The diagnosis and treatment of HIV-infected children in China: challenges and opportunities

We don't dare to tell her … we don't know where to begin: Disclosure experiences and challenges among adolescents living with HIV and their caregivers in China

Background and Objectives

With increasing access to antiretroviral therapy, HIV-infected youth are living longer, but are vulnerable as they navigate the transition to adulthood while managing a highly stigmatized condition. Knowing one's HIV status is critical to assuming responsibility for one's health. The process of disclosure to adolescents living with HIV is not well understood globally, even less so in China. To help address this gap, we explored practices for disclosure to adolescents living with HIV (ALHIV) among Chinese caregivers and clinicians, and the disclosure experiences of the adolescents themselves using qualitative methods.

Design and Setting

The study was conducted in 2014 at the Guangxi Center for Disease Control and Prevention ART (CDC-ART) clinic in Nanning, China. We used a qualitative design, incorporating in-depth interviews (IDIs) and focus group discussions (FGDs).

Patients and Methods

We conducted IDIs with 19 adolescent/caregiver dyads and five FGDs with adolescents and clinicians. Adolescent participants were aged 10–15 years, and had contracted HIV perinatally. Using NVivo^TM software, we summarized major themes.

Results

Only 6/19 caregivers reported disclosing to their child; matched adolescents' statements indicate that 9/19 children knew their HIV status. Caregivers planned to disclose when children were 14 years or older. Concerns about stigma toward children and families were associated with reluctance to disclose.

Conclusion

Disclosure to adolescents living with HIV in China was delayed compared with recommended guidelines. Culturally appropriate disclosure strategies should be developed, focused on supporting caregivers and de-stigmatizing HIV.

Impact of Single Nucleotide Polymorphisms on Plasma Concentrations of Efavirenz and Lopinavir/Ritonavir in Chinese Children Infected with the Human Immunodeficiency Virus

Single nucleotide polymorphisms (SNPs) in the genes that encode the cytochrome P450 (CYP) drug metabolizing enzymes and drug transporters have been reported to influence antiretroviral drug pharmacokinetics. Although primarily metabolized by CYP2B6 and -3A, efavirenz (EFV) and lopinavir/ritonavir (LPV/r) are substrates of P-glycoprotein and the solute carrier organic (SLCO) anion transporter, respectively. We investigated the association between SNPs and efavirenz (EFV) or lopinavir/ritonavir (LPV/r) concentrations in Chinese children infected with the human immunodeficiency virus (HIV). Genotyping was performed on CYP2B6 516G→T, -1459C→T, and -983T→C, ABCB1 3435C→T, and SLCO1B1 521T→C in 229 HIV-infected Chinese pediatric patients (age range 4.0 to 17.5 yrs). Plasma concentrations of EFV and LPV/r were measured using validated high-performance liquid chromatography coupled with the mass spectrum method among 39 and 69 children who received EFV- and LPV/r-containing regimens, respectively. The frequencies of CYP2B6 516G→T in the study participants were 71%, 25%, and 4% for the G/G, G/T, and T/T genotypes, respectively. Among the children under therapeutic drug monitoring, 21% and 39% experienced EFV and LPV concentrations, respectively, above the upper threshold of the therapeutic window. CYP2B6 516G→T was significantly associated with EFV concentrations (p<0.001). Older children (older than 10 yrs) were more likely to have significantly higher EFV concentrations than the younger ones (p=0.0314). CYP2B6 genotyping and EFV concentration monitoring may help optimize antiretroviral therapy in pediatric patients who initiate an EFV-based regimen.

Rapid and Simultaneous Detection of Major Drug Resistance Mutations in Reverse Transcriptase Gene for HIV-1 CRF01_AE, CRF07_BC and Subtype B in China Using Sequenom MassARRAY® System

The development of a rapid, high-throughput and cost-effective HIV-1 drug resistance (HIV-DR) testing system is a challenge for areas consisting different HIV-1 strains. In this study, we established a broadly reactive multiplex assay that could simultaneously detect major drug resistance mutations at 8 loci, which are associated with resistance to commonly used nucleoside reverse transcriptase inhibitors (NRTIs) and Non-nucleoside reverse transcriptase inhibitors (NNRTIs), in specimens of HIV-1 CRF01_AE, CRF07_BC and subtype B, the three major circulating strains in China, using the matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) provided by Sequenom MassARRAY® system. To establish the assay, pol gene fragments were prepared from the plasma viral RNA of 159 patients by nested PCR and the presence of wild type and mutant alleles at the 8 loci were analyzed by MALDI-TOF MS. In terms of loci, the detection rate of the alleles was greater than 97% for M41L, K65R, M184V and G190A, 91.2% for K101E/Q/P, 91.2% for T215F/Y, 89.9% for K103N/S and 80.5% for L210W. In terms of individuals, 80% of the alleles were detected in 95.4% CRF01_AE patients, 100% CRF07_BC patients and 83.3% subtype B patients. Importantly, the MALDI-TOF MS results were concordant to the drug resistance profiles of patients obtained from conventional sequencing analysis after excluded the failed detections. Using plasmid templates, the assay was estimated to be sensitive to detect drug resistant variants at level about 20% of the circulating viral population. The capability of this assay to detect mixed viral populations was further verified by two different patient specimens. In conclusion, this study evaluated the use of Sequenom MassARRAY® system for high-throughput detection of HIV-DR mutations towards the commonly used reverse transcriptase inhibitors in China.

Prevention of mother-to-child HIV transmission cascade in China: a systematic review and meta-analysis

INTRODUCTION

The Chinese government has invested US$140 million annually on prevention of mother-to-child transmission (PMTCT) of HIV. This study evaluates the programme by examining the improvements in programme coverage HIV testing and provision of antiviral drugs along the PMTCT cascade.

METHODS

Data for PMTCT cascade indicators were collected through a comprehensive systematic review of published peer-reviewed English and Chinese literature during 2003-2011. Meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

This study included 113 publications. HIV prevalence among pregnant women in China who accessed antenatal care (ANC) remained below 0.1% during the past decade. HIV testing coverage in pregnant women attending ANC and in HIV-exposed infants at 18 months significantly increased from 62.4% (95% CI 4.7% to 98.2%) and 22.1% (16.3% to 32.3%) in 2003 to 90.3% (88.4% to 91.8%) and 82.8% (66.9% to 99.5%) in 2011 respectively, whereas antiretroviral (ARV) prophylaxis uptake increased from 35.2% (12.2% to 47.3%) and 26.9% (24.3% to 28.9%) to 86.2% (53.2% to 97.2%) and 90.3% (85.5% to 93.7%). HIV vertical transmission rate substantially decreased from 31.8% (25.7% to 38.6%) prior to the programme to 2.3% (1.4% to 3.8%) in 2011. During 2003-2011, among 25,312 (23,995-26,644) infants born to HIV-positive mothers who received ARV prophylaxis, 975 (564-1395) were diagnosed with HIV, corresponding to an average transmission rate of 3.9% (3.2% to 4.6%). However, while including transmissions among HIV-positive pregnant women who were lost along the cascade, the average transmission rate during 2003-2011 was 17.4% (15.8% to 19.0%).

CONCLUSIONS

PMTCT programmes have reduced HIV mother-to-child transmission in China. Further improvements in the continuum of care remain essential in realising the full potential of the programme.

Incidence and associated factors of pulmonary tuberculosis in HIV-infected children after highly active antiretroviral therapy (HAART) in China: a retrospective study

China is a country with high tuberculosis (TB) incidence but relatively low HIV prevalence. However, due to difficulties in diagnosis and reporting, true burden of HIV-associated TB in children is unknown. The objective of this study was to describe the incidence of pulmonary TB (PTB) after antiretroviral therapy (ART) and to study risk factors. A retrospective study was performed based on routinely collected data from China national pediatric free antiretroviral treatment database. A total of 3365 children under 15 years on ART from July 2005 to October 2012 were included. Multivariable logistic regression was used to detect associated factors. Two thousand nine hundred and ninety (89%) children got infected from HIV-positive mother, with median age of 6.7 (4.1, 10.0) years at highly active antiretroviral therapy (HAART) initiation in this program. Seventy-seven (2.3%) children were diagnosed with PTB after ART during 7.3 years cohort observation. Median time of occurrence was 212 (30-514) days. Overall incidence was 0.83 (0.65-1.01)/100 person-years (py), with the peak of 3.6/100 py in the first 3 months after antiretroviral treatment. WHO stage IV at baseline showed 2 (95% CI 1.0-6.8) times more risk for developing TB. Late clinical stage at ART initiation was shown to relate with TB incidence. PTB coinfection leads to higher mortality. Early diagnosis and treatment of HIV are highly required to reduce HIV-associated morbidity and mortality due to TB.

A comparison between antenatal care quality in public and private sector in rural Hebei, China

Aim

To evaluate the quality of antenatal care (ANC) in Hebei Province and compare it between the public and private sector and within the public sector.

Methods

We conducted a Maternal, Newborn and Child Health Household Survey in 2010 using a two-stage sampling procedure and included 1079 mothers. The quality of ANC was assessed on the basis of the number of ANC visits, the time of the first ANC visit, 16 different ANC procedures, owning a maternal health care booklet, and the type of service provider.

Results

Almost all women (98%) received ANC services at least once, 80% at least four times, and 54% at least five times. About half of the women (46%) visited ANC facility within their first trimester. Neither public nor private sector provided all 16 standardized services, but significantly more women in public sector received ANC procedures. Most women received ANC in county or higher-level hospitals (75%) and very few in township hospitals (8%). Significantly fewer women were weighed and tested for HIV/AIDS in township than in county or higher-level hospitals.

Conclusion

The quality of ANC in Hebei was poorer than required by China’s national and World Health Organization norms. Although the public sector performed better than the private sector, the utilization and quality of care of ANC services in this sector varied and women generally visited county or higher-level health facilities.

Progress of the National Pediatric Free Antiretroviral Therapy program in China

In 2003, the Chinese Government initiated a free antiretroviral therapy (ART) program focusing on adult AIDS patients. Pediatric antiretroviral (ARV) formulations were yet unavailable. It was not until July 2005, with the initiation of a two-stage program implemented by the Chinese Ministry of Health, that pediatric formulations became accessible in China. Initially, the pediatric ART program was piloted in six provinces with the highest incidences of pediatric HIV/AIDS. The pilot stage allowed the Chinese Center for Disease Control and Prevention (CCDC) to finalize entry criteria, treatment regimen, and patient monitoring and follow-up procedures. The second stage commenced at the end of 2006 when the program was scaled-up nationally. In order to guarantee treatment of pediatric patients, extensive training in the selection of appropriate ARV drug regimen and dosage was provided to doctors, often through on-site collaboration with domestic and international experts. The CCDC simultaneously established a pediatric ARV management system and a pediatric ART information system. CD4 count and other laboratory tests are being routinely performed on these pediatric patients. By the end of June 2009, 1529 pediatric patients had received ARV under the national program. However, challenges remain. Firstly, many children infected with HIV/AIDS live in rural areas where the treatment quality is hindered by the limited number of medical facilities and skilled medical workers. Secondly, much of the pediatric ARV drug supply depends on donation. An effort needs to be made by the Chinese Government to establish China's own drug procurement and supply system.

Knowledge, attitudes, perceived vulnerability of Chinese nurses and their preferences for caring for HIV-positive individuals: a cross-sectional survey

AIMS

The study was to assess HIV/AIDS knowledge, attitudes and perceived vulnerability with potential factors.

BACKGROUND

HIV/AIDS is a public health catastrophe in China. Nurses are expected to care for nurture, comfort and advocate for all patients regardless of their condition. However, in the area of HIV/AIDS, nurses suffer as a result of expectations put on them by their professional roles.

DESIGN

This was a descriptive, cross-sectional design that used a survey approach.

METHOD

Data were collected from Summer 2003-Winter 2004.

RESULTS

Nurses reported significant perceived severity of risk from occupational exposure. Many nurses were frequently exposed to being stuck by needles (86%) and being splashed by body fluids and more than half of them (59.7%) were concerned about contracting HIV/AIDS. Nurses who had experience of finger pricks worried about potentially contacting HIV and being unaware of it (odds ratio= 0.444, p = 0.004). Nurses demonstrated a lack of knowledge and training in infectious diseases which may be a result of the fact that the study location is not considered a 'concentrated area' for infectious disease transmission; therefore, the need for the infectious diseases training has not been considered urgent.

CONCLUSIONS

A well-designed educational programme on occupational hazards and risk behaviour should be implemented to educate nurses in suburban cities and the general public. Hospital administrators should implement on-site continuing education on HIV/AIDS throughout China. Armed with better knowledge of both transmission routes and precautions, nurses can protect themselves while providing care to patients.

RELEVANCE TO CLINICAL PRACTICE

Nurses in China urgently need psychosocial and physical supports from families, friends, communities and their working environments while combating HIV epidemic. With good support system, nurses will better educate patients and their family members on how to prevent transmission not only of HIV/AIDS but of a wide range of other infectious diseases as well.

Hepatitis B and hepatitis C seroprevalence in children receiving antiretroviral therapy for human immunodeficiency virus-1 infection in China, 2005-2009

BACKGROUND

Coinfection of hepatitis B virus (HBV) or hepatitis C virus (HCV) may compromise pediatric antiretroviral therapy (ART) in China. In this study, we evaluated the seroprevalence of HBV and HCV in children receiving ART and associated factors.

METHODS

Patients were selected from HIV-1-infected children under age 16 enrolled in China National Pediatric ART Cohort since July 2005. Medical assessments, hepatitis B surface antigen (HBsAg), and anti-HCV antibody serologies, and transaminase levels were obtained for analysis.

RESULTS

A total of 53 of 1082 children tested were HBsAg seropositive [4.9%; 95% confidence interval (CI): 3.6% to 6.2%], and 90 of 938 children tested were anti-HCV antibody positive (9.6%; 95% CI: 7.7% to 11.5%). No other serologic assays were performed for HBV detection. Age was associated with HBV coinfection in univariate analysis; older children were more likely to be HBsAg positive. Multivariate analysis revealed that children infected with HIV through transfusion of contaminated blood or blood products were more likely to be anti-HCV antibody positive than those infected with HIV through other routes (adjusted odds ratio = 6.2; 95% CI: 3.3% to 11.7%).

CONCLUSIONS

The high prevalence of HBV and HCV coinfection in HIV-infected children in China receiving ART demands routine screening for viral hepatitis coinfection, intensive prevention of childhood HBV and HCV transmission, and modification of the management of pediatric HIV infection.

Attitudes toward antiretroviral therapy and complementary and alternative medicine in Chinese patients infected with HIV

HIV is an emerging health issue in China, and effective antiretroviral therapy (ART) is now available throughout the country. Complementary and alternative medicine (CAM) includes traditional Chinese medicine (TCM) and has been used in Chinese society for more than 5,000 years. In the West, CAM use is widespread among HIV-infected individuals; however, rates of CAM use among HIV-infected individuals in China are unknown. This qualitative study explores issues related to attitudes toward ART and CAM in HIV-infected individuals in Beijing, China. Semistructured, in-depth interviews were used to explore attitudes, experiences, and perceptions about ART and CAM among people living with HIV (PLWH). Results indicate that Chinese PLWH have both positive and negative attitudes toward ART and CAM, which led many to report taking CAM not only for daily discomforts but to counteract the side effects of ART. This study shows that social, cultural, and governmental factors coalesced to shape Chinese PLWH attitudes toward ART and CAM.

Prevalence of drug-resistant HIV-1 in rural areas of Hubei province in the People's Republic of China

OBJECTIVE

To determine the prevalence of drug-resistant HIV-1 and the efficacy of first-line highly active antiretroviral therapy (HAART) regimens consisted of generic nucleoside reverse transcriptase inhibitor and nonnucleoside reverse transcriptase inhibitor among 339 study subjects in rural areas of Hubei province, China.

METHODS

Two cross-sectional studies were conducted to investigate 150 HAART-naive (99 received subsequent therapy) between 2003 and 2005 and 288 HAART-experienced patients mainly between 2005 and 2006. Patients' CD4+ T-cell count and viral load were determined. HIV-1 pol gene fragments were amplified from patients' plasma by reverse transcriptase-polymerase chain reaction, subsequently sequenced and analyzed.

RESULTS

About 83.5% of the patients were from rural villages. They were dominantly infected with subtype B' HIV-1 (96.7%) through paid blood donation (64.6%) and related blood transfusion (28.3%). We found that there was a steady increase of CD4 count over time among treated patients without detectable viral load (186/288, 64.6%). There was, however, an increasing prevalence of nucleoside reverse transcriptase inhibitor- and nonnucleoside reverse transcriptase inhibitor-resistant mutations among patients with detected viremia (102/288, 35.4%) after treatment for 3-6 (24.3%), 9-12 (57.1%), and 20-24 (63.3%) months, respectively. The increasing rates were associated with significant CD4 count drop and viral load increase. Some patients also developed multidrug-resistant mutants.

CONCLUSIONS

: We report the first HIV-1 drug resistance study after 2 years on HAART among Chinese patients living in rural villages. Our data suggest that a significant portion of patients are failing first-line regimens with a trend of AIDS progression. It is therefore necessary to maximize the drug adherence and to make affordable second-line HAART regimens available immediately. Our results have implications for implementing HAART in underresourced developing country settings.

Clinical management of HIV infection in children

PURPOSE OF REVIEW

The aim of this article is to review recent advances in the clinical care of HIV-infected children.

RECENT FINDINGS

Obstacles to diagnosing HIV in children and providing clinical care to those HIV infected relate to a number of technical and operational factors. Most countries now have antiretroviral treatment guidelines and have incorporated co-trimoxazole prophylaxis for infected and exposed infants and children. Implementation lags behind policy and technical recommendations. Optimal early infant feeding remains difficult and, while breastfeeding remains the safest feeding option for child survival, it carries with it the risk of HIV acquisition. Recent data suggest HIV-free survival at 18 months is comparable in infants who are replacement-fed or exclusively breastfed for the first 6 months of life. Antiretroviral treatment efficacy in children is now well documented. Optimal timing of initiation of antiretroviral treatment remains uncertain; in general it is started earlier, especially in infants. Children starting treatment in infancy are surviving and reaching adulthood; new problems of managing the highly treatment-experienced and adolescents are emerging.

SUMMARY

New antiretroviral drugs and classes will be needed for the future; research is urgently required to characterize optimal nutritional interventions, interpretation of immunological and virological parameters, and develop diagnostic tools for use in health services with limited infrastructure and capacity.