Outcomes among HIV-infected children initiating HIV care and antiretroviral treatment in Ethiopia

OBJECTIVE

To describe pediatric ART scale-up in Ethiopia, one of the 21 global priority countries for elimination of pediatric HIV infection.

METHODS

A descriptive analysis of routinely collected HIV care and treatment data on HIV-infected children (<15 years) enrolled at 70 health facilities in four regions in Ethiopia, January 2006-September 2013. Characteristics at enrollment and ART initiation are described along with outcomes at 1 year after enrollment. Among children who initiated ART, cumulative incidence of death and loss to follow-up (LTF) were estimated using survival analysis.

RESULTS

11 695 children 0-14 years were enrolled in HIV care and 6815 (58.3%) initiated ART. At enrollment, 31.2% were WHO stage III and 6.3% stage IV. The majority (87.9%) were enrolled in secondary or tertiary facilities. At 1 year after enrollment, 17.9% of children were LTF prior to ART initiation. Among children initiating ART, cumulative incidence of death was 3.4%, 4.1% and 4.8%, and cumulative incidence of LTF was 7.7%, 11.8% and 16.6% at 6, 12 and 24 months, respectively. Children <2 years had higher risk of LTF and death than older children (P < 0.0001). Children with more advanced disease and those enrolled in rural settings were more likely to die. Children enrolled in more recent years were less likely to die but more likely to be LTF.

CONCLUSIONS

Over the last decade large numbers of HIV-infected children have been successfully enrolled in HIV care and initiated on ART in Ethiopia. Retention prior to and after ART initiation remains a major challenge.

Pooled individual data analysis of 5 randomized trials of infant nevirapine prophylaxis to prevent breast-milk HIV-1 transmission

BACKGROUND

In resource-limited settings, mothers infected with human immunodeficiency virus type 1 (HIV-1) face a difficult choice: breastfeed their infants but risk transmitting HIV-1 or not breastfeed their infants and risk the infants dying of other infectious diseases or malnutrition. Recent results from observational studies and randomized clinical trials indicate daily administration of nevirapine to the infant can prevent breast-milk HIV-1 transmission.

METHODS

Data from 5396 mother-infant pairs who participated in 5 randomized trials where the infant was HIV-1 negative at birth were pooled to estimate the efficacy of infant nevirapine prophylaxis to prevent breast-milk HIV-1 transmission. Four daily regimens were compared: nevirapine for 6 weeks, 14 weeks, or 28 weeks, or nevirapine plus zidovudine for 14 weeks.

RESULTS

The estimated 28-week risk of HIV-1 transmission was 5.8% (95% confidence interval [CI], 4.3%-7.9%) for the 6-week nevirapine regimen, 3.7% (95% CI, 2.5%-5.4%) for the 14-week nevirapine regimen, 4.8% (95% CI, 3.5%-6.7%) for the 14-week nevirapine plus zidovudine regimen, and 1.8% (95% CI, 1.0%-3.1%) for the 28-week nevirapine regimen (log-rank test for trend, P < .001). Cox regression models with nevirapine as a time-varying covariate, stratified by trial site and adjusted for maternal CD4 cell count and infant birth weight, indicated that nevirapine reduces the rate of HIV-1 infection by 71% (95% CI, 58%-80%; P < .001) and reduces the rate of HIV infection or death by 58% (95% CI, 45%-69%; P < .001).

CONCLUSIONS

Extended prophylaxis with nevirapine or with nevirapine and zidovudine significantly reduces postnatal HIV-1 infection. Longer duration of prophylaxis results in a greater reduction in the risk of infection.

Slower clearance of nevirapine resistant virus in infants failing extended nevirapine prophylaxis for prevention of mother-to-child HIV transmission

Nevirapine resistance mutations arise commonly following single or extended-dose nevirapine (ED-NVP) prophylaxis to prevent mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV), but decay within 6-12 months of single-dose exposure. Use of ED-NVP prophylaxis in infants is expected to rise, but data on decay of nevirapine resistance mutations in infants in whom ED-NVP failed remain limited. We assessed, in Ethiopian infants participating in the Six-Week Extended Nevirapine (SWEN) Trial, the prevalence and persistence of nevirapine resistance mutations at 6 and 12 months following single-dose or up to 6 weeks of ED-NVP, and correlated their presence with the timing of infection and the type of resistance mutations. Standard population genotyping followed by high-throughput cloning were done on dried blood spot samples collected during the trial. More infants who received ED-NVP had nevirapine resistance detected by standard population genotyping (high frequencies) at age 6 months compared with those who received single-dose nevirapine (SD-NVP) (58% of 24 vs. 26% of 19, respectively; p = 0.06). Moreover, 56% of ED-NVP-exposed infants with nevirapine resistance at age 6 months still had nevirapine resistance mutations present at high frequencies at age 1 year. Infants infected before 6 weeks of age who received either SD- or ED-NVP were more likely to have Y181C or K103N; these mutations were also more likely to persist at high frequencies through 1 year of age. HIV-infected infants in whom ED-NVP prophylaxis fails are likely to experience delayed clearance of nevirapine-resistant virus in the first year of life, which in turn places them at risk for early selection of multidrug-resistant HIV after initial therapy with nonnucleoside reverse transcriptase inhibitor-based regimens.

Extended-dose nevirapine to 6 weeks of age for infants to prevent HIV transmission via breastfeeding in Ethiopia, India, and Uganda: an analysis of three randomised controlled trials

BACKGROUND

UNICEF/WHO recommends that infants born to HIV-infected mothers who do not have access to acceptable, feasible, affordable, sustainable, and safe replacement feeding should be exclusively breastfed for at least 6 months. The aim of three trials in Ethiopia, India, and Uganda was to assess whether daily nevirapine given to breastfed infants through 6 weeks of age can decrease HIV transmission via breastfeeding.

METHODS

HIV-infected women breastfeeding their infants were eligible for participation. Participants were randomly assigned to receive either single-dose nevirapine (nevirapine 200 mg to women in labour and nevirapine 2 mg/kg to newborns after birth) or 6 week extended-dose nevirapine (nevirapine 200 mg to women in labour and nevirapine 2 mg/kg to newborn babies after birth plus nevirapine 5 mg daily from days 8-42 for the infant). The randomisation sequences were generated by computer at a central data coordinating centre. The primary endpoint was HIV infection at 6 months of age in infants who were HIV PCR negative at birth. Analyses were by modified intention to treat, excluding infants with missing specimens and those with indeterminate or confirmed HIV infection at birth. These studies are registered with ClinicalTrials.gov, numbers NCT00074399, NCT00061321, and NCT00639938.

FINDINGS

2024 liveborn infants randomised in the study had at least one specimen tested before 6 months of age (1047 infants in the single-dose group and 977 infants in the extended-dose group). The modified intention-to-treat population included 986 infants in the single-dose group and 901 in the extended-dose group. At 6 months, 87 children in the single-dose group and 62 in the extended-dose group were infected with HIV (relative risk 0.80, 95% CI 0.58-1.10; p=0.16). At 6 weeks of age, 54 children in the single-dose group and 25 in the extended-dose group were HIV positive (0.54, 0.34-0.85; p=0.009). 393 infants in the single-dose group and 346 in the extended-dose group experienced grade 3 or 4 serious adverse events during the study (p=0.54).

INTERPRETATION

Although a 6-week regimen of daily nevirapine might be associated with a reduction in the risk of HIV transmission at 6 weeks of age, the lack of a significant reduction in the primary endpoint-risk of HIV transmission at 6 months-suggests that a longer course of daily infant nevirapine to prevent HIV transmission via breast milk might be more effective where access to affordable and safe replacement feeding is not yet available and where the risks of replacement feeding are high.

FUNDING

US National Institutes of Health; US National Institute of Allergy and Infectious Diseases; Fogarty International Center.

Clinical description of children with HIV/AIDS admitted at a referral hospital in Addis Ababa

Seventy-seven definitely HIV infected children were identified at Ethio-Swedish Children's Hospital in Addis Ababa, Ethiopia, between January 1990 and April 2000. There were 39 females and 38 males. Their age ranged from 15 months to 12 years and their median age was 3.8 years. Most commonly diagnosed diseases included disseminated tuberculosis seen in 28 patients, pneumonia in 27, pulmonary tuberculosis in 19, persistent or chronic diarrhoeal disease in 21, otitis media in 17 and marasmus in 17 patients. Pneumocystic carinii pneumonia was considered in 11 patients. One patient was suspected to have lymphoid interstitial pneumonitis. Sixteen children (21%) died in hospital. There was an abandoned child and 20 children were already orphans. All patients presented with clinical opportunistic infections and thus there is a need to develop a pediatric clinical guideline for patient management. Primary prevention of HIV infection in women of the child bearing age is of paramount importance and reduction of mother-to-child transmission of HIV infection by antiretroviral drug needs to be considered as a primary prevention for a child.

Pseudoexfoliation syndrome in Ethiopian glaucoma patients

BACKGROUND

Pseudoexfoliation syndrome (PXS) has variable prevalence rates in the glaucoma population depending on geographic location and racial composition of the population studied. There is no data available on this subject in Ethiopia.

OBJECTIVE

To determine the prevalence of PXS among Ethiopian glaucoma clinic population.

DESIGN

A prospective study.

SETTING

The Glaucoma Clinic of Menelik-II-Hospital, which is a tertiary eye care centre in Addis Ababa, Ethiopia.

PARTICIPANTS

All new patients with glaucoma or ocular hypertension (ocular HPN) seen during the study period from 1st April to 30th September 1996 were included in the study.

RESULTS

Our of the 432 new patients of glaucoma or ocular HPN seen during the study, 108 patients (25%) had PXS. The age of PXS cases ranged from 32 years to 86 years (mean 62.3 years). There were 80 males and 28 females. Of the PXS patients, 104 (96.3%) were cases of chronic open angle glaucoma, while angle closure glaucoma and ocular HPN were rare comprising only two patients (1.85%) each.

CONCLUSION

The relatively high prevalence rate of PXS among Ethiopian glaucoma clinic population found in this study stresses the need for further community-based research in order to prevent blindness due to glaucoma associated with PXS.

Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings

A randomized controlled trial was carried out for 1 y in three tertiary and teaching hospitals, in Addis Ababa (Ethiopia), Yogyakarta (Indonesia) and Merida (Mexico), to study the effectiveness, feasibility, acceptability and cost of kangaroo mother care (KMC) when compared to conventional methods of care (CMC). About 29% of 649 low birthweight infants (LBWI; 1000-1999 g) died before eligibility. Of the survivors, 38% were excluded for various reasons, 149 were randomly assigned to KMC (almost exclusive skin-to-skin care after stabilization), and 136 to CMC (warm room or incubator care). There were three deaths in each group and no difference in the incidence of severe disease. Hypothermia was significantly less common in KMC infants in Merida (13.5 vs 31.5 episodes/100 infants/d) and overall (10.8 vs 14.6). Exclusive breastfeeding at discharge was more common in KMC infants in Merida (80% vs 16%) and overall (88% vs 70%). KMC infants had a higher mean daily weight gain (21.3 g vs 17.7 g) and were discharged earlier (13.4 vs 16.3 d after enrolment). KMC was considered feasible and presented advantages over CMC in terms of maintenance of equipment. Mothers expressed a clear preference for KMC and health workers found it safe and convenient. KMC was cheaper than CMC in terms of salaries (US$ 11,788 vs US$ 29,888) and other running costs (US$ 7501 vs US$ 9876). This study confirms that hospital KMC for stabilized LBWI 1000-1999 g is at least as effective and safe as CMC, and shows that it is feasible in different settings, acceptable to mothers of different cultures, and less expensive. Where exclusive breastfeeding is uncommon among LBWI, KMC may bring about an increase in its prevalence and duration, with consequent benefits for health and growth. For hospitals in low-income countries KMC may represent an appropriate use of scarce resources.

Ocular manifestations of leukaemia in Ethiopians

A prospective ophthalmic evaluation of 74 newly diagnosed and 34 old (on follow-up) leukaemic patients, carried out from March 1990 to December 1995 is described. Primary ocular involvement, that is leukaemic retinal infiltrates, were detected in 32% of the newly diagnosed. In contrast, none of the old leukaemic patients had this lesion. In 69% of the new and 21% of the old cases, secondary ocular manifestations of leukaemia were observed. The major secondary ocular manifestation of leukaemia in both groups was intra-retinal haemorrhage. A variety of miscellaneous ocular findings, such as cataract, pterygium, pingeculae, etc. were detected in 36% of all leukemics. These findings indicate the importance of a complete ophthalmologic evaluation in the diagnosis, follow-up and management of leukaemic patients.

Sociodemographic profile of children affected by AIDS in Addis Abeba

A survey was conducted in Addis Abeba between October 2, 1993 and December 10, 1993 to assess orphanhood due to AIDS deaths. It was possible to trace only 1,047 AIDS cases among residents of Addis Abeba. During the survey, 59% of the cases and 16% of their spouses were already dead. The total number of children born to the index cases were 2186, among which, 883 (40.4%) were below 15 years of age. Two hundred eighty (30.4%) of these children had lost either one or both parents. Other social problems include ill health in 10.5% among which 3.9% had AIDS; 14.1% were school dropouts. There were also children who faced abandonment, displacement and who lacked medical care at the time of their illness. The existing coping mechanism seems to be relying on the extended family, which is an important social support system. However, there is a need to raise community awareness and strengthen the system to enhance the effort in protecting and supporting children affected by AIDS.

Idiopathic thrombocytopenic purpura (ITP) in Ethiopian children: clinical findings and response to therapy

This retrospective study provides information on the clinical findings and response to therapy in Ethiopian children with idiopathic thrombocytopenic purpura. Forty-nine cases of idiopathic thrombocytopenic purpura admitted to the teaching hospital, Ethio-Swedish Children's Hospital (ESCH) in Addis Abeba, Ethiopia between January 1982 and December 1993 were studied. Among these were 31 females and 18 males with a female to male ratio of 1.9:1. The age range was three to 12 years with a mean of seven years. The commonest presenting clinical features were petechiae, epistaxis, gingival and gastro-intestinal bleeding. Twenty-nine patients were treated with prednisolone, out of whom, 27 attained absolute remission. Twenty patients were observed and managed conservatively and attained spontaneous remission. One child went on to develop chronic idiopathic thrombocytopenic purpura and underwent splenectomy after immunosuppressive treatment failure, while another child is still being followed up with recurrent episodes of thrombocytopenia and epistaxis. No mortality was noted in the review of these series of patients.

6-Phosphofructo-2-kinase and fructose-2,6-bisphosphatase from Saccharomyces cerevisiae

In permeabilized yeast cells 6-phosphofructo-2-kinase and fructose-2,6-bisphosphatase are studied during growth. It is shown that in yeast at least two fructose 2,6-bisphosphate degrading enzyme activities occur, differing in pH profile and in their substrate affinities. The activities of 6-phosphofructo-2-kinase and of fructose-2,6-bisphosphatases drop in the exponential and the transition phase while the activity of the alkaline phosphatases steadily increases. In the stationary phase the activities of 6-phosphofructo-2-kinase and of the low Km fructose-2,6-bisphosphatase increase again. Yeast 6-phosphofructo-2-kinase and fructose-2,6-bisphosphatase were purified and separated from each other. The purified 6-phosphofructo-2-kinase was found to exhibit a very high specific activity (1.3 U/mg). The enzyme is efficiently inhibited by ATP. The ATP inhibition is most pronounced at low concentrations of magnesium and fructose-6-phosphate. Phosphoenolpyruvate and sn-glycerol 3-phosphate are inhibitors of the enzyme. The high-affinity yeast fructose-2,6-bisphosphatase releases inorganic phosphate from the 2-position of fructose 2,6-bisphosphate. It displays hyperbolic kinetics towards fructose 2,6-bisphosphate (Km = 0.3 microM) and is strongly inhibited by fructose 6-phosphate. The inhibition is counteracted by sn-glycerol 3-phosphate. The enzyme is shown to be inactivated by cAMP-dependent phosphorylation and reactivated by the action of protein phosphatase 2A.