The safety and antiviral effect of protease inhibitors in children

Adherence to highly active antiretroviral therapy and its correlates among HIV infected pediatric patients in Ethiopia

Background

The introduction of combination antiretroviral therapy (ART) has resulted in striking reductions in HIV-related mortality. Despite increased availability of ART, children remain a neglected population. This may be due to concerns that failure to adhere appears to be related to continued viral replication, treatment failure and the emergence of drug-resistant strains of HIV. This study determines the rates and factors associated with adherence to Antiretroviral (ARV) Drug therapy in HIV-infected children who were receiving Highly Active Antiretroviral Therapy (HAART) in Addis Ababa, Ethiopia in 2008.

Methods

A cross-sectional study was conducted in five hospitals in Addis Ababa from February 18 – April 28, 2008. The study population entailed parents/caretaker and index children who were following ART in the health facilities. A structured questionnaire was used for data collection.

Results

A total of 390 children respondents were included in the study with a response rate of 91%. The majority, equaling 205 (52.6%) of the children, were greater than 9 years of age. Fifty five percent of the children were girls. A total of 339 children (86.9%) as reported by caregivers were adherent to antiretroviral drugs for the past 7 days before the interview. Numerous variables were found to be significantly associated with adherence: children whose parents did not pay a fee for treatment [OR = 0.39 (95%CI: 0.16, 0.92)], children who had ever received any nutritional support from the clinic [OR = 0.34 (95%CI: 0.14, 0.79)] were less likely to adhere. Whereas children who took co-trimoxazole medication/syrup besides ARVs [OR = 3.65 (95%CI: 1.24, 10.74)], children who did not know their sero-status [OR = 2.53 (95%CI: 1.24, 5.19)] and children who were not aware of their caregiver's health problem [OR = 2.45 (95%CI: 1.25, 4.81)] were more likely to adhere than their counterparts.

Conclusion

Adherence to HAART in children in Addis Ababa was higher than other similar setups. However, there are still significant numbers of children who are non-adherent to HAART.

Adherence to antiretroviral therapy for pediatric HIV infection: a qualitative systematic review with recommendations for research and clinical management

Although nonadherence to prescribed therapies is widespread, it is particularly problematic with highly active antiretroviral therapy for HIV infection. This review of >50 studies in the area of pediatric HIV infection revealed varying methods for assessing antiretroviral adherence with a wide range of estimates of adherence. Correlates of adherence could be grouped as those relating to the medication, the patient, and the caregiver/family, with many conflicting findings and a lack of theory guiding the research. Only 8 studies, mainly small feasibility or pilot investigations, evaluated highly active antiretroviral therapy adherence interventions in pediatric populations. We conclude with specific recommendations for assessment and clinical management of adherence and discuss directions for future research in this area.

Adherence to high activity antiretrovial therapy (HAART) in pediatric patients infected with HIV: issues and interventions

It has been proven that HAART is effective in suppressing human immunodeficiency virus (HIV) replication, decreasing morbidity and mortality associated with HIV and improving quality of life in adults as well as children infected with HIV. However, drugs don't work in patients who don't take them and in the management of HIV infection it is now well established that optimum adherence to HAART is critical to successful outcome of patients receiving therapy. At least 95% adherence to HAART is optimum and studies have shown that 50%. Important factors that influence adherence to HAART such as regimen related complexities, patient/family related issues and factors related to healthcare delivery system makes adherence to HAART challenging. Although numerous interventions to improve adherence have been investigated in developed as well as developing countries, majority of work in this area is focused on adherence in adults and data in children is limited. Therefore, in order to facilitate adherence and improve outcome of HAART in pediatric population, it is necessary to have a deep understanding of the factors influencing adherence and interventions that can improve adherence in children.

Disclosure of HIV status and adherence to daily drug regimens among HIV-infected children in Uganda

Pediatric adherence to daily drug regimens has not been widely assessed in Africa where majority of HIV infected children live. Using in-depth interviews of 42 HIV-infected children taking ART and/or cotrimoxazole prophylaxis, and 42 primary caregivers, at a comprehensive HIV/AIDS clinic in Uganda, we evaluated their adherence experiences for purposes of program improvement. Daily drug regimens provided by the pediatric clinic included cotrimoxazole prophylaxis as well as ART and cotrimoxazole combined. Complete disclosure of HIV status by caregivers to children and strong parental relationships were related to good adherence. Structural factors including poverty and stigma were barriers to adherence even for children who had had complete disclosure and a supportive relationship with a parent. To ensure adherence to life-extending medications, our findings underscore the need for providers to support caregivers to disclose, provide on-going support and maintain open communication with HIV-infected children taking cotrimoxazole prophylaxis and ART.

Facilitating adherence to highly active antiretroviral therapy in children with HIV infection: what are the issues and what can be done?

Treatment of HIV infection with highly active antiretroviral therapy (HAART) requires sustained adherence to treatment to maintain efficacy. In pediatric patients, adherence to HAART represents a significant challenge for treated children and for their caregivers and healthcare providers. Many factors can affect adherence to HAART including: (i) factors related to the patient and his/her family; (ii) factors related to the drug/medication; and (iii) factors related to the healthcare system. Different strategies can be employed to tackle the specific obstacles identified in these three groups, and thus to facilitate adherence. Among the key interventions centered on the patient and his/her family are the tailoring of the HAART regimen to the daily activities of the child and his/her family, and the implementation of an intensive education program on adherence for the child and the caregiver, prior to starting the treatment. Specific medication-related problems (depending on drug pharmacokinetic and pharmacodynamic properties, taste and palatability, food interactions, etc.) exist; such problems can not be solved solely by clinicians or by families. Greater commitment of the pharmaceutical industry is needed, and innovative solutions have to be identified by clinicians in partnership with drug manufacturers. Furthermore, the development of an 'adherence strategy/program' can be recommended to all institutions working in pediatric HIV infection. Most of the necessary interventions to be included in such programs can be easily implemented, but they require trained and committed staff (and institutions), and time to be spent with patients and their caregivers.

Prevalence of elevated cholesterol and associated risk factors among perinatally HIV-infected children (4-19 years old) in Pediatric AIDS Clinical Trials Group 219C

BACKGROUND

HIV protease inhibitors (PIs) are known to disturb lipid metabolism in adults, leading to hypercholesterolemia. A number of cross-sectional studies have also reported this phenomenon in perinatally HIV-infected children but differ greatly with respect to prevalence and/or methodology.

METHODS

The Pediatric AIDS Clinical Trials Group 219C (PACTG 219C) is a prospective cohort study designed to examine long-term outcomes in children born to HIV-infected women. The outcome of interest in this analysis was total cholesterol, and patients were classified as hypercholesterolemic if their total cholesterol was above the 95th percentile of US Third National Health and Nutrition Survey (NHANES III) standards for gender, race/ethnicity, and age. We hypothesized that hypercholesterolemia would be more common among older children receiving PI therapy who demonstrated excellent adherence and might be associated with hypertension and obesity. Information regarding treatment, adherence, and laboratory values was obtained using the date closest to the cholesterol measurement. Crude and adjusted effect measures were estimated using exposure odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) from univariate and multivariate logistic regression models.

RESULTS

Among 1812 HIV-infected participants between 4 and 19 years of age, 229 children had hypercholesterolemia (prevalence = 13.0%, 95% CI: 11.1-14.3) compared with 9 of 187 HIV-uninfected children (prevalence = 4.8%, 95% CI: 2.2-8.8). After adjusting for confounders, current PI use (OR = 5.3, 95% CI: 3.1-9.2), age from 4 to <6 years (OR = 2.9, 95% CI: 1.7-4.9), HIV-1 RNA <400 copies/mL (OR = 2.3, 95% CI: 1.7-3.2), self-report of no missed doses in the past 3 days (OR = 2.2, 95% CI: 1.3-3.8), white race (OR = 2.2, 95% CI: 1.4-3.3), age from 6 to <12 years (OR = 1.9, 95% CI: 1.3-2.9), Hispanic ethnicity (OR = 1.8, 95% CI: 1.2-2.5), and current nonnucleoside reverse transcriptase inhibitor use (OR = 1.7, 95% CI: 1.2-2.3) were independently associated with the presence of hypercholesterolemia among the HIV-infected children. There was a positive association with elevated systolic blood pressure in univariate but not multivariate analysis, and no association was present with body mass index.

CONCLUSIONS

Among the HIV-infected children, the overall prevalence of hypercholesterolemia was 13.0% and the strongest associated risk factor for hypercholesterolemia was current use of a PI in the antiretroviral regimen. Continued follow-up is needed to assess the long-term effects of hypercholesterolemia in children.

Adherence to antiretroviral therapy for pediatric HIV infection: review of the literature and recommendations for research

This review described and compared empirical investigations of adherence to pediatric antiretroviral therapy (ART) and predictors/correlates of adherence with regard to methodology and outcome. Thirteen empirical studies of children's adherence to ART, conducted between the years 1981 and 2002 were identified. Investigations varied by age of participant, drug therapy regimen, method of adherence assessment, and by the reporting of predictors/correlates of adherence. Conclusions from the literature are limited by the lack of common sample characteristics and adherence assessment methodologies. Nevertheless, consistent with much of the pediatric adherence literature, adherence to antiretroviral medications among children and adolescents appears to be frequently suboptimal. Few investigations identified predictors/correlates of adherence, but these appear generally similar to those found in adult samples. Recommendations for future investigations are proposed.