (10.5%) children died yielding a mortality rate of 1.8 death per 100 child-years. By multivariate analysis, World Health Organization clinical stage 3 or 4 (AHR; 7.86, 95% CI; 1.02-60.3, P= 0.047), tuberculosis (TB) co-infection (AHR; 6.26, 95% CI; 2.50-15.64, P= 0.001) and having severe immunosuppression before ART (AHR; 11.73, 95% CI; 1.52-90.4, P= 0.018) were independent factors for mortality in these children.

Conclusion

Antiretroviral therapy has reduced mortality in HIV-infected children in resource-limited settings. Independent risk factors for mortality were advanced clinical stage (3 or 4), TB co-infection and severe immunosuppression. Early investigation and treatment of TB co-infection allow early ART initiation which may improve outcomes in our settings.

Mortality rate among HIV-positive children on ART in Northwest Ethiopia: a historical cohort study

Background

Though highly active antiretroviral therapy (HAART) has been available for more than a decade in Ethiopia, information regarding mortality rates of human immunodeficiency virus (HIV)-positive children after antiretroviral therapy antiretroviral therapy (ART) initiation is very scarce. Thus, this study intends to determine the predictors of mortality among HIV-positive children receiving ART in Amhara Region.

Methods

A multicenter facility-based historical cohort study was conducted in 538 HIV-positive children on ART from January 2012 to February 2017. We employed a standardized data extraction tool, adapted from ART entry and follow-up forms. Descriptive analyses were summarized using the Kaplan-Meier survival curve and log rank test. Then, the Cox-proportional hazard regression model was employed to estimate the hazard of death up to five-years after ART initiation. Variables with p-values ≤0.25 in bivariable analysis were candidates to the multivariable analysis. Finally, variables with p-values < 0.05 were considered as significant variables.

Results

The cohort contributed a total follow-up time of 14,600 child-months, with an overall mortality rate of 3.2 (95% CI: 2.3, 4.3) per 100 child-years. This study also indicated that HIV-infected children presenting with opportunistic infections (OIs) (AHR: 2.5, 95% CI: 1.04, 5.9), anemia (AHR: 3.1, 95% CI: 1.4, 6.7), severe immunodeficiency (AHR: 4.4, 95% CI: 1.7, 11.7), severe stunting (AHR: 3.3, 95% CI: 1.4, 8.0), severe wasting (AHR: 3.1, 95% CI: 1.3, 7.3), and advanced disease staging (III and IV) (AHR: 3.0, 95% CI: 1.2, 7.1) were at higher risk of mortality.

Conclusion

A higher rate of mortality was observed in our study as compared to previous Ethiopian studies. HIV-positive children presenting with anemia, OIs, severe immunodeficiency, advanced disease staging (III and IV), severe stunting, and severe wasting were at higher risk of mortality.

Survival of Children Living With HIV on Art in Zambia: A 13-Years Retrospective Cohort Analysis

Background: Research conducted before the introduction of anti-retroviral therapy (ART), showed that the majority of children living with HIV (CLHIV) would die before their second birthday. In Zambia, ART was rolled out to the public health system in 2004 with subsequent improved survival in CLHIV. However, the survival rates of CLHIV on ART in Zambia since 2004 have not been extensively documented. We assessed survival experiences and the factors associated with survival in CLHIV on ART in Zambia.

Methods: We conducted a retrospective cohort analysis of CLHIV (aged up to 15 years) using routinely collected data from health facilities across Zambia, over 13 years to ascertain mortality rates. We explored survival factors using Cox regression giving adjusted hazard ratios (AHR) and 95% confidence intervals (95% CI). Nelson Aalen estimates were used to show the cumulative hazards of mortality for different levels of explanatory factors.

Results: A total of 65,448 eligible children, were initiated on ART between 2005 and 2018, of which 33,483 (51%) where female. They contributed a total survival time of 275,715-person years at risk during which 3,265 children died which translated into an incidence rate of 1.1 deaths per 100 person-years during the review period. Mortality rates were highest in children in the first year of life (Mortality rate 2.24; 95% CI = 2.08–2.42) and during the first year on ART (Mortality rate 3.82 95% CI = 3.67–3.98). Over 50% of the children had been on ART for 5–10 years by 2018, and they had the lowest risk of mortality compared to children who had been on ART for <5 years.

Conclusions: Children with HIV in Zambia are surviving much longer than was predicted before ART was introduced 14 years ago. This key finding adds to the literature on analysis of survival in CLHIV in low income settings like Zambia. However, this survival is dependent on the age at which ART is initiated and the time on ART highlighting the need to increase investments in early infant diagnosis (EID) to ensure timely HIV testing and ART initiation for CLHIV.

Early treated HIV-infected children remain at risk of growth retardation during the first five years of life: Results from the ANRS-PEDIACAM cohort in Cameroon

Background

Long-term growth in HIV-infected infants treated early in resource-limited settings is poorly documented. Incidence of growth retardation, instantaneous risk of death related to malnutrition and growth parameters evolution during the first five years of life of uninfected and early treated HIV-infected children were compared and associated factors with growth retardation were identified.

Methods

Weight-for-age (WAZ), weight-for-length (WLZ), and length-for-age (LAZ) Z-scores were calculated. The ANRS-PEDIACAM cohort includes four groups of infants with three enrolled during the first week of life: HIV-infected (HI, n = 69), HIV-exposed uninfected (HEU, n = 205) and HIV-unexposed uninfected (HUU, n = 196). The last group included HIV-infected infants diagnosed before 7 months of age (HIL, n = 141). The multi-state Markov model was used to describe the incidence of growth retardation and identified associated factors.

Results

During the first 5 years, 27.5% of children experienced underweight (WAZ<-2), 60.4% stunting (LAZ<-2) and 41.1% wasting (WLZ<-2) at least once. The instantaneous risk of death observed from underweight state (35.3 [14.1–88.2], 84.0 [25.5–276.3], and 6.0 [1.5–24.1] per 1000 person-months for 0–6 months, 6–12 months, and 12–60 months respectively) was higher than from non-underweight state (9.6 [5.7–16.1], 20.1 [10.3–39.4] and 0.3 [0.1–0.9] per 1000 person-months). Compared to HEU, HIL and HI children were most at risk of wasting (adjusted HR (aHR) = 4.3 (95%CI: 1.9–9.8), P<0.001 and aHR = 3.3 (95%CI: 1.4–7.9), P = 0.01 respectively) and stunting for HIL (aHR = 8.4 (95%CI: 2.4–29.7). The risk of underweight was higher in HEU compared to HUU children (aHR = 5.0 (CI: 1.4–10.0), P = 0.001). Others associated factors to growth retardation were chronic pathologies, small size at birth, diarrhea and CD4< 25%.

Conclusions

HIV-infected children remained at high risk of wasting and stunting within the first 5 years period of follow-up. There is a need of identifying suitable nutritional support and best ways to integrate it with cART in pediatric HIV infection global care.

Late antiretroviral therapy initiation and associated factors among children on antiretroviral therapy at University of Gondar Comprehensive Specialized Hospital, Gondar, Northwest Ethiopia: a cross-sectional study

Objective

Highly active antiretroviral therapy reduces HIV related morbidity and mortality dramatically. Despite this fact, late ART initiation poses poor treatment outcome in pediatrics. However, the information is scarce in Ethiopia. Therefore, the study was aimed at determining the burden of late ART initiation and its associated factors among children on ART. Cross-sectional study was conducted among 422 children selected by simple random sampling. Patient charts were reviewed using pretested and structured data abstraction tool. Binary logistic regression model was fitted.

Results

A total of 402 child records with a completeness rate of 95.3% were included. The overall proportion of late antiretroviral therapy initiation among children on antiretroviral therapy was 53.2% (95% CI 48.5–58.4%). Under-5 years of age [AOR: 2.165 (95% CI 1.341, 3.495)], rural residence [AOR: 1.825 (95% CI 1.052, 3.166)], taking non-ART medication [AOR: 2.237 (95% CI 1.212, 4.130)], past opportunistic infection [AOR: 2.548 (95% CI 1.554, 4.178)], unmarried caregiver [AOR: 1.618 (95% CI 1.023, 2.559)], male caregiver [AOR: 1.903 (95% CI 1.026–3.527)] and null ANC visit [AOR: 1.721 (95% CI 1.077, 2.752)] were significantly associated factors. There is high burden of late ART initiation in children. Thus, focus should be started from pregnancy.

Survival rate of HIV-infected children after initiation of the antiretroviral therapy and its predictors in Ethiopia: A facility-based retrospective cohort

Objective:

To determine the survival rate and predictors of HIV-infected children on antiretroviral therapy at two selected facilities in North Ethiopia.

Methods:

A facility-based retrospective cohort study was conducted in Debre Tabor General Hospital and Dessie Referral Hospital from December 2005 to November 2015. A total of 426 records were included in the study. Multivariable Cox proportional hazards regression model was used to identify independent predictors of survival.

Results:

At the end of follow-up, 97 (22.9%) HIV-infected children died and 325 (77.1%) were alive. The probabilities of survival at 12, 24, 36 and 48 months of on antiretroviral therapy were 0.91, 0.85, 0.84 and 0.80, respectively. The median survival time was 91.6 months (95% confidence interval: 89.0–94.2). Almost half (51%) of the deaths occurred within the first 2 years of treatment. Study participants who had poor adherence to antiretroviral therapy (adjusted hazard ratio = 3.0; 95% confidence interval: 1.2–7.5) and who started antiretroviral therapy with lower baseline weight-for-age Z-score (adjusted hazard ratio = 2.5; 95% confidence interval: 1.1–6.1) were significantly associated with high risk of mortality. On the other hand, study participants with a baseline CD4 count above 200 cells/mm³ (adjusted hazard ratio = 0.7; 95% confidence interval: 0.4–0.9) and those participants who had psychosocial support during follow-up (adjusted hazard ratio = 0.03; 95% confidence interval: 0.1–0.7) were significantly associated with less mortality event.

Conclusion:

Mortality of children on antiretroviral therapy was high. The risk of mortality is increased if the child was underweight at the commencement of antiretroviral therapy, had lower baseline CD4 count, had poor adherence to antiretroviral therapy and had no psychosocial support. Concerned stakeholders should focus on antiretroviral therapy adherence, nutritional interventions, psychological support and early initiation of antiretroviral therapy regardless of their CD4 count to enhance survival of HIV-infected children on antiretroviral therapy.

Temporal Trends in Co-trimoxazole Use Among Children on Antiretroviral Therapy and the Impact of Co-trimoxazole on Mortality Rates in Children Without Severe Immunodeficiency

BACKGROUND

Co-trimoxazole is recommended for all children with human immunodeficiency virus. In this analysis, we evaluate trends in pediatric co-trimoxazole use and survival on co-trimoxazole in children using antiretroviral therapy (ART).

METHODS

We used data collected between January 1, 2006, and March 31, 2016, from the International Epidemiology Databases to Evaluate AIDS. Logistic regression was used to evaluate factors associated with using co-trimoxazole at ART initiation. Competing risk regression was used to assess factors associated with death.

RESULTS

A total of 54113 children were included in this study. The prevalence of co-trimoxazole use at ART initiation increased from 66.5% in 2006 to a peak of 85.6% in 2010 and then declined to 48.5% in 2015-2016. A similar trend was observed among children who started ART with severe immunodeficiency. After adjusting for year of ART initiation, younger age (odds ratio [OR], 1.18 for <1 vs 1 to <5 years of age [95% confidence interval (CI), 1.09-1.28]), lower height-for-age z score (OR, 1.15 for less than -3 vs greater than -2 [95% CI, 1.08-1.22]), anemia (OR, 1.08 [95% CI, 1.02-1.15]), severe immunodeficiency (OR, 1.25 [95% CI, 1.18-1.32]), and receiving care in East Africa (OR, 8.97 vs Southern Africa [95% CI, 8.17-9.85]) were associated with a high prevalence of co-trimoxazole use. Survival did not differ according to co-trimoxazole use in children without severe immunodeficiency (hazard ratio, 1.01 for nonusers versus users [95% CI, 0.77-1.34]).

CONCLUSIONS

Recent declines in co-trimoxazole use may not be linked to the current shift toward early ART initiation. Randomized trial data might be needed to establish the survival benefit of co-trimoxazole in children without severe immunodeficiency.

Mortality in a Cohort of HIV-Infected Children: A 12-Month Outcome of Antiretroviral Therapy in Makurdi, Nigeria

INTRODUCTION

Recognizing the predictors of mortality among HIV-infected children will allow for concerted management that can reduce HIV-mortality in Nigeria.

METHODOLOGY

A retrospective cohort study in children aged 0-15 years, between October 2010 and December 2013, at the Federal Medical Centre, Makurdi, Nigeria. Kaplan-Meier method analysed the cumulative probability of early mortality (EM) occurring at or before 6 months and after 6 months of follow-up (late mortality-LM) on a 12-month antiretroviral therapy (ART). Multivariate Cox proportional regression models were used to test for hazard ratios (HR).

RESULTS

368 children were included in the analysis contributing 81 children per 100 child-years to the 12-month ART follow-up. A significant reduction in EM rates was noted at 17.3 deaths per 100 child-years (30 deaths) to LM rates of 3.0 deaths per 100 child-years (10 deaths), p < 0.01. At multivariate analysis, children with a high pretreatment viral load (≥10,000 copies/ml) were found to be at risk of EM (aHR; 18. 089, 95% CI; 2.428-134.77, p=0.005). Having severe immunosuppression at/or before 6 months of ART was the predictor of LM (aHR; 17.28, 95% CI; 3.844-77.700, p ≤ 0.001).

CONCLUSIONS

Although a lower mortality rate is seen at 12 months of ART in our setting, predictors of HIV mortality are having high pretreatment HIV viral load and severe immunosuppression. While primary prevention of HIV infection is paramount, early identification of these predictors among our HIV-infected children for an early ART initiation can reduce further the mortality in our setting. In addition, measures to ensure a good standard of care and retention in care for a sustained virologic suppression cannot be ignored and are hereby underscored.

Effects of undernutrition on survival of human immunodeficiency virus positive children on antiretroviral therapy

Background

The relationship between undernutrition and HIV is bidirectional, ultimately contributing to quality of life and survival of affected individuals. Ethiopia is a sub-Saharan nation influenced by both undernutrition and HIV. In Ethiopia, although individuals are often dually impacted, the effect of undernutrition on the survival of HIV positive children on anti-retroviral therapy (ART) has not been well investigated. Therefore, this study assessed the effect of undernutrition on survival rates of HIV positive children on ART in Amhara Regional State of Ethiopia.

Methods

An institution-based retrospective cohort study was conducted among 390 HIV positive children on ART from the 1st of January, 2012 to the 28th of February, 2017 in Amhara Regional State Referral Hospitals. A simple random sampling technique was used to select the study participants. Data were extracted by reviewing patients’ ART intake and follow-up forms. Data were entered into Epi-Data Version 3.1, and analysis was done using STATA Version 13. The Kaplan-Meier survival curve was used to estimate the cumulative survival time of the sample. Log rank tests were employed to compare the survival time between different categories of explanatory variables. Bivariable and multivariable Cox proportional hazards models were fitted to identify predictors of mortality.

Results

Among the 390 records included in the final analysis, 9.7% of the individuals died within the follow-up period. In this study, the overall mortality rate was found to be 4.4 per 100 child-years (95% CI: 3.2, 6.0) while undernourished children had a lower survival time than well-nourished children. Low hemoglobin level (AHR: 3.2, 95% CI: 1.4, 7.4), CD4 cell count or percent below the threshold (AHR: 5.2, 95% CI: 1.9, 14.1), severe stunting (AHR: 3.9, 95% CI: 1.7, 9.4), severe wasting (AHR: 3.0, 95% CI: 1.3, 6.9) and advanced disease stage (III and IV) (AHR: 2.6, 95% CI: 1.1, 6.6) were found to be predictors of mortality.

Conclusion

There was a high rate of mortality. A significant difference was observed in the survival rate of undernourished and well-nourished children. Low hemoglobin level, CD4 count or percent below the threshold, severe wasting, severe stunting, and advanced disease stage were found to be predictors of mortality.

Long-term trends in mortality and AIDS-defining events after combination ART initiation among children and adolescents with perinatal HIV infection in 17 middle- and high-income countries in Europe and Thailand: A cohort study

BACKGROUND

Published estimates of mortality and progression to AIDS as children with HIV approach adulthood are limited. We describe rates and risk factors for death and AIDS-defining events in children and adolescents after initiation of combination antiretroviral therapy (cART) in 17 middle- and high-income countries, including some in Western and Central Europe (W&CE), Eastern Europe (Russia and Ukraine), and Thailand.

METHODS AND FINDINGS

Children with perinatal HIV aged <18 years initiating cART were followed until their 21st birthday, transfer to adult care, death, loss to follow-up, or last visit up until 31 December 2013. Rates of death and first AIDS-defining events were calculated. Baseline and time-updated risk factors for early/late (≤/>6 months of cART) death and progression to AIDS were assessed. Of 3,526 children included, 32% were from the United Kingdom or Ireland, 30% from elsewhere in W&CE, 18% from Russia or Ukraine, and 20% from Thailand. At cART initiation, median age was 5.2 (IQR 1.4-9.3) years; 35% of children aged <5 years had a CD4 lymphocyte percentage <15% in 1997-2003, which fell to 15% of children in 2011 onwards (p < 0.001). Similarly, 53% and 18% of children ≥5 years had a CD4 count <200 cells/mm3 in 1997-2003 and in 2011 onwards, respectively (p < 0.001). Median follow-up was 5.6 (2.9-8.7) years. Of 94 deaths and 237 first AIDS-defining events, 43 (46%) and 100 (42%) were within 6 months of initiating cART, respectively. Multivariable predictors of early death were: being in the first year of life; residence in Russia, Ukraine, or Thailand; AIDS at cART start; initiating cART on a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen; severe immune suppression; and low BMI-for-age z-score. Current severe immune suppression, low current BMI-for-age z-score, and current viral load >400 c/mL predicted late death. Predictors of early and late progression to AIDS were similar. Study limitations include incomplete recording of US Centers for Disease Control (CDC) disease stage B events and serious adverse events in some countries; events that were distributed over a long time period, and that we lacked power to analyse trends in patterns and causes of death over time.

CONCLUSIONS

In our study, 3,526 children and adolescents with perinatal HIV infection initiated antiretroviral therapy (ART) in countries in Europe and Thailand. We observed that over 40% of deaths occurred ≤6 months after cART initiation. Greater early mortality risk in infants, as compared to older children, and in Russia, Ukraine, or Thailand as compared to W&CE, raises concern. Current severe immune suppression, being underweight, and unsuppressed viral load were associated with a higher risk of death at >6 months after initiation of cART.

Brief Report: AIDS-Defining Events and Deaths in HIV-Infected Children and Adolescents on Antiretrovirals: A 14-Year Study in Thailand

BACKGROUND

Data are scarce on the long-term clinical outcomes of perinatally HIV-infected children and adolescents receiving antiretroviral therapy (ART) in low/middle-income countries. We assessed the incidence of mortality before (early) and after (late) 6 months of ART and of the composite outcome of new/recurrent AIDS-defining event or death >6 months after ART start (late AIDS/death) and their associated factors.

METHODS

Study population was perinatally HIV-infected children (≤18 years) initiating ART within the Program for HIV Prevention and Treatment observational cohort (NCT00433030). Factors associated with late AIDS/death were assessed using competing risk regression models accounting for lost to-follow-up and included baseline and time-updated variables.

RESULTS

Among 619 children, "early" mortality incidence was 99 deaths per 1000 person-years of follow-up [95% confidence interval (CI): 69 to 142] and "late" mortality 6 per 1000 person-years of follow-up (95% CI: 4 to 9). Of the 553 children alive >6 months after ART initiation, median age at ART initiation was 6.4 years, CD4% 8.2%, and HIV-RNA load 5.1 log10 copies/mL. Thirty-eight (7%) children developed late AIDS/death after median time of 3.3 years: 24 died and 24 experienced new/recurrent AIDS-defining events (10 subsequently died). Factors independently associated with late AIDS/death were current age ≥13 years (adjusted subdistribution hazard ratio 4.9; 95% CI: 2.4 to 10.1), HIV-RNA load always ≥400 copies/mL (12.3; 95% CI: 4.0 to 37.6), BMI-z-score always <-2 SD (13.7; 95% CI: 3.4 to 55.7), and hemoglobin <8 g/dL at least once (4.6; 95% CI: 2.0 to 10.5).

CONCLUSIONS

After the initial 6 months of ART, being an adolescent, persistent viremia, poor nutritional status, and severe anemia were associated with poor clinical outcomes. This supports the need for novel interventions that target children, particularly adolescents with poor growth and uncontrolled viremia.

Higher retention and viral suppression with adolescent-focused HIV clinic in South Africa

Objective

To determine retention in care and virologic suppression among HIV-infected adolescents and young adults attending an adolescent-friendly clinic compared to those attending the standard pediatric clinic at the same site.

Design

Retrospective cohort analysis.

Setting

Government supported, hospital-based antiretroviral clinic in KwaZulu-Natal, South Africa.

Participants

Two hundred forty-one perinatally HIV-infected adolescents and young adults aged 13 to 24 years attending an adolescent-friendly clinic or the standard pediatric clinic from April 2007 to November 2015.

Intervention

Attendance in an adolescent-friendly clinic compared to a standard pediatric clinic.

Outcomes measures

Retention in care defined as one clinic visit or pharmacy refill in the prior 6 months; HIV-1 viral suppression defined as < 400 copies/ml.

Results

Overall, among 241 adolescents and young adults, retention was 89% (214/241) and viral suppression was 81% (196/241). Retention was higher among those attending adolescent clinic (95%) versus standard pediatric clinic (85%; OR 3.7; 95% confidence interval (CI) 1.2–11.1; p = 0.018). Multivariable logistic regression adjusted for age at ART initiation, gender, pre-ART CD4 count, months on ART, and tuberculosis history indicated higher odds of retention in adolescents and young adults attending adolescent compared to standard clinic (AOR = 8.5; 95% CI 2.3–32.4; p = 0.002). Viral suppression was higher among adolescents and young adults attending adolescent (91%) versus standard pediatric clinic (80%; OR 2.5; 95% CI 1.1–5.8; p = 0.028). A similar multivariable logistic regression model indicated higher odds of viral suppression in adolescents and young adults attending adolescent versus standard pediatric clinic (AOR = 3.8; 95% CI 1.5–9.7; p = 0.005).

Conclusion

Adolescents and young adults attending an adolescent-friendly clinic had higher retention in care and viral suppression compared to adolescents attending the standard pediatric clinic. Further studies are needed to prospectively assess the impact of adolescent-friendly services on these outcomes.

Survival of HIV-1 vertically infected children

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.

Survival Estimates and Mortality Risk Factors in a Cohort of HIV Vertically Infected Individuals in Salvador, Brazil

BACKGROUND

There are few data on long-term survival of Brazilian children with vertically acquired HIV infection. We assessed survival, mortality risk factors and response to antiretroviral therapy (ART). We compared children with early and late access to care.

METHODS

We used Kaplan-Meier survival curves with Log-rank tests to compare survival time and mortality rates of 245 HIV vertically infected children admitted for care during 2002-2014.

RESULTS

Total follow-up sum was 1584.4 person-years. Overall survival was 83.9%. Median age at start of ART was 51.6 (18.0-94.2) months, and median age at death was 8.2 (1.7-10.1) years (mortality rate: 1.7/100 person-years). Pneumonia and sepsis were the main causes of death. Male gender, viral load (VL) ≥100,000 copies, severe immunosuppression, moderate/severe symptoms and history of opportunistic infection were associated with higher mortality in bivariate analysis. Only severe symptoms remained associated in multivariate analysis (P = 0.03). There was no difference in mortality in early compared to late access group. Overall, 217 patients received ART; 192 had a recent VL, of which 116 (59.8%) had ≤400 copies. Variables associated with therapeutic failure were as follows: VL ≥100,000 copies, less immune suppression, age <12 months at admission and age <3 years at ART start.

CONCLUSIONS

We have a high mortality rate in comparison with developed countries. Although early access did not impact mortality, we detected a trend in favor of early treatment as a protecting factor against mortality. We need to increase adherence to care and treatment, and better drugs to optimize outcomes.

Characteristics of HIV-Infected Children at Enrollment into Care and at Antiretroviral Therapy Initiation in Central Africa

Background

Despite the World Health Organization (WHO) regularly updating guidelines to recommend earlier initiation of antiretroviral therapy (ART) in children, timely enrollment into care and initiation of ART in sub-Saharan Africa in children lags behind that of adults. The impact of implementing increasingly less restrictive ART guidelines on ART initiation in Central Africa has not been described.

Materials and Methods

Data are from the Central Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) pediatric cohort of 3,426 children (0–15 years) entering HIV care at 15 sites in Burundi, DRC, and Rwanda. Measures include CD4 count, WHO clinical stage, age, and weight-for-age Z score (WAZ), each at enrollment into HIV care and at ART initiation. Changes in the medians or proportions of each measure by year of enrollment and year of ART initiation were assessed to capture potential impacts of changing ART guidelines.

Results

Median age at care enrollment decreased from 77.2 months in 2004–05 to 30.3 months in 2012–13. The median age at ART initiation (n = 2058) decreased from 83.0 months in 2004–05 to 66.9 months in 2012–13. The proportion of children ≤24 months of age at enrollment increased from 12.7% in 2004–05 to 46.7% in 2012–13, and from 9.6% in 2004–05 to 24.2% in 2012–13 for ART initiation. The median CD4 count at enrollment into care increased from 563 (IQR: 275, 901) in 2004–05 to 660 (IQR: 339, 1071) cells/μl in 2012–13, and the median CD4 count at ART initiation increased from 310 (IQR:167, 600) in 2004–05 to 589 (IQR: 315, 1113) cells/μl in 2012–13. From 2004–05 to 2012–13, median WAZ improved from -2 (IQR: -3.4, -1.1) to -1 (IQR: -2.5, -0.2) at enrollment in care and from -2 (IQR: -3.8, -1.6) to -1 (IQR: -2.6, -0.4) at ART initiation.

Discussion and Conclusion

Although HIV-infected children ≤24 months of age accounted for half of all children enrolling in care in our cohort during 2012–13, they represented less than a quarter of all those who were initiated on ART during the same period. Further research is needed to identify barriers to timely diagnosis, linkage to care, and initiation of ART among children with HIV infection.

Mortality among pulmonary tuberculosis and HIV-1 co-infected Nigerian children being treated for pulmonary tuberculosis and on antiretroviral therapy: a retrospective cohort study

BACKGROUND

Mortality data, including the risk factors for mortality in HIV-infected children with pulmonary TB (PTB) being treated for PTB and who are on antiretroviral therapy (ART), are scarce in Nigeria. We determined the mortality rate and risk factors for mortality among such children, at the pediatric HIV clinic of the Jos University Teaching Hospital (JUTH) in Jos, Nigeria.

METHODS

We performed a retrospective cohort study on 260 PTB-HIV-1 co-infected children, aged 2 months to 13 years, being treated for PTB and on ART from July 2005 to March 2013. The mortality rate and associated risk factors were determined using multivariate Cox proportional hazards modelling.

RESULTS

The mortality rate for the study cohort was 1.4 per 100 child-years of follow-up. Median follow-up time was 5.2 years (IQR, 3.5-6.0 years) with total study time being 1159 child-years. The median age of those who died was lower than that of survivors, 1.9 years (IQR, 0.6-3.6 years) versus 3.8 years (IQR, 1.8-6.0 years), p=0.005). The majority of the deaths occurred in males (13, 81.2%), those <5 years of age (14, 87.4%) and those who had severe immunosuppression (11, 68.8%). Risk factors for death were age (with the risk of dying decreasing by 25% for every 1 year increase in age, adjusted hazard ratio (AHR)=0.75 [0.58-0.98], p=0.032), male gender (AHR=3.80 [1.07-13.5], p=0.039) and severe immunosuppression (AHR=3.35 [1.16-9.66], p=0.025).

CONCLUSION

In our clinic setting, mortality among our PTB-HIV co-infected children being treated for PTB and on ART was low. However, those presenting with severe immunosuppression and who are males and very young, should be monitored more closely during follow-up in order to further reduce mortality.

Predictors of mortality among HIV-infected children receiving highly active antiretroviral therapy

BACKGROUND AND OBJECTIVES

The mortality rate of HIV-infected children can be reversed under highly active antiretroviral therapy (HAART). The impact of HAART on the mortality of HIV-infected children in Cameroon has not been extensively documented. We aimed to measure the mortality rate of HIV-infected children under HAART and to identify predictive factors of mortality.

METHODS

Retrospective cohort study of 221 children initiated on HAART from 2005 to 2009 and followed-up until 2013. Survival data was analyzed using Kaplan Meier method and Cox regression model to identify independent predictors of child mortality on HAART.

RESULTS

Overall, 9.9% of children (n=22) died over a follow-up period of 755 child-years (mortality of 2.9 per 100 child-years); 70% of deaths occurred during the first six months of HAART. The probability of survival after four years of treatment was 88.7% (95% CI=[84.2-93.3]). During the multivariate analysis of baseline variables, we observed that the WHO clinical stages III and IV (HR: 3.55 [1.09-13.6] and HR: 7.7 [3.07-31.2]) and age≤1year at HAART initiation were independently associated with death (HR: 2.1 [1.01-5.08]). Neither orphanhood, baseline CD4 count or hemoglobin level nor low nutritional status predicted death in this cohort.

CONCLUSION

The mortality of children receiving HAART was low after five years of follow-up and it was strongly associated with WHO stages III and IV and a younger age at treatment initiation.

Predictors of Mortality and Mortality Rate in a Cohort of Children Living with HIV from India

OBJECTIVES

To study the predictors of mortality and mortality rate in a clinical cohort of Children Living with Human Immunodeficiency Virus infection (CLHIV) from India.

METHODS

This retrospective cohort analysis of CLHIV aged between 2 mo and 18 y registered during January 2004 through December 2014 at Pediatric Centre of Excellence (PCOE), Indira Gandhi Institute of Child Health (IGICH), was conducted using standard data collection sheet. Demographic and clinical characteristics of all eligible children were analyzed. The primary outcome measured was mortality. The authors also analyzed the cause of death and baseline parameters associated with death to study the predictors of mortality.

RESULTS

Out of 1289 CLHIV registered in the PCOE during the study period, 834 (64.7 %) CLHIV, with or without antiretroviral therapy (ART) care, were included. The total time contributed by the study participants was 2872.8 child-years. The mortality rate in these children was 4.9/100 child-years. A significantly higher mortality rate of 28.2 % was found in children < 5 y, 38.6 % in children with advanced WHO clinical staging, 35.2 % among severely immunosuppressed children and 22.3 % in severely malnourished children. Tuberculosis accounted for 28 % of deaths. Univariate Cox regression analysis showed treatment status, age <5 y, baseline WHO clinical stage 3 and 4, severe immune suppression and severe malnutrition were strongly associated with mortality.

CONCLUSIONS

The mortality rate in the index study cohort was 4.9/100 child-years and tuberculosis was the major cause of death. Younger age, baseline advanced clinical and immunological staging were predictors of mortality. Even though mortality was significantly higher in Pre-ART children, treatment status was not found to be an independent predictor of mortality.

Baseline Inflammatory Biomarkers Identify Subgroups of HIV-Infected African Children With Differing Responses to Antiretroviral Therapy

BACKGROUND

Identifying determinants of morbidity and mortality may help target future interventions for human immunodeficiency virus (HIV)-infected children.

METHODS

CD4(+) T-cell count, HIV viral load, and levels of biomarkers (C-reactive protein, tumor necrosis factor α [TNF-α], interleukin 6 [IL-6], and soluble CD14) and interleukin 7 were measured at antiretroviral therapy (ART) initiation in the ARROW trial (case-cohort design). Cases were individuals who died, had new or recurrent World Health Organization clinical stage 4 events, or had poor immunological response to ART.

RESULTS

There were 115 cases (54 died, 45 had World Health Organization clinical stage 4 events, and 49 had poor immunological response) and 485 controls. Before ART initiation, the median ages of cases and controls were 8.2 years (interquartile range [IQR], 4.4-11.4 years) and 5.8 years (IQR, 2.3-9.3 years), respectively, and the median percentages of lymphocytes expressing CD4 were 4% (IQR, 1%-9%) and 13% (IQR, 8%-18%), respectively. In multivariable logistic regression, cases had lower age-associated CD4(+) T-cell count ratio (calculated as the ratio of the subject's CD4(+) T-cell count to the count expected in healthy individuals of the same age; P < .0001) and higher IL-6 level (P = .002) than controls. Clustering biomarkers and age-associated CD4(+) and CD8(+) T-cell count ratios identified 4 groups of children. Group 1 had the highest frequency of cases (41% cases; 16% died) and profound immunosuppression; group 2 had similar mortality (23% cases; 15% died), but children were younger, with less profound immunosuppression and high levels of inflammatory biomarkers and malnutrition; group 3 comprised young children with moderate immunosuppression, high TNF-α levels, and high age-associated CD8(+) T-cell count ratios but lower frequencies of events (12% cases; 7% died); and group 4 comprised older children with low inflammatory biomarker levels, lower HIV viral loads, and good clinical outcomes (11% cases; 5% died).

CONCLUSIONS

While immunosuppression is the major determinant of poor outcomes during ART, baseline inflammation is an additional important factor, identifying a subgroup of young children with similar mortality. Antiinflammatory interventions may help improve outcomes.

Retention of HIV-Infected Children in the First 12 Months of Anti-Retroviral Therapy and Predictors of Attrition in Resource Limited Settings: A Systematic Review

Current UNAIDS goals aimed to end the AIDS epidemic set out to ensure that 90% of all people living with HIV know their status, 90% initiate and continue life-long anti-retroviral therapy (ART), and 90% achieve viral load suppression. In 2014 there were an estimated 2.6 million children under 15 years of age living with HIV, of which only one-third were receiving ART. Little literature exists describing retention of HIV-infected children in the first year on ART. We conducted a systematic search for English language publications reporting on retention of children with median age at ART initiation less than ten years in resource limited settings. The proportion of children retained in care on ART and predictors of attrition were identified. Twelve studies documented retention at one year ranging from 71–95% amongst 31877 African children. Among the 5558 children not retained, 4082 (73%) were reported as lost to follow up (LFU) and 1476 (27%) were confirmed to have died. No studies confirmed the outcomes of children LFU. Predictors of attrition included younger age, shorter duration of time on ART, and severe immunosuppression. In conclusion, significant attrition occurs in children in the first 12 months after ART initiation, the majority attributed to LFU, although true outcomes of children labeled as LFU are unknown. Focused efforts to ensure retention and minimize early mortality are needed as universal ART for children is scaled up.

Antiretroviral Therapy in Children Less Than 24 Months of Age at Pediatric HIV Centers in Tanzania: 12-Month Clinical Outcomes and Survival

BACKGROUND

Without antiretroviral therapy (ART), approximately one-half of HIV-infected infants will die by two years. In 2010, the World Health Organization (WHO) recommended that all HIV-infected infants < 24 months be initiated on ART regardless of their clinical/immunologic status. However, there remains little published data detailing cohorts of infants on ART in Sub-Saharan Africa. This study describes baseline characteristics and 12 month outcomes of a cohort of HIV-infected children < 24 months of age at pediatric HIV centers in Mwanza and Mbeya, Tanzania.

MATERIALS AND METHODS

Retrospective chart review.

INCLUSION CRITERIA

children < 24 months of age, initiated on ART at Baylor Children s Foundation Tanzania clinics, between March-December 2011.

RESULTS

Baseline: Ninety-three children were initiated on ART at a median age of 13.4 months. Sixty-seven percent had severe immunosuppression and 31.5% had severe malnutrition.

OUTCOME

Seventy-three patients were still in care at 12 month follow-up, there were four (4.3%) deaths, five (5.4%) patients transferred, and 11 (11.8%) loss to follow-up. Average CD4% was 32.7 (p < 0.001). Ninety percent of patients were WHO treatment stage I (p < 0.001). Eighty-six percent had normal nutritional status (p < 0.001).

CONCLUSION

Our cohort of HIV infected children < 24 months initiated on ART did well clinically at 12 month outcomes despite being severely immunocompromised and malnourished at baseline. Nevirapine based regimens had good 12 month clinical outcomes, regardless of maternal exposure. Loss to follow-up rate was high for our cohort, demonstrating the need to develop strong mechanisms to counteract this.

Leaf concentrate compared with skimmed milk as nutritional supplementation for HIV-infected children: a randomized controlled trial in Burundi

OBJECTIVE

The effectiveness of leaf concentrate powder (LCP) as a nutritional supplement was established in trials conducted among adolescent girls and pregnant women in India. Here we evaluate LCP, compared with skimmed milk powder (SMP), as a supplement for antiretroviral-naïve children living with HIV in a sub-Saharan African country.

DESIGN

Randomized controlled, two-arm, 6-month trial comparing effects of isoproteic (5 g) LCP (10 g daily) and SMP (15 g daily) on HIV-1 viral load, CD4+ cell count/percentage, weight/height-for-age, general blood parameters, diarrhoea, respiratory and HIV-related opportunistic infections.

SETTING

Bujumbura and Kirundo, Burundi.

SUBJECTS

Eighty-three HIV-positive, antiretroviral-naïve children aged 5-14 years: median (range) CD4+ count, 716 (361-1690) cells/mm3; log10 HIV-1 viral load, 4·39 (1·79-6·00).

RESULTS

LCP was equivalent to SMP in relation to HIV-specific blood parameters and did not demonstrate superiority over SMP in relation to Hb. Three children in each arm (LCP, 7·1 % (3/42); SMP, 7·3 % (3/41)) proceeded to antiretroviral therapy because their CD4+ counts fell below 350 cells/mm3. Children in the LCP group reported higher levels of appetite and overall health at 6 months. There were no differences in clinical events or any other outcome measures. LCP was less palatable than SMP to the children in this population, but there were few negative perceptions of appearance, texture and taste.

CONCLUSIONS

LCP appears to be equivalent to SMP as a nutritional supplement in this population, despite slightly lower palatability. In relation to viral load and CD4+ count, equivalence may indicate no effect in either group. Effectiveness relative to no supplementation remains to be determined.

Sex Differences in Antiretroviral Therapy Initiation in Pediatric HIV Infection

The incidence and severity of infections in childhood is typically greater in males. The basis for these observed sex differences is not well understood, and potentially may facilitate novel approaches to reducing disease from a range of conditions. We here investigated sex differences in HIV-infected children in relation to antiretroviral therapy (ART) initiation and post-treatment outcome. In a South African cohort of 2,101 HIV-infected children, we observed that absolute CD4+ count and CD4% were significantly higher in ART-naïve female, compared to age-matched male, HIV-infected children. Absolute CD4 count and CD4% were also significantly higher in HIV-uninfected female versus male neonates. We next showed that significantly more male than female children were initiated on ART (47% female); and children not meeting criteria to start ART by >5 yrs were more frequently female (59%; p<0.001). Among ART-treated children, immune reconstitution of CD4 T-cells was more rapid and more complete in female children, even after adjustment for pre-ART absolute CD4 count or CD4% (p=0.011, p=0.030, respectively). However, while ART was initiated as a result of meeting CD4 criteria less often in females (45%), ART initiation as a result of clinical disease in children whose CD4 counts were above treatment thresholds occurred more often in females (57%, p<0.001). The main sex difference in morbidity observed in children initiating ART above CD4 thresholds, above that of TB disease, was as a result of wasting and stunting observed in females with above-threshold CD4 counts (p=0.002). These findings suggest the possibility that optimal treatment of HIV-infected children might incorporate differential CD4 treatment thresholds for ART initiation according to sex.

Challenges of malnutrition care among HIV-infected children on antiretroviral treatment in Africa

More than 90% of the estimated 3.2 million children with HIV worldwide, at the end of 2013, were living in sub-Saharan Africa. The management of these children was still difficult in 2014 despite the progress in access to antiretroviral drugs. A great number of HIV-infected children are not diagnosed at 6 weeks and start antiretroviral treatment late, at an advanced stage of HIV disease complicated by other comorbidities such as malnutrition. Malnutrition is a major problem in the sub-Saharan Africa global population; it is an additional burden for HIV-infected children because they do not respond as well as non-infected children to the usual nutritional care. HIV infection and malnutrition interact, creating a vicious circle. It is important to understand the relationship between these 2 conditions and the effect of antiretroviral treatment on this circle to taking them into account for an optimal management of pediatric HIV. An improved monitoring of growth during follow-up and the introduction of a nutritional support among HIV-infected children, especially at antiretroviral treatment initiation, are important factors that could improve response to antiretroviral treatment and optimize the management of pediatric HIV in resource-limited countries.

Nutritional Status and Other Baseline Predictors of Mortality among HIV-Infected Children Initiating Antiretroviral Therapy in Tanzania

BACKGROUND

We assembled a prospective cohort of 3144 children less than 15 years of age initiating antiretroviral therapy (ART) in Dar es Salaam, Tanzania.

METHODS

The relationships of nutritional status and other baseline characteristics in relation to mortality were examined using Cox proportional hazards model.

RESULTS

Compared with children with weight for age (WAZ) > -1, those with WAZ ≤ -2 to < -3 had a nearly double risk of death (relative risk [RR], 1.85; 95% confidence interval [CI], 1.10-3.11), and among those with WAZ ≤ -3, the risk more than tripled (RR, 3.36; 95% CI, 2.12-5.32). Other baseline risk factors for overall mortality included severe anemia (P < .001), severe immune suppression (P = .02), history of tuberculosis (P = .01), opportunistic infections (P < .001), living in the poorest district (P < .001), and advanced World Health Organization stage (P = .003).

CONCLUSIONS

To sustain the obtained benefit of ART in this setting, interventions to improve nutritional status may be used as an adjunct to ART.

Systematic review of retention of pediatric patients on HIV treatment in low and middle-income countries 2008-2013

OBJECTIVES

There are several published systematic reviews of adult retention in care after antiretroviral therapy (ART) initiation among adults, but limited information on pediatric retention.

DESIGN

Systematic review of pediatric retention on ART in low and middle-income countries during 2008-2013.

METHODS

We estimated all-cause attrition (death and loss to follow-up) and retention for pediatric patients receiving first-line ART in routine settings. We searched PubMed, Embase, Cochrane Register, and ISI Web of Science (January 2008-January 2014) and abstracts from AIDS and IAS (2008-2013). We estimated mean retention across cohorts using simple averages; interpolated any time period not reported to, up to the last period reported; summarized total retention in the population using Kaplan-Meier survival curves; and compared pediatric to adult retention.

RESULTS

We found 39 reports of retention in 45 patient cohorts and 55 904 patients in 23 countries. Among them, 37% of patients not retained in care were known to have died and 63% were lost to follow-up. Unweighted averages of reported retention were 85, 81, and 81% at 12, 24, and 36 months after ART initiation. From life-table analysis, we estimated retention at 12, 24, and 36 months at 88, 72, and 67%. We estimated 36-month retention at 66% in Africa and 74% in Asia.

CONCLUSION

Pediatric ART retention was similar to that among adults. There were limited data from Asia, only one study from Latin America and the Caribbean, and no data from Eastern Europe, Central Asia, or the Middle East.

Weight as predictors of clinical progression and treatment failure: results from the TREAT Asia Pediatric HIV Observational Database

OBJECTIVE

To evaluate the value of time-updated weight and height in predicting clinical progression, and immunological and virological failure in children receiving combination antiretroviral therapy (cART).

METHODS

We used Cox regression to analyze data of a cohort of Asian children.

RESULTS

A total of 2608 children were included; median age at cART was 5.7 years. Time-updated weight for age z score < -3 was associated with mortality (P < 0.001) independent of CD4% and < -2 was associated with immunological failure (P ≤ 0.03) independent of age at cART.

CONCLUSIONS

Weight monitoring provides useful data to inform clinical management of children on cART in resource-limited settings.

Predictors of Mortality in a Clinic Cohort of HIV-1 Infected Children Initiated on Antiretroviral Therapy in Jos, Nigeria

Background:

Mortality among human immunodeficiency virus-1 (HIV-1) infected children initiated on antiretroviral therapy (ART) though on a decline still remains high in resource-limited countries (RLC). Identifying baseline factors that predict mortality could allow their possible modification in order to improve pediatric HIV care and reduce mortality.

Methods:

We conducted a retrospective cohort study analyzing data on 691 children, aged 2 months-15 years, diagnosed with HIV-1 infection and initiated on ART between July 2005 and March 2013 at the pediatric HIV clinic of Jos University Teaching Hospital. Lost to follow-up children were excluded from the analyses. A multivariate Cox proportional hazards model was fitted to identify predictors of mortality.

Results:

Median follow-up time for the 691 children initiated on ART was 4.4 years (interquartile range (IQR), 1.8-5.9) and at the end of 2752 person-years of follow-up, 32 (4.6%) had died and 659 (95.4%) survived. The mortality rate was 1.0 per 100 child-years of follow-up period. The median age of those who died was about two times lower than that of survivors [1.7 years (IQR, 0.6-3.6) versus 3.9 years (IQR, 3.9-10.3), p<0.001]. On unadjusted Cox regression, the risk of dying was about three and half times more in children <5 years of age compared to those >5 years (p=0.02) Multivariate modeling identified age as the main predictor of death with mortality decreasing by 24% for every 1 year increase in age (Adjusted Hazard Ratio (AHR)=0.76 [0.62-0.94], p=0.013.

Conclusion:

The lower mortality rate for our study suggests that even in RLC, mortality rates could be reduced given a good standard of care. Early initiation of ART in younger children with close monitoring during follow-up could further reduce mortality.

Predicting mortality in HIV-infected children initiating highly active antiretroviral therapy in a resource-deprived setting

BACKGROUND

While highly active antiretroviral therapy (HAART) programs have been scaled up across sub-Saharan Africa, no prognostic models for the prediction of mortality risk for children initiating HAART are widely available. Current clinical prediction tools for human immunodeficiency virus (HIV)-infected children are derived from pre-HAART data and therefore cannot predict mortality for children initiating HAART. The purpose of this study was to develop a mortality risk scoring system for HIV-infected children beginning HAART in a resource-deprived setting.

METHODS

Observational data from HIV-infected children initiating HAART from December 2004 through March 2012 in Kinshasa, Democratic Republic of Congo, were analyzed. Cox proportional hazards models were constructed to assess associations between demographic and clinical characteristics at the time of HAART initiation and mortality. Each child received a model-based risk score predicting mortality after HAART initiation.

RESULTS

By 31 March 2012, 1010 children had started HAART. One hundred three children (10.2%) died at a median of 5.3 months post-HAART initiation, yielding a mortality rate of 3.4 deaths per 100 child-years. The final mortality prediction model included undernutrition, low CD4 count, HIV symptoms, and low total lymphocyte count. These factors were highly predictive of mortality in the study population (C statistic = 0.79) and performed well when applied to the validation population (C statistic = 0.77).

CONCLUSIONS

Mortality among children starting HAART in resource-deprived settings can be predicted using a simple scoring system incorporating several readily available factors. Identifying predictors of mortality will help clinicians target modifiable risk factors, such as undernutrition, which are not directly addressed by HAART.

Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement

INTRODUCTION

Residents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15-49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting.

METHODS

We studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006-July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk.

RESULTS

Of 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3-8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001).

CONCLUSIONS

We found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.

The association between quality of HIV care, loss to follow-up and mortality in pediatric and adolescent patients receiving antiretroviral therapy in Nigeria

Access to pediatric HIV treatment in resource-limited settings has risen significantly. However, little is known about the quality of care that pediatric or adolescent patients receive. The objective of this study is to explore quality of HIV care and treatment in Nigeria and to determine the association between quality of care, loss-to-follow-up and mortality. A retrospective cohort study was conducted including patients ≤18 years of age who initiated ART between November 2002 and December 2011 at 23 sites across 10 states. 1,516 patients were included. A quality score comprised of 6 process indicators was calculated for each patient. More than half of patients (55.5%) were found to have a high quality score, using the median score as the cut-off. Most patients were screened for tuberculosis at entry into care (81.3%), had adherence measurement and counseling at their last visit (88.7% and 89.7% respectively), and were prescribed co-trimoxazole at some point during enrollment in care (98.8%). Thirty-seven percent received a CD4 count in the six months prior to chart review. Mortality within 90 days of ART initiation was 1.9%. A total of 4.2% of patients died during the period of follow-up (mean: 27 months) with 19.0% lost to follow-up. In multivariate regression analyses, weight for age z-score (Adjusted Hazard Ratio (AHR): 0.90; 95% CI: 0.85, 0.95) and high quality indicator score (compared a low score, AHR: 0.43; 95% CI: 0.26, 0.73) had a protective effect on mortality. Patients with a high quality score were less likely to be lost to follow-up (Adjusted Odds Ratio (AOR): 0.42; 95% CI: 0.32, 0.56), compared to those with low score. These findings indicate that providing high quality care to children and adolescents living with HIV is important to improve outcomes, including lowering loss to follow-up and decreasing mortality in this age group.

Mortality and long-term virologic outcomes in children and infants treated with lopinavir/ritonavir

BACKGROUND

There is scant data on young children receiving protease inhibitor-based therapy in real-life resource-limited settings and on the optimal timing of therapy among children who survive infancy. Our aim was to evaluate outcomes at the Hospital del Niño, Panama, where children have been routinely treated with lopinavir/ritonavir (LPV/r)-based therapy since 2002.

METHODS

Retrospective cohort analysis of all HIV-infected children enrolled in care between January 1, 1991, and June 1, 2011. Kaplan-Meier method and Cox proportional hazards regression were used to evaluate death, virologic suppression and virologic rebound.

RESULTS

Of 399 children contributing 1944 person-years of follow-up, 254 (63.7%) were treated with LPV/r and 94 (23.6%) were never treated with antiretrovirals (ARVs). Among infants, improved survival was associated with male gender (hazard rate of death[HRdeath] 0.54, 95% confidence interval [CI]: 0.32-0.92) and treatment with highly active antiretroviral therapy (HRdeath 0.32, 95% CI: 0.12-0.83), whereas residence outside of Panama City was associated with poorer survival (HRdeath 1.72, 95% CI: 1.01-2.94). Among children who survived to 1 year of age without exposure to ARVs, LPV/r-based therapy improved survival (HRdeath 0.07, 95% CI: 0.01-0.33). Virologic suppression was achieved in 42.1%, 70.5% and 85.1% by 12, 24 and 60 months of follow-up among children treated with LPV/r. Virologic suppression was not associated with prior ARV exposure or age at initiation of therapy but was associated with residence outside of Panama City (HR suppression 1.93, 95% CI: 1.19-3.14). Patients with a baseline viral load >100,000 copies/mL were less likely to achieve suppression (HR suppression 0.37, 95% CI: 0.21-0.66). No children who achieved virologic suppression after initiating LPV/r died.

CONCLUSIONS

LPV/r-based therapy improved survival not only in infants but also in children over 1 year of age. Age at initiation of LPV/r-based therapy or prior ARVs did not impact virologic outcomes.

Decentralised paediatric HIV care in Ethiopia: a comparison between outcomes of patients managed in health centres and in a hospital clinic

BACKGROUND

In order to increase access to antiretroviral therapy (ART) in HIV-infected children, paediatric HIV care has been introduced in health centres in Ethiopia, where patients are managed by health professionals with limited training.

OBJECTIVE

To compare outcomes of paediatric HIV care in hospital and health centre clinics and to determine risk factors for death and loss to follow-up (LTFU).

DESIGN

Retrospective comparison of patient characteristics and outcomes among children managed in a public hospital and all five public health centres in the uptake area.

RESULTS

Among 1,960 patients (health centres 572, hospital clinic 1,388), 34% were lost to follow-up, 2% died, 14% were transferred out, and 46% remained in care. Children initiating ART in the hospital clinic had lower median CD4 cell counts (age <1 year: 575 vs. 1,183 cells/mm³, p=0.024; age 1-5 years: 370 vs. 598 cells/mm³, p<0.001; age >5 years: 186 vs. 259 cells/mm³, p<0.001), and a higher proportion were <1 year of age (22% vs. 15%, p=0.025). ART initiation rates and retention in care were similar between children managed in health centres and in the hospital clinic (36% vs. 37% and 47% vs. 46%, respectively). Among patients starting ART, mortality was associated with age <1 year [hazard ratio (HR) 12.0; 95% confidence interval (CI): 3.5, 41]. LTFU was associated with CD4 cell counts <350 cells/mm³ (HR 1.8; 95% CI: 1.2, 3.0), weight-for-age z-scores below -4 (HR 2.8; 95% CI: 1.4, 5.6), and age <5 years (1-5 years: HR 1.6; 95% CI: 1.0, 2.5; <1 year: HR 3.3; 95% CI: 1.6, 6.6).

CONCLUSIONS

Outcomes of HIV care were similar for Ethiopian children managed in a hospital clinic or in health centres. However, patients treated at the hospital clinic had characteristics of more advanced disease. Rates of LTFU were high in both types of health facility.

Predictors of mortality among HIV infected children on anti-retroviral therapy in Mekelle Hospital, Northern Ethiopia: a retrospective cohort study

Background

The introduction of antiretroviral therapy in 1996 improved the longevity and wellbeing of peoples living with HIV in the industrialized world including children. This survival benefit of antiretroviral therapy (ART) in reducing HIV related deaths has been well studied in the developed world. In resource-poor settings, where such treatment was started recently, there is inadequate information about impact of ART on the survival of patients especially in children. So, this study aims to investigate predictors of mortality of children on ART. Therefore, the objective of this study was to identify predictors of mortality among children on HAART.

Methods

A retrospective cohort study was conducted on 432 children who initiated antiretroviral therapy from June 2006 to June 2011 at pediatrics ART clinic in Mekelle Hospital, Northern-Ethiopia. Data were extracted from electronic and paper based medical records database and analyzed using Kaplan Meier survival and Cox proportional hazard model to identify independent predictors of children’s mortality on ART.

Results

The total time contributed by the study participants were 14,235 child-months with median follow up of 36 months. The mortality rate of this cohort was 1.40 deaths per 1000 child-months or 16.85 deaths per 1000 child-years. Age less than 18 months [ Adj.HR (95% CI) = (4.39(1.15-17.41)], CD4 percentage <10 [Adj.HR (95% CI) = 2.98(1.12-7.94)], WHO clinical stage (III&IV) [Adj.HR (95% CI) = 4.457(1.01-19.66)], chronic diarrhea[Adj.HR (95% CI) = 4.637(1.50-14.31)] and hemoglobin < 8 g/dl[Adj.HR (95% CI) = 3.77(1.29-10.98)] all at baseline were significantly and independently associated with survival of children on ART.

Conclusions

Mortality of children on ART was low and factors that affect mortality of children on ART were age less than 18 months, lower CD4 percentage, advanced WHO clinical stage (III&IV), presence of chronic diarrhea and lower hemoglobin level all at baseline. The high early mortality rate would support the value of an earlier treatment start before development of signs of immunodeficiency syndrome despite the method of HIV diagnosis and WHO stage.

Mortality and treatment outcomes of China's National Pediatric antiretroviral therapy program

BACKGROUND

The aim of this study was to describe 3-year mortality rates, associated risk factors, and long-term clinical outcomes of children enrolled in China's national free pediatric antiretroviral therapy (ART) program.

METHODS

Records were abstracted from the national human immunodeficiency virus (HIV)/AIDS case reporting and national pediatric ART databases for all HIV-positive children ≤15 years old who initiated ART prior to December 2010. Mortality risk factors over 3 years of follow-up were examined using Cox proportional hazards regression models. Life tables were used to determine survival rate over time. Longitudinal plots of CD4(+) T-cell percentage (CD4%), hemoglobin level, weight-for-age z (WAZ) score, and height-for-age z (HAZ) score were created using generalized estimating equation models.

RESULTS

Among the 1818 children included in our cohort, 93 deaths were recorded in 4022 child-years (CY) of observed time for an overall mortality rate of 2.31 per 100 CY (95% confidence interval [CI], 1.75-2.78). The strongest factor associated with mortality was baseline WAZ score <-2 (adjusted hazard ratio [HR] = 9.1; 95% CI, 2.5-33.2), followed by World Health Organization stage III or IV disease (adjusted HR = 2.4; 95% CI, 1.1-5.2), and hemoglobin <90 g/L (adjusted HR = 2.2; 95% CI, 1.2-3.9). CD4%, hemoglobin level, WAZ score, and HAZ score increased over time.

CONCLUSIONS

Our finding that 94% of children engaged in this program are still alive and of improved health after 3 years of treatment demonstrates that China's national pediatric ART program is effective. This program needs to be expanded to better meet treatment demands, and efforts to identify HIV-positive children earlier must be prioritized.

Pediatric response to second-line antiretroviral therapy in South Africa

BACKGROUND

With improved access to pediatric antiretroviral therapy (ART) in resource-limited settings, more children could experience first-line ART treatment failure.

METHODS

We performed a retrospective cohort analysis using electronic medical records from HIV-infected children who initiated ART at McCord Hospital's Sinikithemba Clinic in KwaZulu-Natal, South Africa, from August 2003 to December 2010. We analyzed all records from children who began second-line ART due to first-line treatment failure. We used logistic regression to compare viral outcomes in Protease Inhibitor (PI)-based versus Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI)-based second-line ART, controlling for time on first-line ART, sex, and whether HIV genotyping guided the regimen change.

RESULTS

Of the 880 children who initiated ART during this time period, 80 (9.1%) switched to second-line ART due to therapeutic failure of first-line ART after a median of 95 weeks (IQR 65-147 weeks). Eight (10%) of the failures received NNRTI-based second-line ART, all of whom failed a PI-based first-line regimen. Seventy (87.5%) received PI-based second-line ART, all of whom failed a NNRTI-based first-line regimen. Two children (2.5%) received non-standard dual therapy as second-line ART. Six months after switching ART regimens, the viral suppression rate was significantly higher in the PI group (82%) than in the NNRTI group (29%; p=0.003). Forty-one children (51%) were tested for genotypic resistance prior to switching to second-line ART. There was no significant difference in six month viral suppression (p=0.38) between children with and without genotype testing.

CONCLUSION

NNRTI-based second-line ART carries a high risk of virologic failure compared to PI-based second-line ART.

Pediatric HIV/AIDS in sub-Saharan Africa: emerging issues and way forward

BACKGROUND

Sub-Saharan Africa has the largest burden of pediatric HIV in the world. Global target has been set for eradication of pediatric HIV by 2015 but there are still so many complex issues facing HIV infected and affected children in the sub-continent.

OBJECTIVE

To review the current and emerging challenges facing pediatric HIV care in sub-Saharan Africa; and proffer solutions that could help in tackling these challenges.

METHOD

A Medline literature search of recent publications was performed to identify articles on "pediatric HIV", "HIV and children", "HIV and infants", "HIV and adolescents" in sub-Saharan Africa.

RESULT

There are a number of challenges and emerging complex issues facing children infected and affected by HIV in sub-Saharan Africa. These include late presentation, limited access to pediatric HIV services, delayed diagnosis, infant feeding choices, malnutrition, limited and complex drug regimen, disclosure, treatment failure and reproductive health concerns. A holistic cost effective preventive, diagnostic and treatment strategies are required in order to eliminate pediatric HIV in SSA.

CONCLUSION

HIV infected children and their families in sub-Saharan Africa face myriad of complex medical and psychosocial issues. A holistic health promotional approach is being advocated as the required step for eradication of pediatric HIV in Africa.

Mortality of HIV-infected and uninfected children in a longitudinal cohort in rural south-west Uganda during 8 years of follow-up

OBJECTIVES

To determine the impact of HIV on child mortality and explore potential risk factors for mortality among HIV-infected and HIV-exposed uninfected children in a longitudinal cohort in rural Uganda.

METHODS

From July 2002 to March 2010, HIV-infected and HIV-exposed uninfected children aged 6 weeks-13 years were enrolled in an open population-based clinical cohort. Antiretroviral therapy (ART) was introduced in 2005. Clinical and laboratory data were collected every 3 months. Person-years at risk were calculated from time of enrolment until earliest date of ART initiation, death or last visit. Cox regression was used to estimate hazard ratios (HR) for mortality.

RESULTS

Eighty-nine (30.2%) HIV-infected and 206 (69.8%) HIV-exposed but uninfected children were enrolled. Twenty-one children died. The mortality rate was six times higher in ART-naive HIV-infected children than in HIV-exposed but uninfected children (HR = 6.4, 95% CI = 2.4-16.6). Among HIV-infected children, mortality was highest in those aged <2 years. Decreasing weight-for-age Z (WAZ) score was the strongest risk factor for mortality among HIV-infected children (HR for unit decrease in WAZ = 2.6, 95% CI = 1.6-4.1). Thirty-five children (aged 7 months-15.6 years; median, 5.4 years) started ART.

CONCLUSIONS

Mortality among HIV-infected children was highest among those aged <2 years. Intensified efforts to prevent mother-to-child transmission of HIV and ensure early HIV diagnosis and treatment are required to decrease child mortality caused by HIV in rural Africa.