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Mega TA, Usamo FB, Negera GZ. Immunologic Response of HIV-Infected Children to Different Regimens of Antiretroviral Therapy: A Retrospective Observational Study. AIDS Res Treat 2020; 2020:6415432. [PMID: 32855823 DOI: 10.1155/2020/6415432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 06/05/2020] [Accepted: 07/31/2020] [Indexed: 12/03/2022] Open
Abstract
Background Both abacavir- (ABC-) based and zidovudine- (AZT-) based regimens are widely utilized for managing HIV infection in children. Unfortunately, there is a lack of data regarding their immunological response and associated risk factors in Ethiopia. Methods A retrospective hospital-based cohort study was conducted on HIV-infected children in Jimma Medical Center (JMC). A total of 179 records were reviewed by including data from November 2015 to April 2017. Data were collected on sociodemographic, clinical characteristics of patients and drug-related variables. Data analysis was done using STATA 13.1. Mixed-effect linear regression was performed to assess the difference in CD4+ changes between groups adjusting for baseline characteristics. The change in predicted CD4 count attributed to each regimen was also assessed by marginal analysis. P < 0.05 for slope of the random-effect linear regression was used as an indicator for the presence of association. Result Of 179 patients, 98 (54.7%) were females. The mean (±SD) duration of follow-up was 939.8 ± 478.3 and 984.92 ± 453.1 days for ABC and AZT groups, respectively. AZT group had a significant CD4+ count gain per visit compared with their ABC counterparts ((β = 20.51, 95% CI [6.37–34.65]), P = 0.004) over time. The regimen AZT + 3TC + LPV/r tended to have an excellent predicted CD4+ lymphocyte count change relative to all other regimens, while ABC + 3TC + LPV/r had the least immunologic recovery (margins 338.0 cells/mm3 versus 249.13 cells/mm3 (P < 0.001)). Baseline CD4+ lymphocyte count, ART group, WHO clinical stages, and viral load were independent predictors for CD4+ change overtime. Conclusion AZT-based regimens seem to have better immunological response compared to ABC-based regimens. Immunologic response was described worse in patients with a viral load of >1000copies/ml, low baseline CD4+ count, advanced WHO clinical stages, and ABC-containing regimens. Further study is needed to clarify these aspects.
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Mossoro-Kpinde CD, Gody JC, Mboumba Bouassa RS, Moussa S, Jenabian MA, Péré H, Charpentier C, Matta M, Longo JDD, Grésenguet G, Djoba Siawaya JF, Bélec L. Escalating and sustained immunovirological dissociation among antiretroviral drug-experienced perinatally human immunodeficiency virus-1-infected children and adolescents living in the Central African Republic: A STROBE-compliant study. Medicine (Baltimore) 2020; 99:e19978. [PMID: 32481261 PMCID: PMC7249904 DOI: 10.1097/md.0000000000019978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Sub-Saharan Africa has the vast majority (∼90%) of new pediatric acquired immunodeficiency syndrome cases worldwide. Biologically monitoring HIV-infected pediatric populations remains challenging. The differential interest of human immunodeficiency virus (HIV)-1 RNA loads and CD4 T-cell counts is debated for the treatment of pediatric acquired immunodeficiency syndrome patients.Long-term antiretroviral treatment (ART) outcomes regarding immunological and virological surrogate markers were longitudinally evaluated between 2009 and 2014 (over 57 months) in 245 perinatally HIV-1-infected children and adolescents born from HIV-infected mothers, treated at inclusion for at least 6 months by the World Health Organization-recommended ART in Bangui, Central African Republic.Patients were monitored over time biologically for CD4 T-cell counts, HIV-1 RNA loads, and drug resistance mutation genotyping.Children lost to follow-up totaled 6%. Four categories of immunovirological responses to ART were observed. At baseline, therapeutic success with sustained immunological and virological responses was observed in 80 (32.6%) children; immunological and virologic nonresponses occurred in 32 (13.0%) children; finally, the majority (133; 54.2%) of the remaining children showed discordant immunovirological responses. Among them, 33 (13.4%) children showed rapid virological responses to ART with an undetectable viral load, whereas immunological responses remained absent after 6 months of treatment and increased progressively over time in most of the cases, suggesting slow immunorestoration. Notably, nearly half of the children (40.8% at baseline and 48.2% at follow-up) harbored discordant immunovirological responses with a paradoxically high CD4 T-cell count and HIV-1 RNA load, which are always associated with high levels of drug resistance mutations. The latter category showed a significant increase over time, with a growth rate of 1.23% per year of follow-up.Our STROBE-compliant study demonstrates the high heterogeneity of biological responses under ART in children with frequent passage from 1 category to another over time. Close biological evaluation with access to routine plasma HIV-1 RNA load monitoring is crucial for adapting the complex outcomes of ART in HIV-infected children born from infected mothers.
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Affiliation(s)
| | - Jean-Chrysostome Gody
- Faculté des Sciences de la Santé, Université de Bangui
- Complexe Pédiatrique, Bangui, Central African Republic
| | - Ralph-Sydney Mboumba Bouassa
- Ecole Doctorale d’Infectiologie Tropicale, Franceville, Gabon
- Laboratoire de virologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (AP-HP) and Université Paris Descartes, Paris Sorbonne Cité, Paris, France
| | - Sandrine Moussa
- Institut Pasteur de Bangui, Bangui, Central African Republic
| | - Mohammad-Ali Jenabian
- Département des Sciences Biologiques et Centre de Recherche BioMed, Université du Québec à Montréal (UQAM), Montreal, QC, Canada
| | - Hélène Péré
- Laboratoire de virologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (AP-HP) and Université Paris Descartes, Paris Sorbonne Cité, Paris, France
| | - Charlotte Charpentier
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Laboratoire de Virologie, Hôpital Bichat, AP-HP, Paris, France
| | - Mathieu Matta
- Laboratoire de virologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (AP-HP) and Université Paris Descartes, Paris Sorbonne Cité, Paris, France
| | - Jean De Dieu Longo
- Faculté des Sciences de la Santé, Université de Bangui
- Unité de Recherches et d’Intervention sur les Maladies Sexuellement Transmissibles et le SIDA, Département de Santé Publique, Faculté des Sciences de la Santé de Bangui, Bangui, Central African Republic
| | - Gérard Grésenguet
- Faculté des Sciences de la Santé, Université de Bangui
- Unité de Recherches et d’Intervention sur les Maladies Sexuellement Transmissibles et le SIDA, Département de Santé Publique, Faculté des Sciences de la Santé de Bangui, Bangui, Central African Republic
| | | | - Laurent Bélec
- Laboratoire de virologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (AP-HP) and Université Paris Descartes, Paris Sorbonne Cité, Paris, France
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Arpadi S, Lamb M, Nzeyimana IN, Vandebriel G, Anyalechi G, Wong M, Smith R, Rivadeneira ED, Kayirangwa E, Malamba SS, Musoni C, Koumans EH, Braaten M, Nsanzimana S. Better Outcomes Among HIV-Infected Rwandan Children 18-60 Months of Age After the Implementation of "Treat All". J Acquir Immune Defic Syndr 2019; 80:e74-83. [PMID: 30422899 DOI: 10.1097/QAI.0000000000001907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: In 2012, Rwanda introduced a Treat All approach for HIV-infected children younger than 5 years. We compared antiretroviral therapy (ART) initiation, outcomes, and retention, before and after this change. Methods: We conducted a retrospective study of children enrolled into care between June 2009 and December 2011 [Before Treat All (BTA) cohort] and between July 2012 and April 2015 [Treat All (TA) cohort]. Setting: Medical records of a nationally representative sample were abstracted for all eligible aged 18–60 months from 100 Rwandan public health facilities. Results: We abstracted 374 medical records: 227 in the BTA and 147 in the TA cohorts. Mean (SD) age at enrollment was [3 years (1.1)]. Among BTA, 59% initiated ART within 1 year, vs. 89% in the TA cohort. Median time to ART initiation was 68 days (interquartile range 14–494) for BTA and 9 days (interquartile range 0–28) for TA (P < 0.0001), with 9 (5%) undergoing same-day initiation in BTA compared with 50 (37%) in TA (P < 0.0001). Before ART initiation, 59% in the BTA reported at least one health condition compared with 35% in the TA cohort (P < 0.0001). Although overall loss to follow-up was similar between cohorts (BTA: 13%, TA: 8%, P = 0.18), loss to follow-up before ART was significantly higher in the BTA (8%) compared with the TA cohort (2%) (P = 0.02). Conclusions: Nearly 90% of Rwandan children started on ART within 1 year of enrollment, most within 1 month, with greater than 90% retention after implementation of TA. TA was also associated with fewer morbidities.
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Low YS, Islahudin F, Razali KAM, Adnan S. Modification of Initial Highly Active Antiretroviral Therapy (HAART) Regimen in Paediatric HIV Patients. Open AIDS J 2018; 12:11-19. [PMID: 29576815 PMCID: PMC5850481 DOI: 10.2174/1874613601812010011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 10/11/2017] [Accepted: 01/30/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Treatment options among Human Immunodeficiency Virus (HIV)-infected children are limited as only a few Highly Active Antiretroviral Therapy (HAART) are approved worldwide for paediatric use. Among children, frequent changes in HAART regimen can rapidly exhaust treatment options, and information addressing this issue is scarce. OBJECTIVE The aim of the study was to determine factors associated with the modification of initial HAART regimen modification among HIV-infected children. METHOD A retrospective study was performed among HIV-infected children aged 18 and below, that received HAART for at least six months in a tertiary hospital in Malaysia. Factors associated with modification of initial HAART regimen were investigated. RESULTS Out of 99 patients, 71.1% (n=71) required initial HAART regime modification. The most common reason for HAART modification was treatment failure (n=39, 54.9%). Other reasons included drug toxicity (n=14, 19.7%), change to fixed-dose products (n=11, 15.5%), product discontinuation (n=4, 5.6%) and intolerable taste (n=3, 4.2%). The overall mean time retention on initial HAART before regimen modification was 3.32 year ± 2.24 years (95% CI, 2.79-3.85). Patient's adherence was the only factor associated with initial regimen modification in this study. Participants with poor adherence showed a five-fold risk of having their initial HAART regimen modified compared to those with good adherence (adjusted OR [95% CI], 5.250 [1.614 - 17.076], p = 0.006). CONCLUSION Poor adherence was significantly associated with initial regimen modification, intervention to improve patient's adherence is necessary to prevent multiple regimen modification among HIV-infected children.
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Affiliation(s)
- Yee Shan Low
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Farida Islahudin
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | | | - Shafnah Adnan
- Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
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Arpadi SM, Shiau S, De Gusmao EP, Violari A. Routine viral load monitoring in HIV-infected infants and children in low- and middle-income countries: challenges and opportunities. J Int AIDS Soc 2018; 20 Suppl 7. [PMID: 29171190 PMCID: PMC5978643 DOI: 10.1002/jia2.25001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 08/21/2017] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The objective of this commentary is to review considerations for implementing routine viral load (VL) monitoring programmes for HIV-infected infants and children living in low- and middle-income countries (LMIC). Since 2013, the World Health Organization (WHO) guidelines recommend VL testing as the preferred monitoring approach for all individuals treated with ART in order to assess treatment response, detect treatment failure and determine the need to switch to a second-line regimen in a timely manner. More recently, WHO guidelines from 2016 identify HIV-infected infants and children as a priority group for routine VL monitoring. DISCUSSION There are a number of reasons why HIV-infected infants and children should be prioritized for routine VL monitoring. Data from national VL monitoring programmes as well as systematic reviews and meta-analyses from LMIC indicate rates of viral suppression are lower for infants and children compared to adults. The number of antiretroviral drugs and palatable formulations suitable for young children are limited. In addition, emotional and developmental issues particular to children can make daily medication administration difficult and pose a challenge to adherence and achievement of sustained viral suppression. VL monitoring can be instrumental for identifying those in need of additional adherence support, reducing regimen switches and preserving treatment options. The needs of infants and children warrant consideration in all aspects of VL monitoring services. If capacity for paediatric venipuncture is not assured, platforms that accept dried blood spot specimens are necessary in order for infants and children to have equitable access. Healthcare systems also need to prepare to manage the substantial number of infants and children identified with elevated VL, including adherence interventions that are appropriate for children. Establishing robust systems to evaluate processes and outcomes of routine VL monitoring services and to support drug forecasting and supply management is essential to determine best practices for infants and children in LMIC. CONCLUSIONS The particular concerns of HIV-infected infants and children warrant attention during all phases of planning and implementation of VL monitoring services. There are a number of key areas, including frequency of monitoring, blood specimen type and adherence challenges, where specific approaches tailored for infants and children may be required.
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Affiliation(s)
- Stephen M Arpadi
- ICAP Columbia University, New York, NY, USA.,Department of Pediatrics, College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Faculty of Health Sciences, Rahima Moosa Mother and Child Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephanie Shiau
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Faculty of Health Sciences, Rahima Moosa Mother and Child Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Avy Violari
- Perinatal Health Research Unit, University of Witwatersrand, Johannesburg, South Africa
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Crowell CS, Maiga AI, Sylla M, Taiwo B, Kone N, Oron AP, Murphy RL, Marcelin AG, Traore B, Fofana DB, Peytavin G, Chadwick EG. High Rates of Baseline Drug Resistance and Virologic Failure Among ART-naive HIV-infected Children in Mali. Pediatr Infect Dis J 2017; 36:e258-63. [PMID: 28198788 DOI: 10.1097/INF.0000000000001575] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Limited data exist on drug resistance and antiretroviral treatment (ART) outcomes in HIV-1-infected children in West Africa. We determined the prevalence of baseline resistance and correlates of virologic failure (VF) in a cohort of ART-naive HIV-1-infected children <10 years of age initiating ART in Mali. METHODS Reverse transcriptase and protease genes were sequenced at baseline (before ART) and at 6 months. Resistance was defined according to the Stanford HIV Genotypic Resistance database. VF was defined as viral load ≥1000 copies/mL after 6 months of ART. Logistic regression was used to evaluate factors associated with VF or death >1 month after enrollment. Post hoc, antiretroviral concentrations were assayed on baseline samples of participants with baseline resistance. RESULTS One-hundred twenty children with a median age 2.6 years (interquartile range: 1.6-5.0) were included. Eighty-eight percent reported no prevention of mother-to-child transmission exposure. At baseline, 27 (23%), 4 (3%) and none had non-nucleoside reverse transcriptase inhibitor (NNRTI), nucleoside reverse transcriptase inhibitor or protease inhibitor resistance, respectively. Thirty-nine (33%) developed VF and 4 died >1 month post-ART initiation. In multivariable analyses, poor adherence [odds ratio (OR): 6.1, P = 0.001], baseline NNRTI resistance among children receiving NNRTI-based ART (OR: 22.9, P < 0.001) and protease inhibitor-based ART initiation among children without baseline NNRTI resistance (OR: 5.8, P = 0.018) were significantly associated with VF/death. Ten (38%) with baseline resistance had detectable levels of nevirapine or efavirenz at baseline; 7 were currently breastfeeding, but only 2 reported maternal antiretroviral use. CONCLUSIONS Baseline NNRTI resistance was common in children without reported NNRTI exposure and was associated with increased risk of treatment failure. Detectable NNRTI concentrations were present despite few reports of maternal/infant antiretroviral use.
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Mossoro-Kpinde CD, Gody JC, Mboumba Bouassa RS, Mbitikon O, Jenabian MA, Robin L, Matta M, Zeitouni K, Longo JDD, Costiniuk C, Grésenguet G, Touré Kane NC, Bélec L. High levels of virological failure with major genotypic resistance mutations in HIV-1-infected children after 5 years of care according to WHO-recommended 1st-line and 2nd-line antiretroviral regimens in the Central African Republic: A cross-sectional study. Medicine (Baltimore) 2017; 96:e6282. [PMID: 28272247 PMCID: PMC5348195 DOI: 10.1097/md.0000000000006282] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 02/09/2017] [Accepted: 02/13/2017] [Indexed: 11/26/2022] Open
Abstract
A large cohort of 220 HIV-1-infected children (median [range] age: 12 [4-17] years) was cared and followed up in the Central African Republic, including 198 in 1st-line and 22 in 2nd-line antiretroviral regimens. Patients were monitored clinically and biologically for HIV-1 RNA load and drug resistance mutations (DRMs) genotyping. A total of 87 (40%) study children were virological responders and 133 (60%) nonresponders. In children with detectable viral load, the majority (129; 97%) represented a virological failure. In children receiving 1st-line regimens in virological failure for whom genotypic resistance test was available, 45% displayed viruses harboring at least 1 DRM to NNRTI or NRTI, and 26% showed at least 1 major DRM to NNRTI or NRTI; more than half of children in 1st-line regimens were resistant to 1st-generation NNRTI and 24% of the children in 1st-line regimens had a major DRMs to PI. Virological failure and selection of DRMs were both associated with poor adherence. These observations demonstrate high rate of virological failure after 3 to 5 years of 1st-line or 2nd-line antiretroviral treatment, which is generally associated with DRMs and therapeutic failure. Overall, more than half (55%) of children receiving 1st-line antiretroviral treatment for a median of 3.4 years showed virological failure and antiretroviral-resistance and thus eligible to 2nd-line treatment. Furthermore, two-third (64%) of children under 2nd-line therapy were eligible to 3rd-line regimen. Taken together, these observations point the necessity to monitor antiretroviral-treated children by plasma HIV-1 RNA load to diagnose as early as possible the therapeutic failure and operate switch to a new therapeutic line.
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Affiliation(s)
| | - Jean-Chrysostome Gody
- Faculté des Sciences de la Santé, Université de Bangui
- Complexe Pédiatrique, Bangui, Central African Republic
| | - Ralph-Sydney Mboumba Bouassa
- Laboratoire de virologie, Hôpital Européen Georges Pompidou and Université Paris Descartes, Paris Sorbonne Cité, Paris, France
| | | | - Mohammad-Ali Jenabian
- Département des Sciences Biologiques et Centre de Recherche BioMed, Université du Québec à Montréal (UQAM), Montreal, QC, Canada
| | - Leman Robin
- Laboratoire de virologie, Hôpital Européen Georges Pompidou and Université Paris Descartes, Paris Sorbonne Cité, Paris, France
| | - Mathieu Matta
- Laboratoire de virologie, Hôpital Européen Georges Pompidou and Université Paris Descartes, Paris Sorbonne Cité, Paris, France
| | - Kamal Zeitouni
- Saint Georges Hospital University Medical Center, Université de Balamand, Beirut, Lebanon
| | - Jean De Dieu Longo
- Faculté des Sciences de la Santé, Université de Bangui
- Unité de Recherches et d’Intervention sur les Maladies Sexuellement Transmissibles et le SIDA, Département de Santé Publique, Faculté des Sciences de la Santé de Bangui, Central African Republic
| | - Cecilia Costiniuk
- Chronic Viral Illnesses Service, Division of Infectious Diseases and Research Institute of the McGill University Health Centre, Montréal
| | - Gérard Grésenguet
- Faculté des Sciences de la Santé, Université de Bangui
- Unité de Recherches et d’Intervention sur les Maladies Sexuellement Transmissibles et le SIDA, Département de Santé Publique, Faculté des Sciences de la Santé de Bangui, Central African Republic
| | - Ndèye Coumba Touré Kane
- Laboratoire de Bactériologie Virologie, Hôpital Aristide Le Dantec, Dakar and Université Cheikh Anta Diop de Dakar, Sénégal
| | - Laurent Bélec
- Laboratoire de virologie, Hôpital Européen Georges Pompidou and Université Paris Descartes, Paris Sorbonne Cité, Paris, France
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Purchase S, Cunningham J, Esser M, Skinner D. Keeping kids in care: virological failure in a paediatric antiretroviral clinic and suggestions for improving treatment outcomes. Afr J AIDS Res 2017; 15:301-9. [PMID: 27681154 DOI: 10.2989/16085906.2016.1210656] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The burden of paediatric HIV in South Africa is extremely high. Antiretrovirals (ARVs) are now widely accessible in the country and the clinical emphasis has shifted from initiation of treatment to retention in care. This study describes the cumulative virological failure rate amongst children on ARVs in a peri-urban clinic, and suggests ways in which clinics and partners could improve treatment outcomes. The study was conducted by the non-profit organisation HOPE Cape Town Association. A retrospective file audit determined the cumulative virological failure rate, that is, the sum of all children with a viral load >1000 copies/ml, children on monotherapy, children who had stopped treatment, children lost to follow-up (LTFU) and children who had died. Interviews were conducted with a purposive sample of 12 staff members and a random sample of 21 caregivers and 4 children attending care. Cumulative virological failure rate was 42%, with most of those children having been LTFU. Both staff and caregivers consistently identified pharmacy queues, ongoing stigma and unpalatable ARVs as barriers to adherence. Staff suggestions included use of adherence aids, and better education and support groups for caregivers. Caregivers also requested support groups, as well as "same day" appointments for caregivers and children, but rejected the idea of home visits. Simple, acceptable and cost-effective strategies exist whereby clinics and their partners could significantly reduce the cumulative virological failure rate in paediatric ARV clinics. These include actively tracing defaulters, improving education, providing support groups, and campaigning for palatable ARV formulations.
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Affiliation(s)
- Susan Purchase
- a HOPE Cape Town Association and Trust , Cape Town , South Africa
| | - Jayne Cunningham
- a HOPE Cape Town Association and Trust , Cape Town , South Africa
| | - Monika Esser
- b Immunology Unit, Division of Medical Microbiology, Department of Pathology , NHLS and Stellenbosch University , Cape Town , South Africa
| | - Donald Skinner
- c Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
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Salou M, Dagnra AY, Butel C, Vidal N, Serrano L, Takassi E, Konou AA, Houndenou S, Dapam N, Singo-Tokofaï A, Pitche P, Atakouma Y, Prince-David M, Delaporte E, Peeters M. High rates of virological failure and drug resistance in perinatally HIV-1-infected children and adolescents receiving lifelong antiretroviral therapy in routine clinics in Togo. J Int AIDS Soc 2016; 19:20683. [PMID: 27125320 PMCID: PMC4850147 DOI: 10.7448/ias.19.1.20683] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 03/03/2016] [Accepted: 03/08/2016] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Antiretroviral treatment (ART) has been scaled up over the last decade but compared to adults, children living with HIV are less likely to receive ART. Moreover, children and adolescents are more vulnerable than adults to virological failure (VF) and emergence of drug resistance. In this study we determined virological outcome in perinatally HIV-1-infected children and adolescents receiving ART in Togo. METHODS HIV viral load (VL) testing was consecutively proposed to all children and adolescents who were on ART for at least 12 months when attending HIV healthcare services for their routine follow-up visit (June to September 2014). Plasma HIV-1 VL was measured using the m2000 RealTime HIV-1 assay (Abbott Molecular, Des Plaines, IL, USA). Genotypic drug resistance was done for all samples with VL>1000 copies/ml. RESULTS AND DISCUSSION Among 283 perinatally HIV-1-infected children and adolescents included, 167 (59%) were adolescents and 116 (41%) were children. The median duration on ART was 48 months (interquartile range: 28 to 68 months). For 228 (80.6%), the current ART combination consisted of two nucleoside reverse transcriptase inhibitors (NRTIs) (zidovudine and lamivudine) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) (nevirapine or efavirenz). Only 28 (9.9%) were on a protease inhibitor (PI)-based regimen. VL was below the detection limit (i.e. 40 copies/ml) for 102 (36%), between 40 and 1000 copies/ml for 35 (12.4%) and above 1000 copies/ml for 146 (51.6%). Genotypic drug-resistance testing was successful for 125/146 (85.6%); 110/125 (88.0%) were resistant to both NRTIs and NNRTIs, 1/125 (0.8%) to NRTIs only, 4/125 (3.2%) to NNRTIs only and three harboured viruses resistant to reverse transcriptase and PIs. Overall, 86% (108/125) of children and adolescents experiencing VF and successfully genotyped, corresponding thus to at least 38% of the study population, had either no effective ART or had only a single effective drug in their current ART regimen. CONCLUSIONS Our study provided important information on virological outcome on lifelong ART in perinatally HIV-1-infected children and adolescents who were still on ART and continued to attend antiretroviral (ARV) clinics for follow-up visits. Actual conditions for scaling up and monitoring lifelong ART in children in resource-limited countries can have dramatic long-term outcomes and illustrate that paediatric ART receives inadequate attention.
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Affiliation(s)
- Mounerou Salou
- Laboratoire de Biologie Moléculaire et d'Immunologie, Faculté des Sciences de la Santé, Université de Lomé, Lomé, Togo
| | - Anoumou Y Dagnra
- Laboratoire de Biologie Moléculaire et d'Immunologie, Faculté des Sciences de la Santé, Université de Lomé, Lomé, Togo
| | - Christelle Butel
- UMI 233, Institut de Recherche pour le Développement, INSERM U1175, Université de Montpellier, Montpellier, France
| | - Nicole Vidal
- UMI 233, Institut de Recherche pour le Développement, INSERM U1175, Université de Montpellier, Montpellier, France
| | - Laetitia Serrano
- UMI 233, Institut de Recherche pour le Développement, INSERM U1175, Université de Montpellier, Montpellier, France
| | - Elom Takassi
- Service de Pédiatrie CHU Sylvanus Olympio, Lomé, Togo
| | - Abla A Konou
- Laboratoire de Biologie Moléculaire et d'Immunologie, Faculté des Sciences de la Santé, Université de Lomé, Lomé, Togo
| | | | | | | | - Palokinam Pitche
- Conseil National de Lutte contre le SIDA and Faculté des Sciences de la Santé, Lomé, Togo
| | - Yao Atakouma
- Service de Pédiatrie CHU Sylvanus Olympio, Lomé, Togo
- Département de Pédiatrie, Faculté des Sciences de la Santé, Université de Lomé, Lomé, Togo
| | - Mireille Prince-David
- Laboratoire de Biologie Moléculaire et d'Immunologie, Faculté des Sciences de la Santé, Université de Lomé, Lomé, Togo
| | - Eric Delaporte
- UMI 233, Institut de Recherche pour le Développement, INSERM U1175, Université de Montpellier, Montpellier, France
| | - Martine Peeters
- UMI 233, Institut de Recherche pour le Développement, INSERM U1175, Université de Montpellier, Montpellier, France;
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Paintsil E, Martin R, Goldenthal A, Bhandari S, Andiman W, Ghebremichael M. Frequent Episodes of Detectable Viremia in HIV Treatment-Experienced Children is Associated with a Decline in CD4+ T-cells Over Time. ACTA ACUST UNITED AC 2016; 7. [PMID: 27379199 DOI: 10.4172/2155-6113.1000565] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The clinical consequences of the magnitude and the duration of detectable viremia in HIV-infected children have not been well characterized. We examined the predictors and immunologic consequences over time of frequent episodes of detectable viremia in HIV-infected children followed at Yale-New Haven Hospital. METHODS We analyzed the CD4+ T-cell and HIV viral load over a 19-year period (1996 to 2013) of 104 HIV-infected children enrolled in the Yale Prospective Longitudinal Pediatric HIV Cohort. Both CD4+ T-lymphocytes and HIV viral load were measured at clinic visits every 3 to 4 months. Longitudinal data analyses using polynomial random coefficients models were conducted to examine overtime changes in CD4+ T-cell counts by frequency of episodes of detectable viremia. Moreover, regression analyses using logistic regression models were used to assess the predictors of frequent episodes of detectable viremia. RESULTS One hundred and four (104) HIV-infected children with more than one HIV viral load measurement between 1996 and November 2013 were included in the analysis. Over 80% (N=86) of the children had detectable viral load (HIV RNA viral load ≥50 copies/ml) during more than 50% of their clinic visits. Children with infrequent episodes of detectable viremia had significantly higher CD4+ T-cell counts overtime compared to those with frequent episodes of detectable viremia (P<0.0001). CONCLUSIONS Both frequency and magnitude of episodes of detectable viremia had effect on CD4+ T-cells. Strict adherence to a treatment goal of undetectable HIV viremia in children is likely to be beneficial.
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Affiliation(s)
- Elijah Paintsil
- Departments of Pediatrics and Pharmacology, Yale University School of Medicine, New Haven, USA
| | | | - Ariel Goldenthal
- Columbia University College of Physicians and Surgeons, New York, USA
| | | | - Warren Andiman
- Department of Pediatrics, Yale University School of Medicine, New Haven, USA
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Kukoyi O, Renner L, Powell J, Barry O, Prin M, Kusah J, Cong X, Paintsil E. Viral load monitoring and antiretroviral treatment outcomes in a pediatric HIV cohort in Ghana. BMC Infect Dis 2016; 16:58. [PMID: 26843068 DOI: 10.1186/s12879-016-1402-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/28/2016] [Indexed: 11/21/2022] Open
Abstract
Background HIV-infected children in sub-Saharan Africa may be at a high risk of staying on a failing first-line regimen and developing drug-resistance HIV variants due to lack of routine viral load monitoring. We investigated whether cumulative viral load, measured as viremia copy-years (VCY) could predict morbidity in a setting where viral load is not routinely monitored. Methods This was a single-center prospective observational longitudinal study of HIV-infected children initiating antiretroviral therapy (ART) at the Pediatric HIV/AIDS Care program at Korle-Bu Teaching Hospital in Accra, Ghana. The main outcome was morbidity measured as frequency of hospitalizations, opportunistic infections, and outpatient sick visits. The main explanatory variable was viral load measured as VCY. Results The study included 140 children who initiated ART between September 2009 and May 2013 and had at least 2 viral load measurements. There were 184 hospitalizations, with pneumonia being the most common cause (22.8 %). A total of 102 opportunistic infections was documented, with tuberculosis being the most common opportunistic infection (68 %). A total of 823 outpatient sick visits was documented, with upper respiratory infections (14.2 %) being the most common cause. Forty-four percent of our study participants had >4 log10 VCY. Children in this sub-cohort had a higher frequency of sick visits compared with those with <4 log10 VCY (p = 0.03). Only 6.5 % of children with >4 log10 VCY had been identified as treatment failure using WHO clinical and immunological treatment failure criteria. Conclusions High level of cumulative viral load may translate to virological failure and subsequent increased all-cause morbidity. Our finding of potential utility of VCY in pediatrics warrants further investigations. VCY may be a good alternate to routine viral load measurement as its determination may be less frequent and could be personalized to save cost.
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Vreeman RC, Scanlon ML, McHenry MS, Nyandiko WM. The physical and psychological effects of HIV infection and its treatment on perinatally HIV-infected children. J Int AIDS Soc 2015; 18:20258. [PMID: 26639114 PMCID: PMC4670835 DOI: 10.7448/ias.18.7.20258] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/25/2015] [Accepted: 09/02/2015] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION As highly active antiretroviral therapy (HAART) transforms human immunodeficiency virus (HIV) into a manageable chronic disease, new challenges are emerging in treating children born with HIV, including a number of risks to their physical and psychological health due to HIV infection and its lifelong treatment. METHODS We conducted a literature review to evaluate the evidence on the physical and psychological effects of perinatal HIV (PHIV+) infection and its treatment in the era of HAART, including major chronic comorbidities. RESULTS AND DISCUSSION Perinatally infected children face concerning levels of treatment failure and drug resistance, which may hamper their long-term treatment and result in more significant comorbidities. Physical complications from PHIV+ infection and treatment potentially affect all major organ systems. Although treatment with antiretroviral (ARV) therapy has reduced incidence of severe neurocognitive diseases like HIV encephalopathy, perinatally infected children may experience less severe neurocognitive complications related to HIV disease and ARV neurotoxicity. Major metabolic complications include dyslipidaemia and insulin resistance, complications that are associated with both HIV infection and several ARV agents and may significantly affect cardiovascular disease risk with age. Bone abnormalities, particularly amongst children treated with tenofovir, are a concern for perinatally infected children who may be at higher risk for bone fractures and osteoporosis. In many studies, rates of anaemia are significantly higher for HIV-infected children. Renal failure is a significant complication and cause of death amongst perinatally infected children, while new data on sexual and reproductive health suggest that sexually transmitted infections and birth complications may be additional concerns for perinatally infected children in adolescence. Finally, perinatally infected children may face psychological challenges, including higher rates of mental health and behavioural disorders. Existing studies have significant methodological limitations, including small sample sizes, inappropriate control groups and heterogeneous definitions, to name a few. CONCLUSIONS Success in treating perinatally HIV-infected children and better understanding of the physical and psychological implications of lifelong HIV infection require that we address a new set of challenges for children. A better understanding of these challenges will guide care providers, researchers and policymakers towards more effective HIV care management for perinatally infected children and their transition to adulthood.
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Affiliation(s)
- Rachel C Vreeman
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya;
| | - Michael L Scanlon
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Megan S McHenry
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Winstone M Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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Antunes F, Zindoga P, Gomes P, Augusto O, Mahumane I, Veloso L, Valadas E, Camacho R. Development of Nevirapine Resistance in Children Exposed to the Prevention of Mother-to-Child HIV-1 Transmission Programme in Maputo, Mozambique. PLoS One 2015; 10:e0131994. [PMID: 26161559 DOI: 10.1371/journal.pone.0131994] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/09/2015] [Indexed: 12/05/2022] Open
Abstract
Background Single-dose nevirapine (sd-NVP) has been the main option for prevention of mother-to-child transmission (PMTCT) of HIV-1 in low-resource settings. However, sd-NVP can induce the selection of HIV-1 resistant mutations in mothers and infants. In Mozambique, there are limited data regarding the profile of NVP resistance associated mutations (RAM) in the context of PMTCT. Objectives To assess the prevalence and the factors associated with NVP RAM among children born to HIV-1 infected mothers enrolled in the PMTCT programme adopted in Mozambique. Methods One hundred and fifty seven children aged 6 to 48 weeks were sequentially included (July 2011 to March 2012) at four centres in Maputo. Genotyping of RAM was performed in samples with HIV-1 RNA≥ 100 copies/μL (Viroseq). Sequencing was performed with ABI 3100 (Applied Biosystems). Logistic regression modelling was undertaken to identify the factors associated with NVP RAM. Results Seventy-nine children had their samples genotyped. Their median age was 7.0 (3–12) months and 92.4% received prophylaxis with sd-NVP at birth plus daily NVP. 35.4% of mothers received antiretrovirals (ARVs) for PMTCT. ARV RAM were detected in 43 (54.4%) of the children. 45.6% of these children had at least one NVP RAM. The most common mutations associated with NVP resistance were K103N (n = 16) and Y181C (n = 15). NVP RAM was significantly associated with mother exposure to PMTCT (crude odds ratio [OR] 30.3, 95% CI 4.93–186.34) and with mother’s CD4 count < 350 cells/mm3 (crude OR 3.08, 95% CI 1.02–9.32). In the multivariable analysis the mother’s exposure to PMTCT was the only variable significantly associated with NVP RAM (adjusted OR 48.65, 95% CI 9.33–253.66). Conclusions We found a high prevalence of NVP RAM among children who were exposed to the drug regimen for PMTCT in Mozambique. The mothers’ exposure to PMTCT significantly increased the risk of NVP RAM.
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Vermund SH, Blevins M, Moon TD, José E, Moiane L, Tique JA, Sidat M, Ciampa PJ, Shepherd BE, Vaz LME. Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement. PLoS One 2014; 9:e110116. [PMID: 25330113 PMCID: PMC4203761 DOI: 10.1371/journal.pone.0110116] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 09/16/2014] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Sten H. Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Troy D. Moon
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Eurico José
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Linda Moiane
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - José A. Tique
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Mohsin Sidat
- School of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Philip J. Ciampa
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Bryan E. Shepherd
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Lara M. E. Vaz
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
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Desmonde S, Essanin JB, Aka AE, Messou E, Amorissani-Folquet M, Rondeau V, Ciaranello A, Leroy V. Morbidity and health care resource utilization in HIV-infected children after antiretroviral therapy initiation in Côte d'Ivoire, 2004-2009. J Acquir Immune Defic Syndr 2014; 65:e95-103. [PMID: 24525473 DOI: 10.1097/QAI.0b013e3182a4ea6f] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We describe severe morbidity and health care resource utilization (HCRU) among HIV-infected children on antiretroviral therapy (ART) in Abidjan, Côte d'Ivoire. METHODS All HIV-infected children enrolled in an HIV-care program (2004-2009) were eligible for ART initiation until database closeout, death, ART interruption, or loss to follow-up. We calculated incidence rates (IRs) of density per 100 child-years (CYs) for severe morbidity, HCRU (outpatient care and inpatient care), and associated factors using frailty models with a Weibull distribution. RESULTS Of 332 children with a median age of 5.7 years and median follow-up of 2.5 years, 65.4% were severely immunodeficient by World Health Organization (WHO) criteria, and all received cotrimoxazole prophylaxis. We recorded 464 clinical events in 228 children; the overall IR was 57.6/100 CYs [95% confidence interval (CI): 52.1 to 62.5]. Severe morbidity was more frequent in children on protease inhibitor (PI)-based ART compared to those on other regimens [adjusted hazards ratio (aHR): 1.83; 95% CI: 1.35 to 2.47] and to those moderately/severely immunodeficient compared to those not (aHR: 1.57; 95% CI: 1.13 to 2.18 and aHR: 2.53; 95% CI: 1.81 to 3.55, respectively). Of the 464 events, 371 (80%) led to outpatient care (IR: 45.6/100 CYs) and 164 (35%) to inpatient care (IR: 20.2/100 CYs). In adjusted analyses, outpatient care was significantly less frequent in children older than 10 years compared with children younger than 2 years (aHR: 0.49; 95% CI: 0.31 to 0.78) and in those living furthest from clinics compared with those living closest (aHR: 0.65; 95% CI: 0.47 to 0.90). Both inpatient and outpatient HCRU were negatively associated with cotrimoxazole prophylaxis. CONCLUSIONS Despite ART, HIV-infected children still require substantial utilization of health care services.
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Barry O, Powell J, Renner L, Bonney EY, Prin M, Ampofo W, Kusah J, Goka B, Sagoe KWC, Shabanova V, Paintsil E. Effectiveness of first-line antiretroviral therapy and correlates of longitudinal changes in CD4 and viral load among HIV-infected children in Ghana. BMC Infect Dis 2013; 13:476. [PMID: 24119088 PMCID: PMC3852953 DOI: 10.1186/1471-2334-13-476] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 10/07/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) scale-up in resource-limited countries, with limited capacity for CD4 and HIV viral load monitoring, presents a unique challenge. We determined the effectiveness of first-line ART in a real world pediatric HIV clinic and explored associations between readily obtainable patient data and the trajectories of change in CD4 count and HIV viral load. METHODS We performed a longitudinal study of a cohort of HIV-infected children initiating ART at the Korle-Bu Teaching Hospital Pediatric HIV clinic in Accra, Ghana, aged 0-13 years from 2009-2012. CD4 and viral load testing were done every 4 to 6 months and genotypic resistance testing was performed for children failing therapy. A mixed linear modeling approach, combining fixed and random subject effects, was employed for data analysis. RESULTS Ninety HIV-infected children aged 0 to 13 years initiating ART were enrolled. The effectiveness of first-line regimen among study participants was 83.3%, based on WHO criteria for virologic failure. Fifteen of the 90 (16.7%) children met the criteria for virologic treatment failure after at least 24 weeks on ART. Sixty-seven percent virologic failures harbored viruses with ≥ 1 drug resistant mutations (DRMs); M184V/K103N was the predominant resistance pathway. Age at initiation of therapy, child's gender, having a parent as a primary care giver, severity of illness, and type of regimen were associated with treatment outcomes. CONCLUSIONS First-line ART regimens were effective and well tolerated. We identified predictors of the trajectories of change in CD4 and viral load to inform targeted laboratory monitoring of ART among HIV-infected children in resource-limited countries.
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Affiliation(s)
- Oliver Barry
- Departments of Pediatrics and Pharmacology, Yale School of Medicine, New Haven, CT, USA.
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Wamalwa DC, Lehman DA, Benki-Nugent S, Gasper MA, Gichohi R, Maleche-Obimbo E, Farquhar C, John-Stewart GC, Overbaugh J. Long-term virologic response and genotypic resistance mutations in HIV-1 infected Kenyan children on combination antiretroviral therapy. J Acquir Immune Defic Syndr 2013; 62:267-74. [PMID: 23196827 DOI: 10.1097/QAI.0b013e31827b4ac8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV-infected children may require the use of combination antiretroviral treatment (cART) into adulthood. However, regimens are limited to first line and second line in many African settings. Therefore, understanding the long-term rate of virologic failure and drug resistance during prolonged antiretroviral treatment is important for establishing treatment strategies in African pediatric cohorts. METHODS Children aged 18 months to 12 years initiated first-line cART and were followed every 1-3 months, for up to 5.5 years. Treatment was switched to second-line cART based on clinical and immunologic criteria according to national guidelines. Virologic failure was determined retrospectively as defined by ≥2 viral loads >5000 copies per milliliter. Drug resistance was assessed during viral failure by population-based sequencing. RESULTS Among 100 children on first-line cART followed for a median of 49 months, 34% children experienced virologic failure. Twenty-three (68%) of the 34 children with viral failure had detectable resistance mutations, of whom 14 (61%) had multiclass resistance. Fourteen (14%) children were switched to second-line regimens and followed for a median of 28 months. Retrospective analysis revealed that virologic failure had occurred at a median of 12 months before switching to second line. During prolonged first-line treatment in the presence of viral failure, additional resistance mutations accumulated; however, only 1 (7%) of 14 children had persistent viremia during second-line treatment. DISCUSSION Virologic suppression was maintained on first-line cART in two-thirds of HIV-infected children for up to 5 years. Switch to second line based on clinical/immunologic criteria occurred ∼1 year after viral failure, but the delay did not consistently compromise second-line treatment.
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Omoni AO, Christian PS, Sadoh WE, Okechukwu A, Olateju E, Omoigberale A, Blattner W, Charurat ME. Immunologic outcomes of antiretroviral therapy among HIV-infected Nigerian children and its association with early infant feeding and nutritional status at treatment initiation. Pediatr Infect Dis J 2013; 32:e291-7. [PMID: 23411626 DOI: 10.1097/INF.0b013e31828b2a2f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To evaluate immunologic response to antiretroviral treatment (ART) among HIV-infected Nigerian children (<36 months old) and to assess its association with early infant feeding pattern and nutritional status at treatment initiation. DESIGN Mixed prospective and retrospective cohort study. METHODS One hundred fifty HIV-infected children were followed for 12 months from initiation of ART. CD4 count/CD4% was assessed at baseline and every 4-6 months. Nutritional status was assessed by height-for-age, weight-for-age and weight-for-height Z scores using the 2006 World Health Organization growth reference. Children were classified into 4 feeding groups--exclusively breast-fed, predominantly breast-fed, mixed fed and exclusively formula fed. Logistic regression was used to model odds of failure to reach CD4% of ≥ 25% at the 12-month follow-up. Linear random effects models were used to model the longitudinal change in CD4%. RESULTS There was a significant increase in CD4% for all children from 13.8% at baseline to 28.5% after 12 months (ΔCD4% = 14.7%, 95% confidence interval: 12.1%-17.4%). There was no association of feeding pattern with immunologic outcomes. In adjusted analyses, children who were underweight (weight-for-age < -2.0) or with CD4% <15% at baseline were 4.30 (95% confidence interval: 1.16, 15.87; P < 0.05) times and 3.41 (95% confidence interval: 1.10, 10.52; P < 0.05) times, respectively, more likely not to attain CD4% of ≥ 25% at 12 months. CONCLUSION Baseline nutritional status and CD4% were independently associated with failure to reach CD4% ≥ 25% at 12 months among HIV-infected Nigerian children on ART. These results emphasize the importance of early screening and initiation of ART among children in resource-poor settings before malnutrition and severe immunosuppression sets in.
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Kebe K, Thiam M, Diagne Gueye NR, Diop H, Dia A, Signate Sy H, Charpentier C, Belec L, Mboup S, Toure Kane C. High rate of antiretroviral drug resistance mutations in HIV type 1-infected Senegalese children in virological failure on first-line treatment according to the World Health Organization guidelines. AIDS Res Hum Retroviruses 2013; 29:242-9. [PMID: 22860571 DOI: 10.1089/aid.2011.0300] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The rates of virological failure (VF) and HIV-1 drug resistance were evaluated in a cross-sectional study in HIV-1-infected children living in Dakar, and taking antiretroviral treatment (ART) according to WHO recommendations. The plasma HIV-1 RNA load was measured using the Abbott m2000 RealTime HIV-1 assay. The full-length protease gene and partial reverse transcriptase gene were sequenced, and resistance mutations were assessed by reference to the Stanford University HIV drug resistance database. Of 125 included children (median age, 7 years) taking first-line ART for a median duration of 20 months, 82 (66%) showed detectable HIV-1 RNA load, and 70 (56%) met the 2010 revised WHO criteria of VF (defined as plasma HIV-1 RNA load ≥3.7 log(10) copies/ml). Drug resistance results were available for 52 children with plasma HIV-1 RNA load ≥3.0 log(10) copies/ml, and viruses carrying resistance mutations were found in 48 (92%) children. Among these 48, mutations conferring resistance to nucleoside reverse transcriptase inhibitors (NRTIs) or non-NRTIs (NNRTIs) were found in 42 (88%) and 47 (99%) children, respectively. The NRTI-resistant viruses harbored the M184V/I (95%), Q151M (2%), and thymidine-analogue mutations (40%), and the NNRTI-resistant viruses harbored the K103N (34%), Y181C (32%), G190A (23%), and K101E (21%) mutations. A high rate (56%) of VF was demonstrated in Senegalese children after 20 months of first-line ART and therapeutic failure was assessed by the presence of antiretroviral drug resistance mutations in 9 out of 10 children in VF. These findings point out the difficulties of optimizing ART in children living in sub-Saharan Africa, and the crucial need of laboratory monitoring reinforcement.
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Affiliation(s)
- Khady Kebe
- Laboratoire de Bactériologie-Virologie, CHU Aristide le Dantec, Dakar, Sénégal
| | - Moussa Thiam
- Laboratoire de Bactériologie-Virologie, CHU Aristide le Dantec, Dakar, Sénégal
| | | | - Halimatou Diop
- Laboratoire de Bactériologie-Virologie, CHU Aristide le Dantec, Dakar, Sénégal
| | | | | | - Charlotte Charpentier
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Laboratoire de Virologie, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Laurent Belec
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Laboratoire de Virologie, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Souleymane Mboup
- Laboratoire de Bactériologie-Virologie, CHU Aristide le Dantec, Dakar, Sénégal
| | - Coumba Toure Kane
- Laboratoire de Bactériologie-Virologie, CHU Aristide le Dantec, Dakar, Sénégal
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Vaz P, Augusto O, Bila D, Macassa E, Vubil A, Jani IV, Pillon R, Sandstrom P, Sutherland D, Giaquinto C, Jordan MR, Bertagnolio S. Surveillance of HIV drug resistance in children receiving antiretroviral therapy: a pilot study of the World Health Organization's generic protocol in Maputo, Mozambique. Clin Infect Dis 2012; 54 Suppl 4:S369-74. [PMID: 22544205 DOI: 10.1093/cid/cis006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Between 2007 and 2008, the Mozambique Ministry of Health conducted an assessment of human immunodeficiency virus drug resistance (HIVDR) using World Health Organization (WHO) methods in a cohort of children initiating antiretroviral therapy (ART) at the main pediatric ART referral center in Mozambique. It was shown that prior to ART initiation 5.4% of children had HIVDR that was associated with nevirapine perinatal exposure (P < .001). Twelve months after ART initiation, 77% had viral load suppression (<1000 copies/mL), exceeding the WHO target of ≥ 70%; 10.3% had HIVDR at 12 months. Baseline HIVDR (P = .04), maternal prevention of mother-to-child transmission (P = .02), and estimated days of missed medication (P = .03) predicted HIVDR at 12 months. As efforts to eliminate pediatric AIDS are intensified, implementation of ritonavir-boosted protease inhibitor regimens in children with prevention of mother-to-child transmission exposure may reduce risk of virological failure in our setting.
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Affiliation(s)
- P Vaz
- Department of Pediatrics, Hospital Dia Pediátrico, Maputo Central Hospital, Maputo, Mozambique.
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Okomo U, Togun T, Oko F, Peterson K, Townend J, Peterson I, Jaye A. Treatment outcomes among HIV-1 and HIV-2 infected children initiating antiretroviral therapy in a concentrated low prevalence setting in West Africa. BMC Pediatr 2012; 12:95. [PMID: 22770231 PMCID: PMC3407729 DOI: 10.1186/1471-2431-12-95] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 07/08/2012] [Indexed: 12/04/2022] Open
Abstract
Background There is little data on responses to combination antiretroviral therapy (cART) among HIV-infected children in the West African region. We describe treatment outcomes among HIV-1 and HIV-2 infected children initiating cART in a research clinic in The Gambia, West Africa. Methods All treatment naive HIV-infected children who initiated cART according to the WHO ART guidelines for children between October 2004 and December 2009 were included in the analysis. Kaplan-Meir estimates and sign-rank test were used to investigate the responses to treatment. Results 65 HIV-1 and five HIV-2 infected children aged < 15 years were initiated on cART over this time period. HIV-1 infected children were treated with a combination of Zidovudine or Stavudine + Lamivudine + Nevirapine or Efavirenz while children with HIV-2 were treated with Zidovudine + Lamivudine + ritonavir-boosted Lopinavir. HIV-1 infected children were followed-up for a median (IQR) duration of 20.1 months (6.9 – 34.3), with their median (IQR) age at treatment initiation, CD4% and plasma viral load at baseline found to be 4.9 years (2.1 – 9.1), 13.0% (7.0 – 16.0) and 5.4 log10 copies/ml (4.4 – 6.0) respectively. The median age at treatment initiation of the five HIV-2 infected children was 12 years (range: 4.6 – 14.0) while their median baseline CD4+ T cell count and HIV-2 viral load were 140 cells/mm3 (Range: 40 – 570 cells/mm3) and 4.5 log10copies/mL (Range: 3.1 - 4.9 log10copies/mL) respectively. Among HIV-1 infected children <5 years of age at ART initiation, the median (IQR) increases in CD4% from baseline to 12, 24 and 36 months were 14% (8 – 19; P = 0.0004), 21% (15 – 22; P = 0.005) and 15% (15 – 25; P = 0.0422) respectively, while the median (IQR) increase in absolute CD4 T cell count from baseline to 12, 24 and 36 months for those ≥5 years at ART initiation were 470 cells/mm3 (270 – 650; P = 0.0005), 230 cells/mm3 (30 – 610; P = 0.0196) and 615 cells/mm3 (250 – 1060; P = 0.0180) respectively. The proportions of children achieving undetectable HIV-1 viral load at 6-, 12-, 24- and 36 months of treatment were 24/38 (63.2%), 20/36 (55.6%), 8/22 (36.4%) and 7/12 (58.3%) respectively. The probability of survival among HIV-1 infected children after 12 months on ART was 89.9% (95% CI 78.8 – 95.3). CD4 T cell recovery was sub-optimal in all the HIV-2 infected children and none achieved virologic suppression. Two of the HIV-2 infected children died within 6 months of starting treatment while the remaining three were lost to follow-up. Conclusions The beneficial effects of cART among HIV-1 infected children in our setting are sustained in the first 24 months of treatment with a significant improvement in survival experience up to 36 months; however the outcome was poor in the few HIV-2 infected children initiated on cART.
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Affiliation(s)
- Uduak Okomo
- Medical Research Council (UK) Laboratories, Fajara, Banjul, The Gambia.
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Charpentier C, Gody JC, Mbitikon O, Moussa S, Matta M, Péré H, Fournier J, Longo JDD, Bélec L. Virological response and resistance profiles after 18 to 30 months of first- or second-/third-line antiretroviral treatment: a cross-sectional evaluation in HIV type 1-infected children living in the Central African Republic. AIDS Res Hum Retroviruses 2012; 28:87-94. [PMID: 21599597 DOI: 10.1089/aid.2011.0035] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A total of 242 HIV-1-infected children were followed up at the Complexe Pédiatrique of Bangui, Central African Republic, including 165 receiving antiretroviral treatment in first- (n=150) or second-/third-line (n=15) regimens. They were prospectively included in a study, in 2009, to assess their virological status and prevalence of antiretroviral drug-resistance mutations in cases of virological failure, according to revised 2010 WHO criteria (e.g., HIV-1 RNA >3.7 log(10) copies/ml). Detectable plasma HIV-1 RNA was observed in 53% of children under first-line treatment, and virological failure was diagnosed in 40%, which was associated in 85% of cases with viruses harboring at least one drug-resistance mutation to nucleoside reverse transcriptase inhibitors (NRTI) or nonnucleoside reverse transcriptase inhibitors (NNRTI), and in 36% of cases with at least one major drug-resistance mutation to NRTI or NNRTI when excluding the M184V mutation. Overall, the proportion of children receiving a first-line regimen for a median of 18 months with virological failure associated with drug-resistance mutations, and thus eligible for a second-line treatment, was estimated at 34% of the whole cohort. In children under second-/third-line therapy, virological failure occurred in 47%, plus at least one major drug-resistance mutation to NRTI or NNRTI, though less commonly to protease inhibitors. Taken together, these findings argue in favor of the urgent need to improve distribution of pediatric antiretroviral drugs in the Central African Republic, to increase adherence by treated children, and to offer adequate HIV biological monitoring.
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Affiliation(s)
- Charlotte Charpentier
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Laboratoire de Virologie, and Université Paris Descartes, Paris, France
| | - Jean-Chrysostome Gody
- Complexe Pédiatrique and Faculté des Sciences de la Santé, Bangui, République Centrafricaine
| | - Olivia Mbitikon
- Complexe Pédiatrique and Faculté des Sciences de la Santé, Bangui, République Centrafricaine
| | - Sandrine Moussa
- Institut Pasteur de Bangui, Bangui, République Centrafricaine
| | - Mathieu Matta
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Laboratoire de Virologie, and Université Paris Descartes, Paris, France
| | - Hélène Péré
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Laboratoire de Virologie, and Université Paris Descartes, Paris, France
| | - Julien Fournier
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Laboratoire de Virologie, and Université Paris Descartes, Paris, France
| | - Jean De Dieu Longo
- Ministère de la Santé Publique, de la Population et du SIDA et Unité de Recherches et d'Intervention sur les Maladies Sexuellement Transmissibles et le SIDA, Faculté des Sciences de la Santé, Bangui, République Centrafricaine
| | - Laurent Bélec
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Laboratoire de Virologie, and Université Paris Descartes, Paris, France
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Ahoua L, Guenther G, Rouzioux C, Pinoges L, Anguzu P, Taburet AM, Balkan S, Olson DM, Olaro C, Pujades-Rodríguez M. Immunovirological response to combined antiretroviral therapy and drug resistance patterns in children: 1- and 2-year outcomes in rural Uganda. BMC Pediatr 2011; 11:67. [PMID: 21791095 PMCID: PMC3176156 DOI: 10.1186/1471-2431-11-67] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 07/26/2011] [Indexed: 02/05/2023] Open
Abstract
Background Children living with HIV continue to be in urgent need of combined antiretroviral therapy (ART). Strategies to scale up and improve pediatric HIV care in resource-poor regions, especially in sub-Saharan Africa, require further research from these settings. We describe treatment outcomes in children treated in rural Uganda after 1 and 2 years of ART start. Methods Cross-sectional assessment of all children treated with ART for 12 (M12) and 24 (M24) months was performed. CD4 counts, HIV RNA levels, antiretroviral resistance patterns, and non-nucleoside reverse transcriptase inhibitor (NNRTI) plasma concentrations were determined. Patient adherence and antiretroviral-related toxicity were assessed. Results Cohort probabilities of retention in care were 0.86 at both M12 and M24. At survey, 71 (83%, M12) and 32 (78%, M24) children remained on therapy, and 84% participated in the survey. At ART start, 39 (45%) were female; median age was 5 years. Median initial CD4 percent was 11% [IQR 9-15] in children < 5 years old (n = 12); CD4 count was 151 cells/mm3 [IQR 38-188] in those ≥ 5 years old (n = 26). At M12, median CD4 gains were 11% [IQR 10-14] in patients < 5 years old, and 206 cells/mm3 [IQR 98-348] in ≥ 5 years old. At M24, median CD4 gains were 11% [IQR 5-17] and 132 cells/mm3 [IQR 87-443], respectively. Viral suppression (< 400 copies/mL) was achieved in 59% (M12) and 33% (M24) of children. Antiretroviral resistance was found in 25% (M12) and 62% (M24) of children. Overall, 29% of patients had subtherapeutic NNRTI plasma concentrations. Conclusions After one year of therapy, satisfactory survival and immunological responses were observed, but nearly 1 in 4 children developed viral resistance and/or subtherapeutic plasma antiretroviral drug levels. Regular weight-adjustment dosing and strategies to reinforce and maintain ART adherence are essential to maximize duration of first-line therapy in children in resource-limited countries.
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Ndondoki C, Dabis F, Namale L, Becquet R, Ekouevi D, Bosse-Amani C, Arrivé E, Leroy V. Survie et évolution clinique et biologique des enfants infectés par le VIH traités par les antiretroviraux en Afrique : revue de littérature, 2004–2009. Presse Med 2011. [DOI: 10.1016/j.lpm.2010.11.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Peacock-Villada E, Richardson BA, John-Stewart GC. Post-HAART outcomes in pediatric populations: comparison of resource-limited and developed countries. Pediatrics 2011; 127:e423-41. [PMID: 21262891 PMCID: PMC3025421 DOI: 10.1542/peds.2009-2701] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2010] [Indexed: 11/24/2022] Open
Abstract
CONTEXT No formal comparison has been made between the pediatric post-highly active antiretroviral therapy (HAART) outcomes of resource-limited and developed countries. OBJECTIVE To systematically quantify and compare major baseline characteristics and clinical end points after HAART between resource-limited and developed settings. METHODS Published articles and abstracts (International AIDS Society 2009, Conference on Retroviruses and Opportunistic Infections 2010) were examined from inception (first available publication for each search engine) to March 2010. Publications that contained data on post-HAART mortality, weight-for-age z score (WAZ), CD4 count, or viral load (VL) changes in pediatric populations were reviewed. Selected studies met the following criteria: (1) patients were younger than 21 years; (2) HAART was given (≥ 3 antiretroviral medications); and (3) there were >20 patients. Data were extracted for baseline age, CD4 count, VL, WAZ, and mortality, CD4 and virologic suppression over time. Studies were categorized as having been performed in a resource-limited country (RLC) or developed country (DC) on the basis of the United Nations designation. Mean percentage of deaths per cohort and deaths per 100 child-years, baseline CD4 count, VL, WAZ, and age were calculated for RLCs and DCs and compared by using independent samples t tests. RESULTS Forty RLC and 28 DC publications were selected (N = 17 875 RLCs; N = 1835 DC). Mean percentage of deaths per cohort and mean deaths per 100 child-years after HAART were significantly higher in RLCs than DCs (7.6 vs 1.6, P < .001, and 8.0 vs 0.9, P < .001, respectively). Mean baseline CD4% was 12% in RLCs and 23% in DCs (P = .01). Mean baseline VLs were 5.5 vs 4.7 log(10) copies per mL in RLCs versus DCs (P < .001). CONCLUSIONS Baseline CD4% and VL differ markedly between DCs and RLCs, as does mortality after pediatric HAART. Earlier diagnosis and treatment of pediatric HIV in RLCs would be expected to result in better HAART outcomes.
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Barth RE, Tempelman HA, Smelt E, Wensing AM, Hoepelman AI, Geelen SP. Long-term outcome of children receiving antiretroviral treatment in rural South Africa: substantial virologic failure on first-line treatment. Pediatr Infect Dis J 2011; 30:52-6. [PMID: 20631647 DOI: 10.1097/INF.0b013e3181ed2af3] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Long-term (>12 months follow-up) virologic data of children receiving antiretroviral therapy (ART) in Sub-Saharan Africa are limited. Data from rural areas are especially scarce. The aim of this study was to evaluate the long-term virologic outcome of a pediatric cohort in rural South Africa. METHODS We performed a retrospective, observational cohort study, including children who initiated ART at least 1 year before data-analysis. Regular monitoring, including HIV-RNA testing, was performed. Genotypic resistance testing was done for children with virologic failure (HIV-RNA >1000 copies/mL). Logistic regression analysis was used to determine predictors of virologic failure. RESULTS A total of 101 children were included. Median duration since beginning ART was 31 months. Overall patient retention-rate was 76% (77/101), with early mortality being the main cause of attrition (13/24, 54%). Initial immunologic and virologic responses were excellent. However, 38% (31/81) of children subsequently experienced virologic failure. Correlation between virologic failure and immunologic decline was nearly absent. At the time of failure, multiple non-nucleoside reverse transcription inhibitor-associated mutations were observed in 52% (12/23) of children. No definite predictors of virologic failure could be determined. CONCLUSIONS ART provides significant benefits for children in this rural African setting, but the finding that a large proportion of children had virologic failure and developed major drug-resistance mutations on first-line ART is worrying. Causes of failure need to be analyzed and effective prevention strategies are needed. Because of the lack of a correlation between immunologic and virologic failure, treatment failure generally stays unnoticed in settings where HIV-RNA testing is not available.
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Naidoo R, Rennert W, Lung A, Naidoo K, McKerrow N. The influence of nutritional status on the response to HAART in HIV-infected children in South Africa. Pediatr Infect Dis J 2010; 29:511-3. [PMID: 20179664 DOI: 10.1097/INF.0b013e3181d1e989] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While the impact of HAART on growth in children is well established, the influence of prior nutritional status on the response to HAART is not well known. METHODS A retrospective study was conducted on 120 children in South Africa. Patients were divided into 3 groups (normal, moderately underweight, and severely underweight) based on weight-for-age z-scores (WAZ). Age, weight, height, CD4 cell percentage, and viral load were recorded at initiation of HAART and after 24 months of therapy. Data were analyzed using t-tests, chi tests, and one-way ANOVA. RESULTS At baseline, 58% of children were normal weight, 18% moderately underweight, and 23% severely underweight. After 24 months of HAART, WAZ improved significantly in moderately and severely underweight patient groups compared with the normal group. Height-for-age z-scores (HAZ) increased in all 3 groups with severely underweight children gaining more height than normal weight counterparts. Weight-for-height z-scores (WHZ) normalized in the severely underweight group. Mean CD4 cell percentages increased significantly in all 3 groups while viral loads decreased significantly in all groups with no differences among the groups at the end of 24 months of therapy. Of the entire cohort, 75% achieved undetectable HIV RNA viral loads. CONCLUSIONS Underlying malnutrition does not adversely affect growth, immunologic or virologic response to HAART in HIV-infected children. Underweight children exhibit an equally robust response to treatment as their well-nourished peers.
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Towler WI, Barlow-Mosha L, Church JD, Bagenda D, Ajuna P, Mubiru M, Musoke P, Eshleman SH. Analysis of drug resistance in children receiving antiretroviral therapy for treatment of HIV-1 infection in Uganda. AIDS Res Hum Retroviruses 2010; 26:563-8. [PMID: 20455758 DOI: 10.1089/aid.2009.0164] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We analyzed drug resistance in HIV-infected Ugandan children who received antiretroviral therapy in a prospective, observational study (2004-2006); some children had prior single-dose nevirapine (sdNVP) exposure. Children received stavudine (d4T), lamivudine (3TC), and nevirapine (NVP); treatment was continued if they were clinically and immunologically stable. Samples with >1,000 copies/ml HIV RNA were analyzed by using the ViroSeq HIV Genotyping System (ViroSeq). Subtype A and D pretreatment samples also were analyzed with the LigAmp assay (for K103N, Y181C, and G190A). ViroSeq results were obtained for 74 pretreatment samples (35 from sdNVP-exposed children (median age, 19 months) and 39 from sdNVP-unexposed children (median age, 84 months). This included 39 subtype A, 22 subtype D, 1 subtype C, and 12 inter-subtype recombinant samples. One sample had nonnucleoside reverse transcriptase inhibitor (NNRTI) resistance, one had nucleoside reverse transcriptase inhibitor (NRTI) resistance, and three had protease inhibitor (PI) resistance. Y181C was detected by using LigAmp in five pretreatment samples [four (14.8%) of 37 samples from sdNVP-exposed children, one (4.2%) of 24 samples from children without prior sdNVP exposure; p = 0.35]. Among children who were not virally suppressed at 48 weeks of treatment, all 12 tested had NNRTI resistance, as well as resistance to 3TC and emtricitibine (FTC); three had resistance to other NRTIs. Seven of those children had a ViroSeq result at 96 weeks of treatment; four of the seven acquired resistance to additional NRTIs by 96 weeks. In Uganda, clinically and immunologically stable children receiving nonsuppressive antiretroviral treatment regimens are at risk for development of drug resistance.
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Affiliation(s)
- William I. Towler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Linda Barlow-Mosha
- Makerere University-Johns Hopkins University Research Collaboration (MU-JHU), Baltimore, Maryland and Kampala, Uganda
| | - Jessica D. Church
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Danstan Bagenda
- Makerere University-Johns Hopkins University Research Collaboration (MU-JHU), Baltimore, Maryland and Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Patrick Ajuna
- Makerere University-Johns Hopkins University Research Collaboration (MU-JHU), Baltimore, Maryland and Kampala, Uganda
| | - Micheal Mubiru
- Makerere University-Johns Hopkins University Research Collaboration (MU-JHU), Baltimore, Maryland and Kampala, Uganda
| | - Philippa Musoke
- Makerere University-Johns Hopkins University Research Collaboration (MU-JHU), Baltimore, Maryland and Kampala, Uganda
- Department of Paediatrics, Makerere University, Mulago, Kampala, Uganda
| | - Susan H. Eshleman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Germanaud D, Derache A, Traore M, Madec Y, Toure S, Dicko F, Coulibaly H, Traore M, Sylla M, Calvez V, Marcelin AG. Level of viral load and antiretroviral resistance after 6 months of non-nucleoside reverse transcriptase inhibitor first-line treatment in HIV-1-infected children in Mali. J Antimicrob Chemother 2010; 65:118-24. [PMID: 19933171 DOI: 10.1093/jac/dkp412] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate the virological response and to describe the resistance profiles in the case of failure after 6 months of first-line highly active antiretroviral therapy (HAART) in HIV-1-infected children living in resource-limited settings. PATIENTS AND METHODS Ninety-seven HIV-1-infected children who started two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) (mainly zidovudine/lamivudine/nevirapine) in Mali were prospectively studied. Virological failure (VF) was defined as loss to follow-up, death or HIV-1 RNA viral load (VL) of >400 copies/mL at 6 months. When VL was >50 copies/mL, a genotypic resistance test was performed. RESULTS Among the 97 children, median age at antiretroviral initiation was 31 months and the majority were in WHO clinical (77.3%) and immunological (70.1%) stage III or IV. At month 6, 44% of children had VL > 400 copies/mL (61% VF). Among the children with detectable VL, 30/37 genotypic resistance tests were available, 8 with wild-type viruses and 22 with resistance mutations (73%): 19 M184V/I, 21 NNRTI mutations and only 3 thymidine analogue mutations (TAMs) (K70R, D67N and L210W in three distinct viruses). At failure, 6/8 children with wild-type viruses had a VL of <1000 copies/mL whereas 21/22 with resistant viruses had a VL of >1000 copies/mL. CONCLUSIONS Under NNRTI-based regimens, early detection of VF could allow the reinforcement of adherence when VL was <1000 copies/mL, because in most of these cases no resistance mutations were detected, or a change to a protease inhibitor-based regimen if VL was >1000 copies/mL. The low frequency of TAMs suggests that most NRTIs can be used in a second-line regimen after early failure.
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Hoffmann CJ, Charalambous S, Sim J, Ledwaba J, Schwikkard G, Chaisson RE, Fielding KL, Churchyard GJ, Morris L, Grant AD. Viremia, resuppression, and time to resistance in human immunodeficiency virus (HIV) subtype C during first-line antiretroviral therapy in South Africa. Clin Infect Dis 2009; 49:1928-35. [PMID: 19911963 PMCID: PMC2789416 DOI: 10.1086/648444] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Episodes of viremia are common in African antiretroviral therapy (ART) programs. We sought to describe viremia, resuppression, and accumulation of resistance during first-line combination ART (cART) in South Africa. METHODS Retrospective analysis of a cohort receiving zidovudine, lamivudine, and either efavirenz or nevirapine with human immunodeficiency virus (HIV) RNA monitoring every 6 months. We assessed viremia (HIV RNA >1000 copies/mL after initial HIV RNA response) and resuppression (HIV RNA <400 copies/mL after viremia). Genotypic resistance testing was performed using stored plasma on a subset of patients at first detection of viremia and subsequently among patients with persistent viremia. RESULTS Between 2002 and 2006, 3727 patients initiated cART (median CD4, 147 cells/mm(3)). Of 1007 patients who developed viremia, 815 had subsequent HIV RNA assays, and 331 (41%) of these resuppressed without regimen switch. At identification of viremia, 45 (66%) of 68 patients had HIV-1 drug resistance, 42 (62%) had nonnucleoside reverse-transcriptase inhibitor (NNRTI)-resistance, 25 (37%) had M184V/I, and 4 (6%) had multi-nucleoside analogue drug mutations. By 12 months of persistent viremia among a subset of 14 patients with resistance testing to 12 months, 11 (78%) had nonnucleoside reverse-transcriptase inhibitor (NNRTI)-resistance, 8 (57%) had M184V/I, and 2 (14%) had multi-nucleoside analogue drug mutations. Resistance was associated with a reduced probability of resuppression; however, 50% of patients with NNRTI resistance resuppressed while receiving an NNRTI. CONCLUSIONS The majority of patients had NNRTI resistance mutations at detection of viremia. However, 41% resuppressed without regimen switch. Our findings support maximizing first-line use while minimizing risk of significant cross-resistance by implementing intensive adherence support and repeat HIV RNA testing 3-6 months after detecting viremia, with regimen switch only if viremia persists.
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Affiliation(s)
- Christopher J Hoffmann
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland 21205, USA.
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Vaz P, Chaix ML, Jani I, Macassa E, Bila D, Vubil A, Anderson S, Rouzioux C, Briand N, Blanche S. Risk of extended viral resistance in human immunodeficiency virus-1-infected Mozambican children after first-line treatment failure. Pediatr Infect Dis J 2009; 28:e283-7. [PMID: 19907359 DOI: 10.1097/INF.0b013e3181ba6c92] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Resistant virus may be selected by sub-optimal control of HIV-1 replication during antiretroviral treatment. The incidence and profile of resistance in children receiving World Health Organization-recommended treatment remains to be evaluated on a large scale. GOALS Assessment of the frequency and profile of resistant virus in HIV-1-infected children, treated for at least 6 months with stavudine/zidovudine + lamivudine + nevirapine and presenting virological failure in a large access program in Maputo, Mozambique. RESULTS Cross-sectional evaluation of plasma HIV-1 viral load (VL) in 495 evaluable children among 512 treated for at least 6 months showed that 360 (72.7%) had a VL of <50 copies/mL of HIV-1 RNA. Genotypic resistance tests were performed in the 84 available samples from the 135 treated children with VL > or = 50 copies/mL: 92% of the viruses were resistant to lamivudine and/or nevirapine, and 15% were resistant to stavudine. Twenty children (24%) harbored virus with a extended spectrum of cross-resistance defined as resistance to the 3 drugs of the combination received by the child and/or at least 1 resistance to a drug to which the child had never been exposed (abacavir: 5%, tenofovir: 6%, didanosine: 3.5% and the new generation non nucleoside inhibitor, etravirine: 6%). The only factor identified by multivariate analysis as being associated with this extended resistance profile was the duration of treatment (aOR: 6.67 [95% CI: 1.24-35.93], P = 0.015 for treatment >24 months) with a per month increase of 1.09 (1.02-1.16) P = 0.007. CONCLUSIONS Residual viral replication in children receiving stavudine/zidovudine + lamivudine + nevirapine treatment is associated with a time-dependent risk of acquiring cross-resistance, including resistance to drugs currently used for second-line treatment and also to the new generation of non nucleoside reverse transcriptase inhibitors.
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Lehman TL, O'Halloran KP, Hoover EA, Avery PR. Utilizing the FIV model to understand dendritic cell dysfunction and the potential role of dendritic cell immunization in HIV infection. Vet Immunol Immunopathol 2009; 134:75-81. [PMID: 19896214 DOI: 10.1016/j.vetimm.2009.10.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Dendritic cells (DC) are potent antigen presenting cells which initiate and coordinate the immune response making them central targets of and attractive candidates for manipulation in chronic lentiviral infections. Emerging evidence suggests that DC immune function is disrupted during both acute and chronic infection with human immunodeficiency virus (HIV), simian immunodeficiency virus (SIV), and feline immunodeficiency virus (FIV). Despite some early promising data, the use of DC for lentiviral immunotherapy has not fulfilled its expected potential and has been complicated by the large number of variables involved in DC harvesting, purifying, and antigen loading. Pre-clinical studies aimed at identifying successful strategies for DC augmentation of current HIV treatment protocols are needed. Over the past two decades, the FIV model for HIV infection has increased the understanding of retroviral pathogenesis, and studies have begun using the FIV model to study DC dysfunction and DC-mediated immunotherapy. Careful consideration of the many variables involved in DC function and therapy should help develop protocols to explore the potential of DC vaccine-based therapies for lentiviral infection.
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Affiliation(s)
- Tracy L Lehman
- Department of Microbiology, Immunology, and Pathology, Colorado State University, 1619 Campus Delivery, Colorado State University, Fort Collins, CO 80523, USA.
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Abstract
Even as pediatric rollout programs are struggling to meet global need, increasing numbers of children are failing first-line antiretroviral therapy in low- and middle-income countries. Without better access to viral load monitoring, second-line antiretrovirals and research to guide optimal regimen selection, it will be difficult to ensure that HIV-infected children will survive into adulthood. Data available on pediatric drug resistance demonstrate that failure occurs early in childhood. Studies of salvage drug options have been promising, but are primarily conducted in adults. Evidence-based approaches to regimen selection, pediatric antiretroviral formulations and expanded access to novel drugs are now required to prepare for the future.
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Affiliation(s)
- Annette H Sohn
- TREAT Asia/amfAR – The Foundation for AIDS Research, Bangkok, Thailand
| | - Jintanat Ananworanich
- The Southeast Asia Research Collaboration with Hawaii (SEARCH), Bangkok, Thailand
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
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Mubiana-Mbewe M, Bolton-Moore C, Banda Y, Chintu N, Nalubamba-Phiri M, Giganti M, Guffey MB, Sambo P, Stringer EM, Stringer JSA, Chi BH. Causes of morbidity among HIV-infected children on antiretroviral therapy in primary care facilities in Lusaka, Zambia. Trop Med Int Health 2009; 14:1190-8. [PMID: 19708902 DOI: 10.1111/j.1365-3156.2009.02360.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the pattern of incident illness in children after initiation of antiretroviral therapy (ART) in a large public health sector programme in Lusaka, Zambia. METHODS Systematic chart review to retrospectively extract data from medical records of children (i.e. <15 years) initiating ART in the Lusaka, Zambia public sector. Incident conditions were listed separately and then grouped according to broad categories. Predictors for incident diagnoses were determined using univariate and multivariable analysis. RESULTS Between May 2004 and June 2006, 1705 HIV-infected children initiated ART. Of these, 1235 (72%) had their medical records reviewed. Median age at ART initiation was 77 months and 554 (45%) were females. Eight hundred and forty-one (68%) children had an incident condition during this period, with a median time of occurrence of 64 days from ART initiation. Twenty-eight incident conditions were documented. When categorized, the most common were mucocutaneous conditions [incidence rate (IR): 70.6 per 100 child-years, 95% CI: 64.5-77.2] and upper respiratory tract infection (IR: 70.1 per 100 child-years; 95% CI: 64.0-76.7). Children with severe immunosuppression (i.e. CD4 < 10%) were more likely to develop lower respiratory tract infection (16.3%vs. 10.2%; P = 0.003) and mucocutaneous conditions (43.9% vs. 35.3%; P = 0.005) than those with CD4 > or = 10%. CONCLUSION There is a high incidence of new illness after ART initiation, emphasizing the importance of close monitoring during this period. Early initiation of ART and use of antimicrobial prophylaxis may also help to reduce the occurrence of such co-morbidities.
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Abstract
PURPOSE OF REVIEW Children have higher rates of virological failure than adults, often associated with more extensive resistance and limited second-line options. In order to maintain clinical benefits of highly active antiretroviral therapy (HAART) into adulthood, particularly for children starting at a young age, strategies are needed to limit the emergence of resistance and to offer highly effective subsequent lines of therapy. Similarly, well resourced settings face challenges regarding extensive resistance accumulated over the past decade or more, particularly resulting from suboptimal therapies. RECENT FINDINGS Rates of resistance at failure of nonnucleoside reverse-transcriptase inhibitor based HAART are higher in developing countries than in well resourced settings. In the latter, second-generation protease inhibitors tipranavir and darunavir are promising, with tipranavir now licensed for those above 2 years and darunavir showing good trial results in children above 6 years. However, combination with new classes such as integrase inhibitors (currently in phase I trials) and CCR5 antagonists (no paediatric data yet) will probably be necessary to gain maximal long-term benefits. SUMMARY Common goals in paediatric HIV for both resource-rich and resource-limited settings are to limit vertical transmission, minimize emergence of resistant viruses in both mother and child where prevention of mother-to-child transmission fails, and limit resistance in children starting HAART. Optimal sequencing of regimens in the absence of resistance testing is a priority research area. Paediatric studies using newer classes of agents are of paramount importance, as well as expanding access to existing antiretrovirals.
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