Impact of protease inhibitor-containing combination antiretroviral therapies on height and weight growth in HIV-infected children

Growth and Metabolic Changes After Antiretroviral Initiation in South African Children

BACKGROUND

Poor growth and metabolic disturbances remain concerns for children living with HIV (CLHIV). We describe the impact of viral load (VL) on growth and lipid outcomes in South African CLHIV <12 years initiating World Health Organization recommended first-line antiretroviral therapy (ART) from 2012 to 2015.

METHODS

Z scores for length-for-age (LAZ), weight-for-age (WAZ) and body mass index-for-age were calculated. Lipids (total cholesterol, low-density lipoprotein and high-density lipoprotein) were measured. Hemoglobin A1C ≥5.8 was defined as at risk for type 2 diabetes. Mixed effects models were used to assess the association of VL at ART initiation with Z scores and lipids over time.

RESULTS

Of 241 CLHIV, 151 (63%) were <3 years initiating LPV/r-based ART and 90 (37%) were ≥3 years initiating EFV-based ART. Among CLHIV <3 years, higher VL at ART initiation was associated with lower mean LAZ (ß: -0.30, P=0.03), WAZ (ß: -0.32, P=0.01) and low-density lipoprotein (ß: -6.45, P=0.03) over time. Among CLHIV ≥3, a log 10 increase in pretreatment VL was associated with lower mean LAZ (ß: -0.29, P=0.07) trending towards significance and lower WAZ (ß: -0.32, P=0.05) as well as with more rapid increases in LAZ (ß: 0.14 per year, P=0.01) and WAZ (ß: 0.19 per year, P=0.04). Thirty percent of CLHIV were at risk for type 2 diabetes at ART initiation.

CONCLUSIONS

CLHIV initiating ART <3 years exhibited positive gains in growth and lipids, though high viremia at ART initiation was associated with persistently low growth and lipids, underscoring the need for early diagnosis and rapid treatment initiation. Future studies assessing the long-term cardiometabolic impact of these findings are warranted.

Better Outcomes Among HIV-Infected Rwandan Children 18-60 Months of Age After the Implementation of "Treat All"

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.

Impact of antiretroviral treatment on height evolution of HIV infected children

BACKGROUND

Antiretroviral treatment (ART) has been shown to have a beneficial effect on the weight evolution but its effect on height remains unclear. We described patterns of height evolution and identified predictors of catch-up growth in HIV-infected children on ART.

METHODS

To describe the height evolution from birth to adulthood, we developed a nonlinear mixed effect model using data from perinatally HIV-infected children who initiated ART from 1999 to 2013 in a prospective cohort study in Thailand. The main covariates of interest were: sex, ART regimen (dual nucleoside reverse-transcriptase inhibitor, non-nucleoside reverse transcriptase inhibitor (NNRTI)-, or protease inhibitor (PI)-based), baseline CD4 percentage, HIV-RNA load and CDC HIV Classification stage and occurrence of AIDS-defining events.

RESULTS

A total 477 children (43% boys) contributed 18,596 height measurements over a median duration of 6.3 years on ART (interquartile range, 3.0 to 8.3). At ART initiation, median age was 6.2 years (1.8 to 9.6), 16% of children were underweight (weight-for-age z-score < - 2), 49% presented stunting (height-for-age z-score < - 2), and 7% wasting (weight-for-height z-score < - 2). The most frequent regimen at ART initiation was NNRTI-based (79%). A model with 4 components, birth length and 3 exponential functions of age accounting for the 3 growth phases was developed and show that the height-growth velocity was inversely associated with the age at ART initiation, the adult height was significantly lower in those who had experienced at least one AIDS-defining event while, as expected, the model found that adult height in females was lower than in males. Age at ART initiation, type of ART regimen, CDC stage, CD4 percentages, and HIV-RNA load were not associated with the final height.

CONCLUSIONS

The younger the children at ART initiation, the greater the effect on height-growth velocity, supporting the World Health Organization's recommendation to start ART as early as possible. However, final adult height was not linked to the age at ART initiation.

Influence of AIDS antiretroviral therapy on the growth pattern

OBJECTIVES

Human immunodeficiency virus infection can result in the early impairment of anthropometric indicators in children and adolescents. However, combined antiretroviral therapy has improved, in addition to the immune response and viral infection, the weight and height development in infected individuals. Therefore, the objective was to evaluate the effect of combined antiretroviral on the growth development of human immunodeficiency virus infected children and adolescents.

SOURCE OF DATA

A systematic review was performed. In the study, the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) strategy was used as the eligibility criterion. The MEDLINE-PubMed and LILACS databases were searched using these descriptors: HIV, children, growth, antiretroviral therapy. The objective was defined by the population, intervention, comparison/control, and outcome (PICO) technique. Inclusion and exclusion criteria were applied for study selection.

SYNTHESIS OF DATA

Of the 549 studies indexed in MEDLINE-PubMed and LILACS, 73 were read in full, and 44 were included in the review (33 showed a positive impact of combined antiretroviral therapy on weight/height development, ten on weight gain, and one on height gain in children and adolescents infected with human immunodeficiency virus). However, the increase in growth was not enough to normalize the height of infected children when compared to children of the same age and gender without human immunodeficiency virus infection.

CONCLUSIONS

Combined antiretroviral therapy, which is known to play a role in the improvement of viral and immunological markers, may influence in the weight and height development in children infected with human immunodeficiency virus. The earlier the infection diagnosis and, concomitantly, of malnutrition and the start of combined antiretroviral therapy, the lower the growth impairment when compared to healthy children.

Nevirapine- Versus Lopinavir/Ritonavir-Based Antiretroviral Therapy in HIV-Infected Infants and Young Children: Long-term Follow-up of the IMPAACT P1060 Randomized Trial

BACKGROUND

The International Maternal Pediatric Adolescent AIDS Clinical Trials Network (IMPAACT) P1060 study demonstrated short-term superiority of lopinavir/ritonavir (LPV/r) over nevirapine (NVP) in antiretroviral therapy (ART), regardless of prior NVP exposure. However, NVP-based ART had a marginal benefit in CD4 percentage (CD4%) and growth. We compared 5-year outcomes from this clinical trial.

METHODS

Human immunodeficiency virus (HIV)-infected, ART-eligible children were enrolled into 2 cohorts based on prior NVP exposure and randomized to NVP- or LPV/r-based ART. The data safety monitoring board recommended unblinding results in both cohorts due to superiority of LPV/r for the primary endpoint: stopping randomized treatment, virologic failure (VF), or death by 6 months. Participants were offered a switch in regimens (if on NVP) and continued observational follow-up. We compared time to VF or death, death, and CD4% and growth changes using intention-to-treat analyses. Additionally, inverse probability weights were used to account for treatment switching and censoring.

RESULTS

As of September 2014, 329 of the 451 (73%) enrolled participants were still in follow-up (median, 5.3 years; interquartile range [IQR], 4.3-6.4), with 52% on NVP and 88% on LPV/r as originally randomized. NVP arm participants had significantly higher risk of VF or death (adjusted hazard ratio [aHR], 1.90; 95% confidence interval [CI], 1.37-2.65) but not death alone (aHR, 1.65; 95% CI, .72-3.76) compared with participants randomized to LPV/r. Mean CD4% was significantly higher in the NVP arm up to 1 year after ART initiation, but not beyond. Mean weight-for-age z scores were marginally higher in the NVP arm, but height-for-age z scores did not differ. Similar trends were observed in sensitivity analyses.

CONCLUSIONS

These findings support the current World Health Organization recommendation of LPV/r in first-line ART regimens for HIV-infected children.

CLINICAL TRIALS REGISTRATION

NCT00307151.

Growth in HIV-infected children on long-term antiretroviral therapy

OBJECTIVES

To describe growth in HIV-infected children on long-term antiretroviral therapy (ART) and to assess social, clinical, immunological and virological factors associated with suboptimal growth.

METHODS

This observational cohort study included all HIV-infected children at an urban ART site in South Africa who were younger than 5 years at ART initiation and with more than 5 years of follow-up. Growth was assessed using weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ) and body mass index (BMI)-for-age Z-scores (BAZ). Children were stratified according to pre-treatment anthropometry and age. Univariate and mixed linear analysis were used to determine associations between independent variables and weight and height outcomes.

RESULTS

The majority of the 159 children presented with advanced clinical disease (90%) and immunosuppression (89%). Before treatment underweight, stunting and wasting were common (WAZ<-2 = 50%, HAZ<-2 = 73%, BAZ<-2 = 19%). Weight and BMI improved during the initial 12 months, while height improved over the entire 5-year period. Height at study exit was significantly worse for children with growth impairment at ART initiation (P < 0.001), and infants (<1 year) demonstrated superior improvement in terms of BMI (P = 0.04). Tuberculosis was an independent risk factor for suboptimal weight (P = 0.01) and height (P = 0.02) improvement. Weight gain was also hindered by lack of electricity (P = 0.04). Immune reconstitution and virological suppression were not associated with being underweight or stunted at study endpoint.

CONCLUSIONS

Malnutrition was a major clinical concern for this cohort of HIV-infected children. Early ART initiation, tuberculosis co-infection management and nutritional interventions are crucial to ensure optimal growth in HIV-infected children.

Impact of highly active antiretroviral therapy on nutritional and immunologic status in HIV-infected children in the low-income country of Ethiopia

OBJECTIVE

HIV/AIDS and malnutrition combine to undermine the immunity of individuals and are inextricably interrelated. Although the effect of highly active antiretroviral therapy (HAART) on growth in HIV-infected children is well known, the influence of prior nutritional and immunologic status on the response to HAART is not well documented. The aim of the present study was to determine the effects of HAART on nutritional and immunological status in HIV-infected children in the low-income country of Ethiopia.

METHODS

A multicenter, retrospective cohort study was conducted on HIV-infected children receiving antiretroviral therapy at the pediatric units of public hospitals in Addis Ababa (Black Lion, Zewditu, Yekatit 12 and ALERT hospitals), Ethiopia. Nutritional status was defined as stunting (height-for-age Z score [HAZ] <-2), wasting (weight-for-height Z score [WHZ] <-2), and underweight (weight-for-age Z score [WAZ] <-2). Multivariable logistic regression was used to analyze factors associated with treatment success and to establish whether growth (baseline nutritional status) in children predicts immunologic outcomes. In all, 556 HIV-infected children receiving HAART from January 2008 to December 2009 were included in this study.

RESULTS

Over the 24-mo follow-up period, the study showed that the immunologic recovery of stunted and underweight children, regardless of their baseline nutritional status, responded equally to treatment. However, wasted children showed less immunologic recovery at the different follow-up visits. Predictors of positive shift in WHZ after 24 mo of follow-up were advanced disease stage (World Health Organization clinical stages 3 and 4) with odds ratio (OR), 0.25 (95% confidence interval [CI], 0.34-0.99; P = 0.045) and baseline severe underweight OR, 0.19 (95% CI, 0.09-0.56; P = 0.003). The independent predictors of positive shift of growth shift in WAZ over 24 mo were lower baseline age (<36 mo) with OR, 0.21 (95% CI, 0.04-0.90; P = 0.036) and baseline moderate underweight itself with OR, 0.11 (95% CI, 0.05-0.25; P = 0.0001) were predictors of positive shift (shift to normal).

CONCLUSION

Despite the apparent growth response in HIV-infected children after initiation of HAART, moderate and severe underweight are both independent predictors of a positive shift. The latter suggests that children on HAART require nutritional supplementation, especially during the early initiation of HAART.

Growth reconstitution following antiretroviral therapy and nutritional supplementation: systematic review and meta-analysis

OBJECTIVE

As antiretroviral therapy (ART) expands for HIV-infected children, it is important to determine its impact on growth. We quantified growth and its determinants following ART in resource-limited (RLS) and developed settings.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched publications reporting growth [weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) z scores] in HIV-infected children following ART through August 2014. Inclusion criteria were as follows: younger than 18 years; ART; at least 20 patients; growth at ART; and post-ART growth. Standardized and overall weighted mean differences were calculated using random-effects models.

RESULTS

A total of 67 articles were eligible (RLS = 54; developed settings = 13). Mean age was 5.8 years, and comparable between settings (P = 0.90). Baseline growth was substantially lower in RLS vs. developed settings (WAZ -2.1 vs. -0.5; HAZ -2.2 vs. -0.9; both P < 0.01). Rate of weight but not height reconstitution during 12 and 24 months was higher in RLS (12-month WAZ change 0.84 vs. 0.17, P < 0.01). Growth deficits persisted in RLS after 2 years ART (P = 0.04). Younger cohort age was associated with greater growth reconstitution. Protease inhibitor and nonnucleoside reverse-transcriptase inhibitor regimens yielded comparable growth. Adjusting for age and setting, cohorts with nutritional supplements had greater growth gains (24-month rate difference: WAZ 0.55, P = 0.03; HAZ 0.60, P = 0.007). Supplement benefits were attenuated after adjusting for baseline cohort growth.

CONCLUSION

RLS children had substantial growth deficits compared with developed settings counterparts at ART; growth shortfalls in RLS persisted despite reconstitution. Earlier age and nutritional supplementation at ART may improve growth outcomes. Scant data on supplementation limit evaluation of impact and underscores need for systematic data collection regarding supplementation in pediatric ART programmes/cohorts.

Effect of Age at Antiretroviral Therapy Initiation on Catch-up Growth Within the First 24 Months Among HIV-infected Children in the IeDEA West African Pediatric Cohort

BACKGROUND

We described malnutrition and the effect of age at antiretroviral therapy (ART) initiation on catch-up growth over 24 months among HIV-infected children enrolled in the International epidemiologic Databases to Evaluate Aids West African paediatric cohort.

METHODS

Malnutrition was defined at ART initiation (baseline) by a Z score <-2 standard deviations, according to 3 anthropometric indicators: weight-for-age (WAZ) for underweight, height-for-age (HAZ) for stunting and weight-for-height/BMI-for-age (WHZ/BAZ) for wasting. Kaplan-Meier estimates for catch-up growth (Z score ≥-2 standard deviations) on ART, adjusted for gender, immunodeficiency and malnutrition at ART initiation, ART regimen, time period and country, were compared by age at ART initiation. Cox proportional hazards regression models determined predictors of catch-up growth on ART over 24 months.

RESULTS

Between 2001 and 2012, 2004 HIV-infected children <10 years of age were included. At ART initiation, 51% were underweight, 48% were stunted and 33% were wasted. The 24-month adjusted estimates for catch-up growth were 69% [95% confidence interval (CI): 57-80], 61% (95% CI: 47-70) and 90% (95% CI: 76-95) for WAZ, HAZ and WHZ/BAZ, respectively. Adjusted catch-up growth was more likely for children <5 years of age at ART initiation compared with children ≥5 years for WAZ, HAZ (P < 0.001) and WHZ/BAZ (P = 0.026).

CONCLUSIONS

Malnutrition among these children is an additional burden that has to be urgently managed. Despite a significant growth improvement after 24 months on ART, especially in children <5 years, a substantial proportion of children still never achieved catch-up growth. Nutritional care should be part of the global healthcare of HIV-infected children in sub-Saharan Africa.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nutritional Care of the Child with Human Immunodeficiency Virus Infection in the United States

In well-resourced settings, early infant diagnosis and administration of life-saving antiretrovirals (ARVs) have significantly improved clinical outcomes in pediatric human immunodeficiency virus (HIV) infection. The dramatic increase in survival rates is associated with enhancements in overall quality of life, which reflect a multidisciplinary, holistic approach to care. Current optimism starkly contrasts with the outlook and prognosis two decades ago, when failure to thrive and wasting syndrome from uncontrolled pediatric HIV infection resulted from poor oral intake, malabsorption, chronic diarrhea, and a persistently catabolic state. The tenets of care developed from that era still hold true in that all infants, children, and adolescents with HIV require comprehensive nutritional services in addition to effective combination antiretroviral therapy (cART). This chapter will review the principles of nutrition in the pre- and post-cART eras and discuss the etiologic factors associated with malnutrition, with an emphasis on interventions that have favorably impacted the growth and body composition of infants, children and adolescents with HIV.

Growth failure and nutrition considerations in chronic childhood wasting diseases

Growth failure is a common problem in many children with chronic diseases. This article is an overview of the most common causes of growth failure/growth retardation that affect children with a number of chronic diseases. We also briefly review the nutrition considerations and treatment goals. Growth failure is multifactorial in children with chronic conditions, including patients with cystic fibrosis, chronic kidney disease, chronic liver disease, congenital heart disease, human immunodeficiency virus, inflammatory bowel disease, short bowel syndrome, and muscular dystrophies. Important contributory factors to growth failure include increased energy needs, increased energy loss, malabsorption, decreased energy intake, anorexia, pain, vomiting, intestinal obstruction, and inflammatory cytokines. Various metabolic and pathologic abnormalities that are characteristic of chronic diseases further lead to significant malnutrition and growth failure. In addition to treating disease-specific abnormalities, treatment should address the energy and protein deficits, including vitamin and mineral supplements to correct deficiencies, correct metabolic and endocrinologic abnormalities, and include long-term monitoring of weight and growth. Individualized, age-appropriate nutrition intervention will minimize the malnutrition and growth failure seen in children with chronic diseases.

Endocrinopathies in children infected with human immunodeficiency virus

Endocrine changes (including adrenal insufficiency, disorders of growth and puberty, thyroid dysfunction, metabolic abnormalities and osteopenia) accompany human immunodeficiency virus (HIV) infection in pediatric patients. The cause of these changes is multifactorial and includes direct viral effects of HIV, and effects of antiretroviral therapy. These effects may be of particular importance in childhood given the critical developmental processes that occur during this time period and the likelihood of prolonged exposure to the virus and medications.

A pilot study to investigate the muscle strength of children infected with HIV

Background/aims

Paediatric HIV remains a significant challenge to children and caregivers in South Africa. Little is known about the effect of HIV infection on muscle strength in children, however potential decrease in muscle strength has been inferred to affect functional ability in these children. The aim of this pilot study was to compare the muscle strength of children infected with HIV who had been receiving highly active antiretroviral therapy (HAART) to that of children infected with HIV not receiving HAART.

Methods

The study population included a group of 16 children receiving HAART and 16 children not receiving HAART. A one-off test of muscle strength was undertaken using a hand-held dynamometer for the child, and a demographic questionnaire and social status index to their primary caregiver. Two-sample student t tests, Pearson correlation analyses, and backward regression analyses were used to analyse data.

Results

The cluster of differentiation (CD4) count of the group on HAART was significantly higher than the group not receiving HAART. The group not receiving HAART was stronger than the HAART group. No significant correlation was shown between length of time having received HAART and muscle strength, or between CD4 count and muscle strength in the group receiving HAART. A significant negative correlation was shown between CD4 count and muscle strength in the group not receiving HAART.

Conclusion

Further research is needed to establish the impact of earlier administration of HAART on muscle strength in children infected with HIV.

Initiation of antiretroviral therapy before 6 months of age is associated with faster growth recovery in South African children perinatally infected with human immunodeficiency virus

OBJECTIVE

To describe the effects of age at antiretroviral therapy (ART) initiation on growth outcomes among children infected with HIV followed for 48 months after treatment initiation.

STUDY DESIGN

This secondary analysis describes anthropometric changes in children infected with HIV in Johannesburg, South Africa who initiated ritonavir-boosted lopinavir-based ART before 24 months of age and were randomized to continue ritonavir-boosted lopinavir or to receive nevirapine after achieving and maintaining virologic suppression. Weight, height, and head circumference were measured at visits over 48 months post-ART initiation. Growth patterns including weight-for-age z-scores (WAZs), height-for-age z-scores, body mass index-for-age z-scores, and head circumference for age z-score were compared between children initiating ART<6 months, 6-12 months, and 12-24 months of age.

RESULTS

A total of 195 children (mean±SD age 10.7±5.9 months), including 54 (27.7%)<6 months, 69 (35.4%) 6-12 months, and 72 (36.9%) 12-24 months of age at ART initiation, were evaluated. In the first 12 months on treatment, children<6 months of age at ART initiation experienced more rapid improvement in WAZ (1.98 vs 1.44, P=.084) and head circumference for age z-score (1.24 vs 0.45, P=.004) than children who initiated ART between 12-24 months of age. By 48 months on ART, growth outcomes were similar, regardless of age at ART initiation. WAZ approached population norms by 12 months on ART. Although improving, height-for-age z-scores remained on average 1.0 z-score below population norms at 48 months of therapy.

CONCLUSIONS

Initiation of ART before 6 months of age results in more rapid growth recovery in children infected with HIV. These data provide further evidence for the importance of prompt diagnosis and early initiation of ART for infants infected with HIV.

Variability of growth in children starting antiretroviral treatment in southern Africa

BACKGROUND

Poor growth is an indication for antiretroviral therapy (ART) and a criterion for treatment failure. We examined variability in growth response to ART in 12 programs in Malawi, Zambia, Zimbabwe, Mozambique, and South Africa.

METHODS

Treatment naïve children aged <10 years were included. We calculated weight for age z scores (WAZs), height for age z scores (HAZs), and weight for height z scores (WHZs) up to 3 years after starting ART, by using the World Health Organization standards. Multilevel regression models were used.

RESULTS

A total of 17990 children (range, 238-8975) were followed for 36181 person-years. At ART initiation, most children were underweight (50%) and stunted (66%). Lower baseline WAZ, HAZ, and WHZ were the most important determinants of faster catch-up growth on ART. WAZ and WHZ increased rapidly in the first year and stagnated or reversed thereafter, whereas HAZ increased continuously over time. Three years after starting ART, WAZ ranged from -2.80 (95% confidence interval [CI]: -3.66 to -2.02) to -1.98 (95% CI: -2.41 to -1.48) in children with a baseline z score < -3 and from -0.79 (95% CI: -1.62 to 0.02) to 0.05 (95% CI: -0.42 to 0.51) in children with a baseline WAZ ≥ -1. For HAZ, the corresponding range was -2.33 (95% CI: -2.62 to -2.02) to -1.27 (95% CI: -1.58 to -1.00) for baseline HAZ < -3 and -0.24 (95% CI: -0.56 to 0.15) to 0.84 (95% CI: 0.53 to 1.16) for HAZ ≥ -1.

CONCLUSIONS

Despite a sustained growth response and catch-up growth in children with advanced HIV disease treated with ART, normal weights and heights are not achieved over 3 years of ART.

Nevirapine versus ritonavir-boosted lopinavir for HIV-infected children

BACKGROUND

Nevirapine-based antiretroviral therapy is the predominant (and often the only) regimen available for children in resource-limited settings. Nevirapine resistance after exposure to the drug for prevention of maternal-to-child human immunodeficiency virus (HIV) transmission is common, a problem that has led to the recommendation of ritonavir-boosted lopinavir in such settings. Regardless of whether there has been prior exposure to nevirapine, the performance of nevirapine versus ritonavir-boosted lopinavir in young children has not been rigorously established.

METHODS

In a randomized trial conducted in six African countries and India, we compared the initiation of HIV treatment with zidovudine, lamivudine, and either nevirapine or ritonavir-boosted lopinavir in HIV-infected children 2 to 36 months of age who had no prior exposure to nevirapine. The primary end point was virologic failure or discontinuation of treatment by study week 24.

RESULTS

A total of 288 children were enrolled; the median percentage of CD4+ T cells was 15%, and the median plasma HIV type 1 (HIV-1) RNA level was 5.7 log(10) copies per milliliter. The percentage of children who reached the primary end point was significantly higher in the nevirapine group than in the ritonavir-boosted lopinavir group (40.8% vs. 19.3%; P<0.001). Among the nevirapine-treated children with virologic failure for whom data on resistance were available, more than half (19 of 32) had resistance at the time of virologic failure. In addition, the time to a protocol-defined toxicity end point was shorter in the nevirapine group (P=0.04), as was the time to death (P=0.06).

CONCLUSIONS

Outcomes were superior with ritonavir-boosted lopinavir among young children with no prior exposure to nevirapine. Factors that may have contributed to the suboptimal results with nevirapine include elevated viral load at baseline, selection for nevirapine resistance, background regimen of nucleoside reverse-transcriptase inhibitors, and the standard ramp-up dosing strategy. The results of this trial present policymakers with difficult choices. (Funded by the National Institute of Allergy and Infectious Diseases and others; P1060 ClinicalTrials.gov number, NCT00307151.).

The nutritional status of children and adolescents with HIV/AIDS on antiretroviral therapy

The objective of this cross-sectional study was to assess the nutritional status of children and adolescents with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) receiving highly active antiretroviral therapy (HAART). One hundred and eighteen subjects aged 6-19 years attending an outpatient clinic in São Paulo city were involved in the study. The following anthropometric measurements were assessed: weight, height, waist circumference and triceps and subscapular skinfold thickness. One (0.9%) adolescent was diagnosed with abdominal obesity based on waist circumference measurement; three (2.5%) adolescents were obese based on subscapular skinfold thickness. According to the body mass index, the population studied was mainly eutrophic. The prevalence of fat redistribution, a characteristic of patients with HIV/AIDS under HAART, was low. We advise the development of further studies to assess the nutritional status of children and adolescents with HIV/AIDS using anthropometric measurements as well as computed tomography to detect fat redistribution.

Post-HAART outcomes in pediatric populations: comparison of resource-limited and developed countries

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.

Antiretroviral treatment for children with peripartum nevirapine exposure

BACKGROUND

Single-dose nevirapine is the cornerstone of the regimen for prevention of mother-to-child transmission of human immunodeficiency virus (HIV) in resource-limited settings, but nevirapine frequently selects for resistant virus in mothers and children who become infected despite prophylaxis. The optimal antiretroviral treatment strategy for children who have had prior exposure to single-dose nevirapine is unknown.

METHODS

We conducted a randomized trial of initial therapy with zidovudine and lamivudine plus either nevirapine or ritonavir-boosted lopinavir in HIV-infected children 6 to 36 months of age, in six African countries, who qualified for treatment according to World Health Organization (WHO) criteria. Results are reported for the cohort that included children exposed to single-dose nevirapine prophylaxis. The primary end point was virologic failure or discontinuation of treatment by study week 24. Enrollment in this cohort was terminated early on the recommendation of the data and safety monitoring board.

RESULTS

A total of 164 children were enrolled. The median percentage of CD4+ lymphocytes was 19%; a total of 56% of the children had WHO stage 3 or 4 disease. More children in the nevirapine group than in the ritonavir-boosted lopinavir group reached a primary end point (39.6% vs. 21.7%; weighted difference, 18.6 percentage-points; 95% confidence interval, 3.7 to 33.6; nominal P=0.02). Baseline resistance to nevirapine was detected in 18 of 148 children (12%) and was predictive of treatment failure. No significant between-group differences were seen in the rate of adverse events.

CONCLUSIONS

Among children with prior exposure to single-dose nevirapine for perinatal prevention of HIV transmission, antiretroviral treatment consisting of zidovudine and lamivudine plus ritonavir-boosted lopinavir resulted in better outcomes than did treatment with zidovudine and lamivudine plus nevirapine. Since nevirapine is used for both treatment and perinatal prevention of HIV infection in resource-limited settings, alternative strategies for the prevention of HIV transmission from mother to child, as well as for the treatment of HIV infection, are urgently required. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00307151.).

Predictors of growth and body composition in HIV-infected children beginning or changing antiretroviral therapy

OBJECTIVES

The aim of the study was to describe growth and body composition changes in HIV-positive children after they had initiated or changed antiretroviral therapy (ART) and to correlate these with viral, immune and treatment parameters.

METHODS

Ninety-seven prepubertal HIV-positive children were observed over 48 weeks upon beginning or changing ART. Anthropometry and bioelectrical impedance analysis results were compared with results from the National Health and Nutrition Examination Survey 1999-2002 (NHANES) to generate z-scores and with results for HIV-exposed, uninfected children from the Women and Infants Transmission Study (WITS). Multivariate analysis was used to evaluate associations between growth and body composition and disease parameters.

RESULTS

All baseline lean and fat mass measures were below those of controls from NHANES. Weight, height and fat free mass (FFM) index (FFM/height(2)) z-scores increased over time (P = 0.004, 0.037 and 0.027, respectively) and the waist:height ratio z-score decreased (P = 0.045), but body mass index and per cent body fat z-scores did not change. Measures did not increase more than in uninfected WITS controls. In multivariate analysis, baseline height, mid-thigh circumference and FFM z-scores related to CD4 percentage (P = 0.029, P = 0.008 and 0.020, respectively) and change in FFM and FFM index z-scores to CD4 percentage increase (P = 0.010 and 0.011, respectively). Compared with WITS controls, baseline differences in height and mid-thigh muscle circumference were also associated with CD4 percentage. Case-control differences in change in both subscapular skinfold (SSF) thickness and the SSF:triceps skinfold ratio were inversely associated with viral suppression. No measures related to ART class(es) at baseline or over time.

CONCLUSIONS

In these HIV-positive children, beginning or changing ART was associated with improved growth and lean body mass (LBM), as indicated by FFM index. Height and LBM related to CD4 percentage at baseline and over time. Altered fat distribution and greater central adiposity were associated with detectable virus but not ART class(es) received.

The use of second-generation antipsychotics and the changes in physical growth in children and adolescents with perinatally acquired HIV

Second-generation antipsychotics (SGAs) are increasingly prescribed to treat psychiatric symptoms in pediatric patients infected with HIV. We examined the relationship between prescribed SGAs and physical growth in a cohort of youth with perinatally acquired HIV-1 infection. Pediatric AIDS Clinical Trials Group (PACTG), Protocol 219C (P219C), a multicenter, longitudinal observational study of children and adolescents perinatally exposed to HIV, was conducted from September 2000 until May 2007. The analysis included P219C participants who were perinatally HIV-infected, 3-18 years old, prescribed first SGA for at least 1 month, and had available baseline data prior to starting first SGA. Each participant prescribed an SGA was matched (based on gender, age, Tanner stage, baseline body mass index [BMI] z score) with 1-3 controls without antipsychotic prescriptions. The main outcomes were short-term (approximately 6 months) and long-term (approximately 2 years) changes in BMI z scores from baseline. There were 236 participants in the short-term and 198 in the long-term analysis. In linear regression models, youth with SGA prescriptions had increased BMI z scores relative to youth without antipsychotic prescriptions, for all SGAs (short-term increase = 0.192, p = 0.003; long-term increase = 0.350, p < 0.001), and for risperidone alone (short-term = 0.239, p = 0.002; long-term = 0.360, p = 0.001). Participants receiving both protease inhibitors (PIs) and SGAs showed especially large increases. These findings suggest that growth should be carefully monitored in youth with perinatally acquired HIV who are prescribed SGAs. Future research should investigate the interaction between PIs and SGAs in children and adolescents with perinatally acquired HIV infection.

Impact of medications prescribed for treatment of attention-deficit hyperactivity disorder on physical growth in children and adolescents with HIV

OBJECTIVE

To examine the relationships between physical growth and medications prescribed for symptoms of attention-deficit hyperactivity disorder in children with HIV.

METHODS

Analysis of data from children with perinatally acquired HIV (N = 2251; age 3-19 years), with and without prescriptions for stimulant and nonstimulant medications used to treat attention-deficit hyperactivity disorder, in a long-term observational study. Height and weight measurements were transformed to z scores and compared across medication groups. Changes in z scores during a 2-year interval were compared using multiple linear regression models adjusting for selected covariates.

RESULTS

Participants with (n = 215) and without (n = 2036) prescriptions were shorter than expected based on US age and gender norms (p < .001). Children without prescriptions weighed less at baseline than children in the general population (p < .001) but gained height and weight at a faster rate (p < .001). Children prescribed stimulants were similar to population norms in baseline weight; their height and weight growth velocities were comparable with the general population and children without prescriptions (for weight, p = .511 and .100, respectively). Children prescribed nonstimulants had the lowest baseline height but were similar to population norms in baseline weight. Their height and weight growth velocities were comparable with the general population but significantly slower than children without prescriptions (p = .01 and .02, respectively).

CONCLUSION

The use of stimulants to treat symptoms of attention-deficit hyperactivity disorder does not significantly exacerbate the potential for growth delay in children with HIV and may afford opportunities for interventions that promote physical growth. Prospective studies are needed to confirm these findings.

Efficacy of antiretroviral therapy program in children in India: prognostic factors and survival analysis

The objective of this article is to study the survival pattern and the prognostic factors for HIV-infected children on antiretroviral therapy (ART) for two and half years at the Government Hospital of Thoracic Medicine, Tambaram, Chennai, India. We studied 295 children who were initiated on ART from 1 April 2004 to 30 September 2006 at a large, public tertiary care facility in Chennai, India. Weight for age Z-score was calculated. Survival curves and Cox proportional hazard models were used to identify risk factors for mortality. The mean and median follow up was 11 and 10 months, respectively. The cumulative survival probability at 6, 12, 18, 24 and 30 months was 93, 90, 89.7, 89.7 and 89.7%, respectively. Of the children who died, about 50% died within the first month. Nearly 6% of the children had adherence less than 95%. The children who had a baseline CD4 percent less than or equal to 14% had significantly (p < 0.05) higher mortality as compared to children who had 20% or more. The children who had negative or no change in weight for age Z-score and hemoglobin had 18.9 (3.7-95.7) times significantly higher mortality as compared to children who had positive change in both variables (p < 0.001). The sensitivity, specificity and likelihood ratio of the positive test for negative change or no change in HB was 65%, 85% and 4.3, respectively. Similarly, these were 80%, 73% and 3% for negative or no change in Absolute Lymphocyte Count (ALC). These findings indicate the feasibility and effectiveness of implementing an ART program in a large government hospital in India. Simple nutritional variable hemoglobin and immunologic variable ALC could be used to monitor the progression of disease in children.

Pediatric HIV infection: the state of antiretroviral therapy

Pediatric HIV/AIDS has become less of a problem in resource-rich countries as the number of perinatal infections has reduced dramatically since the advent of antiretrovirals, resulting in the effective prevention of mother-to-child transmission. In resource-limited settings, however, pediatric HIV infection remains a colossal problem; a separate review in this same issue of Expert Review of Anti-Infective Therapy examines the international aspects of pediatric HIV/AIDS. Treatment of HIV infection in children differs from that in adults in the use of immunologic markers and owing to drug pharmacokinetics and age-related adherence issues. This review, geared for the general pediatrician or family practitioner who may see the HIV-positive child in the clinic or the hospital, summarizes the most recent pediatric data and guidelines for the testing and treatment of HIV, including the US NIH guidelines released in February 2008. Treatment-experienced patients, who should be cared for by pediatric HIV specialists, are not addressed here specifically. Adolescents, infected either perinatally or sexually, with their own unique issues, deserve a separate review.

Long-term effects of highly active antiretroviral therapy on CD4+ cell evolution among children and adolescents infected with HIV: 5 years and counting

BACKGROUND

Lower percentages of CD4(+) T lymphocytes are associated with adverse clinical outcomes among children and adolescents infected with human immunodeficiency virus (HIV). CD4(+) lymphocyte percentage generally increases with receipt of highly active antiretroviral therapy (HAART), but long-term follow-up is required to assess whether these increases in CD4(+) cell percentage are maintained and whether they lead to normal CD4(+) cell percentages in children with severe immunosuppression.

METHODS

The study population included 1236 children and adolescents perinatally infected with HIV who were enrolled in a US-based multicenter prospective cohort study (Pediatric AIDS Clinical Trials Group 219/219C) and who were not receiving HAART at study initiation. We estimated the effects of HAART, HAART with protease inhibitors, and HAART with nonnucleoside reverse-transcriptase inhibitors on CD4(+) cell percentage, using marginal structural models to account for confounding by severity.

RESULTS

Initiation of any type of HAART increased CD4(+) cell percentage by 2.34% (95% confidence interval, 1.35%-3.33%) in the first year, relative to noninitiation of HAART. The substantial increases in CD4(+) cell percentage observed after the first year of experience with these combination therapies were followed by relatively smaller increases that continued for 5 years after initiation. Although larger increases in CD4(+) cell percentage were observed among children with a greater degree of immunosuppression at baseline, the mean CD4(+) cell percentage after 5 years of HAART did not reach normal levels.

CONCLUSIONS

Our study supports the initiation of HAART in children before severe immunosuppression occurs for long-term maintenance of normal CD4(+) cell percentages. This beneficial result must be weighed against the evidence of potential adverse events associated with the prolonged use of such therapy.

Growth in HIV-infected children receiving antiretroviral therapy at a pediatric infectious diseases clinic in Uganda

Antiretroviral therapy (ART) improves growth and survival of HIV-infected individuals. We designed a retrospective cohort study to assess clinical factors associated with growth in HIV-infected children on ART in Uganda between July 2003 and March 2006. Height and weight measurements taken pre- and post-ART initiation for at least 6 months were age- and gender-standardized to CDC 2000 reference. We analyzed medical records of 749 children receiving ART. Descriptive and logistic regression analyses were conducted to identify covariates associated with risk of either stunting or being underweight. Longitudinal regression analysis with a mixed model using autoregressive covariance structure was used to compare change in height and weight before and after initiation of ART. The mean age of the study population at first visit was 7.5 years. Mean height-for-age, weight-for-age, and weight-for-height percentiles at first visit were 8.6, 7.7, and 7.9, respectively. At last visit mean height-for-age, weight-for-age, and weight-for-height percentiles were 8.6, 13.3, and 13.8, respectively. Baseline weight-for-age z score of 1 or more was protective against stunting (odds ratio [OR] 0.25, confidence interval [CI] 0.18-0.35) while baseline height-for-age z score of 1 or more was protective against becoming underweight (OR 0.75, CI 0.63-0.88). Children in World Health Organization (WHO) stages II, III, and IV at baseline were 1.5 times more likely to become underweight (OR 1.51, CI 1.07-2.14). Initiation of ART resulted in improvement in mean standardized weight-for-age z score and weight-for-age percentiles (p < 0.001). Weight-for-age percentile and z score improved significantly after initiation of ART. This pediatric population gained weight more rapidly than height after initiation of ART.

A systematic review on the application of pharmacoepidemiology in assessing prescription drug-related adverse events in pediatrics

OBJECTIVES

To conduct a systematic review of recent case-control and cohort studies in assessing adverse drug events (ADEs) among pediatric patients aged between 0 and 18 years; to establish strengths and limitations of pharmacoepidemiology when applied in evaluating pediatric drug safety; and to identify areas of pediatric drug safety that may be suitable for future pharmacoepidemiological investigations.

METHODS

A PubMed search was conducted using a list of keywords representing drugs, adverse drug events, case control and cohort studies, and pediatric population. Selection criteria were used to extract relevant studies published from 1/1 2000 to 7/1 2006.

RESULTS

Twenty-seven studies met our criteria. Of them, 12 used a prospective cohort design. The others were either case-control (seven) or retrospective cohort (eight) studies, based on the analysis of existing databases. More than half of the studies included more than 500 subjects. Inclusion and exclusion criteria for participants in these studies were generally not very stringent. The subjects closely resembled patients in the real-world settings. The length of study follow-up ranged from 1 day to 40 years. In eight studies, the length of follow-up surpassed 5 years. Potential confounding factors were taken into consideration in all of the studies. But the database-based studies generally failed to control for some important clinical variables such as disease severity. Misclassification of drug exposures also occurred in some of these studies.

CONCLUSIONS

Despite some limitations, pharmacoepidemiology proves to be useful for assessing ADEs in pediatrics. With appropriate study design, this methodology can bolster our understanding about the safety of pediatric drug use. Several areas of pediatric drug safety may especially be suitable for future pharmacoepidemiological investigations. These areas include the safety of polypharmacy, long-term drug effects, and off-label drug use.

Niacin nutritional status in HIV type 1-positive children: preliminary data

OBJECTIVE

HIV infection induces a state of pellagra in cell culture models. This study compared the nutritional status and the 24-hour urine excretion of N-methylnicotinamide between HIV-positive children and HIV-negative children who were or were not born of mothers with HIV-1 infection.

PATIENTS AND METHODS

Forty patients were included in the study: HIV-positive children (group 1; n = 20), HIV-negative children born to infected mothers (group 2; n = 10), and HIV-negative control children (group 3; n = 10). Usual dietary intake was assessed by a semiquantitative food-frequency questionnaire. Weight and height were assessed and compared with the reference data of the U.S. National Center for Health Statistics/Centers for Disease Control and Prevention. For the estimation of fat-free mass and total body water, bioelectrical impedance technique was used. N-methylnicotinamide was measured by a modified method of high-performance liquid chromatography.

RESULTS

Groups were matched in relation to age, sex, percentage of malnutrition, anthropometric measures, and body composition. Daily niacin intake did not differ statistically across groups (group 1 = 18.0 +/- 11.4 mg/day; group 2 = 18.9 +/- 8.0 mg/day; group 3 = 14.2 +/- 5.2 mg/day), nor did intake of tryptophan, vitamin B6, and zinc. The values of urinary niacin per gram of creatinine were similar and adequate across the groups (group 1 = 4.68 [0.75-14.9]; group 2 = 3.74 [1.13-5.69]; group 3 = 3.85 [1.80-8.19]).

CONCLUSIONS

HIV-positive children excreted the same amount of N-methylnicotinamide in urine as did the control children. These findings may be attributed to similarities in nutritional status, adequate intestinal absorption (no children experienced diarrhea) and stable clinical condition.

Impact on weight and height with the use of HAART in HIV-infected children

BACKGROUND

There are few data on long-term effects of highly active antiretroviral therapy (HAART) on weight and height in HIV-infected children.

OBJECTIVES

Our objective was to assess the effect of HAART on the weight and height of HIV-infected children over time in the Madrid cohort, and analyze possible factors associated with the effect.

PATIENTS AND METHODS

This was a retrospective study of HIV-infected children starting HAART in 1997 or later. Serial measurements of weight, height and body mass index (BMI) were performed and converted to z-scores using the Spanish revised reference data. Changes from baseline in weight, height and BMI at 12, 24, 36, 48 and 60 months were determined. Associations of z-scores at the last visit with immunologic (CD4% above 25%) and virologic responses (more than 50% of samples below 400 copies/mL), CDC (Centers for Disease Control) clinical category, and the presence and type of lipodystrophy (lipoatrophy or lipohypertrophy) were evaluated.

RESULTS

Twelve hundred and twelve children, 97% of them vertically-infected, received HAART starting in 1997 for a median of 71 months (4-102 months). Median age at initiation of HAART was 6 years (1 month-18 years). Thirty-nine percentage were antiretroviral naive and 61% had received NRTI therapy previously. Thirty-two percentage and 53% had CDC class C and immunologic class 3, respectively. At the final evaluation, 24% of children remained on their first combination therapy, 39% on the second and 37% had received at least 3 different HAART regimens. Fifty-one percentage were classified as virologic responders. Thirty-nine percentage of children in this study were diagnosed with lipodystrophy. At baseline, median z-score for weight, height and BMI were -0.45, -0.60 and -0.33, respectively. HAART was associated with significant increases in z-scores of weight and height but not BMI at the different time-points analyzed. Virologic nonresponders had significantly lower z-scores for weight and height but not for BMI. CDC class C was associated with lower z-scores for height. No differences in final measurements were observed for baseline CD4, immunologic response or lipoatrophy. Children with lipohypertophy had a significantly higher BMI at the last visit.

CONCLUSIONS

HIV-infected children experienced a continued catch-up in weight and height 5 years after starting HAART. Virologic control is related to sustained growth.

Neurodevelopmental functioning in HIV-infected infants and young children before and after the introduction of protease inhibitor-based highly active antiretroviral therapy

OBJECTIVES

The purpose of this work was to examine the effects of HIV infection and the impact of highly active antiretroviral treatment with protease inhibitors on neurodevelopmental functioning during the first 3 years of life.

PATIENTS AND METHODS

Pediatric AIDS Clinical Trials Group 219/219C is a longitudinal cohort study that has enrolled HIV-infected (HIV+) and HIV-exposed but uninfected (HIV-) infants and children since 1993. Longitudinal profiles of neurodevelopmental functioning as measured by the Bayley Scales of Infant Development were compared by HIV-infection status before and after the availability of highly active antiretroviral therapy with a protease inhibitor and within infants with Bayley tests available before and after initiating protease inhibitor therapy.

RESULTS

In the pre-protease inhibitor era, mean mental and motor scores in HIV+ (n = 54) infants <1 year of age were significantly lower than those among HIV- infants (n = 221) and remained lower up to 2 years of age. After protease inhibitors became available, mean mental and motor functioning of HIV+ infants (n = 91) <1 year of age were still significantly lower than those of HIV- infants (n = 838). However, against a background of declining scores among the HIV- infants, there was evidence of limited improvement in the HIV+ infants relative to their uninfected peers. Among infants who had Bayley II evaluations before and after starting a protease inhibitor, there was a trend to improved mental and motor scores after initiation of protease inhibitor therapy.

CONCLUSIONS

The suppression of systemic viral replication and subsequent substantial improvements in survival and immunologic status brought about by highly active antiretroviral therapy have been followed by limited improvements in neurodevelopmental functioning in young children. Additional longitudinal research is needed to better understand the role of antiretroviral therapy as well as the impact of genetic and environmental factors on neurodevelopmental functioning in children affected by HIV.

Endocrine abnormalities and impaired growth in human immunodeficiency virus-infected children

OBJECTIVES

Identify endocrine differences between human immunodeficiency virus- (HIV) infected versus uninfected children and evaluate associations of growth and body composition with endocrine measures.

STUDY DESIGN

Nested case-control study in 21 HIV-infected and 46 age- and sex-matched uninfected children in the Women and Infant Transmission Study. Plasma specimens from children between 2.5 to 7.0 years of age, taken during 3-4 visits, were tested for insulin-like growth factor binding protein-3 (IGFBP-3), cortisol, dehydroepiandrosterone (DHEA), growth hormone and thyroid studies. Longitudinal mixed and generalized estimating equation models compared group means and examined effects of endocrine measures on growth and body composition, respectively.

RESULTS

HIV-infected children had lower IGFBP-3 than uninfected children (1.96 +/- 0.09 mg/L versus 2.34 +/- 0.06 mg/L, P < 0.001). In infected but not in uninfected children, IGFBP-3 values and DHEA:cortisol ratios were associated with weight- and body mass index-for-age z scores ([WAZ] P = 0.019, <.001 respectively, and [BMZ] P = 0.029, 0.038). DHEA concentration was associated with height-for-age z score (P = 0.049).

CONCLUSIONS

In these HIV-infected children compared with their uninfected counterparts, IGFBP-3 concentration was different between groups. Infected children had multiple endocrine associations with growth and body composition not found in their uninfected peers. We hypothesize that in HIV-infected children, growth hormone resistance and shunting of precursors from adrenal androgen to cortisol production contributes to altered body composition and stunting.

Clinical profile and natural history of children with HIV infection

OBJECTIVE

As the HIV infection spreads in India, increasing number of children are affected. We report the clinical manifestations, the laboratory parameters and follow up of these children.

METHODS

We reviewed case records of all children diagnosed as pediatric HIV infection since 1995 in our department at a tertiary care hospital in north India. Since September 1999, all children with HIV infection registered in our clinic were prospectively followed up. Complete clinical and laboratory evaluation was performed at baseline and thereafter children were followed up. The children were managed according to standard treatment guidelines.

RESULTS

109 children (82 boys, 27 girls) were diagnosed to have HIV infection. The median (range) age at presentation was 48 months (range: 0.75 months-180 months). Eighty one (74.3%) children acquired the infection vertically. Ninety-one (83.5%) children were symptomatic at time of presentation. The common symptoms in the former were failure to thrive (81.3%), recurrent fever (73.6%), diarrhea (50.5%) and recurrent or persistent pneumonia (44%). All children had poor nutritional status at baseline. Of the 67 children who followed up, 36 were receiving antiretroviral drugs (32 received 3 drugs), while families of 31 children did not opt for antiretroviral therapy. Children receiving antiretroviral therapy showed improvement in nutritional parameters.

CONCLUSION

Majority of children with HIV infection presented with various clinical manifestations, poor nutritional status and immunosuppression. Administration of nevirapine based antiretroviral therapy leads to improvement in growth and immune restoration.

Ritonavir-based highly active antiretroviral therapy in human immunodeficiency virus type 1-infected infants younger than 24 months of age

BACKGROUND

Few data are available regarding clinical outcomes or dosing requirements for the protease inhibitor ritonavir in human immunodeficiency virus (HIV)-infected children younger than under 24 months of age.

METHODS

This prospective, multicenter phase I/II open label treatment trial used ritonavir, zidovudine and lamivudine to treat protease inhibitor-naive, HIV-infected infants between the ages of 4 weeks and 24 months. Two sequential dosing cohorts were treated with 350 or 450 mg/m(2) ritonavir every 12 hours; this report includes results of pharmacokinetics, safety, tolerability and efficacy through 104 weeks of follow-up of all subjects.

RESULTS

Fifty HIV-infected children were treated. By week 16, 36 had achieved HIV-1 RNA <400 copies/mL (72% intent-to-treat, 84% as-treated analysis); by week 104, 18 maintained durable viral suppression (36% intent-to-treat, 46% as-treated). Poor medication adherence by caregiver report contributed to virologic failure. Few subjects experienced treatment-limiting toxicity: emesis or ritonavir refusal in 6 (12%); and severe but reversible anemia or elevated serum hepatic transaminases in 1 (4%) each. Apparent oral clearance was higher and the median predose concentrations were substantially lower than those found in adults. Median z scores for weight and height for age/gender were below normal at baseline but improved by week 104.

CONCLUSIONS

A combination regimen of ritonavir, zidovudine and lamivudine was generally safe and produced sustained viral suppression in more than one-third of infants who initiated therapy before 2 years of age. Improved palatability of liquid preparations of protease inhibitors, supporting infrastructure and behavioral approaches to improve medication adherence with antiretrovirals will likely be necessary to further improve efficacy.

Growth of human immunodeficiency virus-infected children receiving highly active antiretroviral therapy

BACKGROUND

Weight and height growth of HIV-infected children tends to lag behind that of uninfected children of similar age. Previous reports of the effect of highly active antiretroviral therapy (HAART) on the growth of HIV-infected children have been contradictory.

METHODS

Age- and gender-adjusted height and weight z scores were studied for 192 HIV-infected children, 4 months to 17 years of age, who had been treated with antiretroviral therapy for at least 16 weeks. These children, in clinically and immunologically stable condition, were enrolled into one of 4 HAART regimens and evaluated for 96 weeks.

RESULTS

At baseline, these HIV-infected children were significantly shorter than uninfected children (mean z score, -0.57; 95% confidence interval, -0.73 to -0.41; P < 0.001). Children with greater viral loads at baseline were significantly shorter and lighter than children with smaller viral loads (both P < 0.001). Administration of HAART led to an increase in mean weight z scores to normal values (mean z score increase, from -0.16 to >0) by week 48 and an increase in mean height z scores of 72% toward normal values (mean z score increase, from -0.57 to -0.16) by week 96. Younger children gained height more rapidly (P < 0.001), and children with greater baseline viral loads gained weight more rapidly (P < 0.001). There was no evidence of differential height or weight changes in 48 weeks between children with different degrees of virologic control.

CONCLUSIONS

HAART improved the average weight gain of HIV-infected children from subnormal to normal after 1 year and improved average height growth to nearly normal after 2 years.

Protease inhibitor combination therapy, severity of illness, and quality of life among children with perinatally acquired HIV-1 infection

OBJECTIVES

This study examines quality of life (QOL) among school-aged children with perinatally acquired HIV infection and compares QOL outcomes between treatment groups that differ according to the use of protease inhibitor (PI) combination therapy (PI therapy). To gain insights into how PI therapy might influence QOL, associations between severity of illness and QOL were also investigated.

METHODS

Cross-sectional data for 940 children, 5 to 18 years of age, who were enrolled in Pediatric AIDS Clinical Trials Group Late Outcomes Protocol 219 were used to examine domains of caregiver-reported QOL, as assessed with the General Health Assessment for Children, during 1999. The General Health Assessment for Children is an age-specific, modular, QOL assessment that was developed for the study with previously validated measures. QOL differences between treatment groups were estimated with linear and logistic regressions that controlled for sociodemographic characteristics (age, gender, race/ethnicity, maternal/caregiver education, and respondent) and severity-of-illness indicators related to receipt of PI therapy (AIDS status, log(10) CD4+ cell counts, and height-for-age z scores).

RESULTS

The mean age of participants was 9.7 years. Most children were non-Hispanic black (54%) or Hispanic (31%), and 49% of the participants were female. At the 1999 study visit, approximately 14% of children had severe immune suppression (<15% CD4+ cells), whereas 62% of children had > or =25% CD4+ cells, ie, no immune suppression. Participants did exhibit some lag in growth, with mean height and weight z scores of -0.70 and -0.20, respectively. Twenty-eight percent of the children were reported to have met criteria for AIDS at study entry (1993-1999). When treatment groups were compared, children receiving PI therapy (72%) were older, had lower CD4+ cell percentages, and had lower height and weight z scores than did those receiving non-PI therapies. They were also more likely to have met criteria for AIDS at study entry. The most commonly used PIs were ritonavir (46%) and nelfinavir (63%). Health perceptions ratings for most children were at the upper end of the scale, whereas ratings for 25% of the children ranged over the lower 70% of scale scores. Almost one half of the children had at least some limitations in physical functioning, with more frequent limitations in energy-demanding activities (46%) than in basic activities of daily living (32%). The Behavior Problems Index was used to assess psychologic functioning. The mean total Behavior Problems Index score (9.34) and the proportion of children with extreme scores (23%) were consistent with values reported for chronically ill children and those at social and economic risk. One or more limitations in social/school functioning were reported for 58% of children. More than one third of the children (38%) experienced > or =1 physical symptoms that were at least moderately distressing. Health perceptions, physical functioning, psychologic functioning, social/school functioning, and overall HIV symptom scores did not differ between treatment groups. However, receipt of PI therapy was associated with an increased rate of diarrhea (28 vs 13%; adjusted odds ratio: 2.59; 95% confidence interval: 1.74-3.85). Severity of illness was associated with QOL in all domains except psychologic functioning. Higher log(10) CD4+ cell counts, higher height-for-age z scores, and absence of AIDS at study entry were independently associated with fewer social/school limitations and better HIV symptom scores. Health perceptions and physical functioning scores were associated with log(10) CD4+ cell counts and height z scores, respectively.

CONCLUSIONS

QOL among children receiving PI therapy differed little from that among children receiving non-PI therapy, despite clinical indications of more advanced disease. Importantly, the study found no evidence of direct negative effects of PI therapy on QOL outcomes, other than an increased rate of diarrhea. Findings suggest that the effects of PI combination therapies to slow or to prevent disease progression and to increase CD4+ cell counts and height growth have the potential to improve QOL among children with HIV infection. However, many children do experience a constellation of functional impairments indicated by behavioral problems and clinical symptoms, with limitations in activities and in school performance. Comprehensive health services will continue to be required to minimize long-term illness and disability and to maximize children's potential as they move into adolescence and adulthood.

Two-year clinical and immune outcomes in human immunodeficiency virus-infected children who reconstitute CD4 T cells without control of viral replication after combination antiretroviral therapy

OBJECTIVE

To evaluate 96-week clinical and immune outcomes to protease inhibitor-containing antiretroviral therapy.

METHODS

A prospective study was conducted of 40 human immunodeficiency virus (HIV)-infected children who displayed viral suppression (VS) with successful immune reconstitution (IS), failure to suppress virus (VF) or develop immune reconstitution (IF), or discordant immune and viral responses (VF/IS) at 24 weeks posttherapy. All children enrolled had viral RNA >4.0 log10 copies per mL and were Centers for Disease Control ad Prevention immune stage 2 or 3. Clinical, viral, and immune outcomes were assessed during the subsequent 72 weeks.

RESULTS

VS/IS and VF/IS groups displayed similar sustained increases in CD4 T cells, although viral levels rebounded by 48 and 96 weeks posttherapy to pretherapy levels in the discordant group. The VF/IS outcome group had significant increases in height and weight z scores compared with entry and were similar to the VS/IS group. After treatment, antigen-specific responses after tetanus immunization were similar in the VF/IS and VS/IS groups. Prevalence of HIV-associated illnesses decreased in both VS/IS and VF/IS but not in VF/IF response groups.

CONCLUSIONS

The findings indicate that viral replication under the selective pressure of protease inhibitors fails to exhibit the same deleterious impact on T-cell immunity as pretherapy viruses. CD4 T-cell counts may be a better predictor of disease progression and improvement in growth than viral burden in HIV-infected children who receive a protease inhibitor as part of a highly active antiretroviral therapy regimen.

Principles of antiretroviral treatment of children and adolescents with human immunodeficiency virus infection

Human immunodeficiency virus (HIV) infection requires life-long therapy to attain durable suppression of HIV replication and prevent or reverse HIV-related symptoms or immune system dysfunction. Combination therapy with 3 or more antiretroviral medications is currently widely recommended for treatment of children and adolescents with HIV infection. While potent regimens can initially reduce virus load to below assay quantitation limits in the majority of persons with HIV infection, 30% to 80% of children will have regimen failure and return of detectable plasma virus within 1 year. Adherence to therapy is critical to regimen success. Optimal treatment requires careful use of potent combinations of drugs, with attention to adherence, palatability, toxicity, and pharmacokinetics. Practitioners with experience caring for children and adolescents with HIV infection should be involved.

Long-term effects of protease-inhibitor-based combination therapy on CD4 T-cell recovery in HIV-1-infected children and adolescents

BACKGROUND

There is limited evidence about longer-term effects of combination antiretroviral therapy that includes protease inhibitors (PIs) on the immunological status of HIV-1-infected children. Better understanding might help to resolve questions on when to initiate treatment.

METHODS

The change in percentage of CD4-positive T lymphocytes (CD4%) was investigated in 1012 previously treated HIV-1-infected children (aged 0-17 years) who were enrolled in research clinics in the USA before 1996 and followed up to 2000. 702 started PI-based combination therapy. Data analyses ignored subsequent treatment changes.

FINDINGS

Among the 1012 children, the median CD4% increased from 22% to 28% between 1996, when PIs were first prescribed, and 2000. For the 702 who started PI-based therapy, the mean CD4% increase after 3 years was largest among participants with the greatest immunosuppression (15.7%, 10.6%, 5.1%, and 2.0% for participants with CD4% before therapy of <5%, 5-14%, 15-24%, and >25%; p<0.0001). After adjustment for pre-PI CD4%, the mean increase was largest among the youngest participants (9.2%, 8.0%, and 4.3% for ages <5 years, 5-9 years, and >10 years; p=0.001). However, only a minority of significantly immunocompromised participants (33%, 26%, and 49% of those with pre-PI CD4% of <5%, 5-14%, or 15-24%) achieved CD4% values above 25%, whereas 84% of those with pre-PI values above 25% maintained such values.

INTERPRETATION

Although PI-based therapy was associated with substantial improvements in CD4%, initiation before severe immunosuppression and at younger ages may be more effective for recovery or maintenance of normal CD4%. Randomised investigation of when to start combination therapy in children, particularly infants, is needed.

Growth, survival and viral load in symptomatic childhood human immunodeficiency virus infection

BACKGROUND

The relationships among weight and height growth, viral load and survival in HIV-infected children remain unclear.

OBJECTIVES

To determine whether weight or height growth velocity independently predicts survival and to investigate associations of weight, height and head circumference growth velocities with viral loads in symptomatic HIV-infected children.

METHODS

We analyzed data from a prospective antiretroviral study utilizing clinical endpoints (PACTG 152). Viral load [log(RNA PCR)] and anthropometric measures 12 weeks before and after viral load measures were available in 494 of 831 children. Interval changes during 24 weeks in z-scores for weight-for-age (DeltaWAZ), height-for-age (DeltaHAZ) and head circumference-for-age (DeltaHCZ) were used as growth velocity surrogates. Logistic regression determined whether DeltaWAZ and/or DeltaHAZ correlated with survival when age, viral load and CD4+ cell count were controlled. Bivariate analysis assessed correlation among viral load and DeltaWAZ, DeltaHAZ and/or DeltaHCZ.

RESULTS

Survival related significantly to height growth velocity (P = 0.03, n = 434) but not to weight growth velocity (P = 0.84, n = 446) or head circumference growth velocity (P = 0.67, n = 148). Viral load was not significantly associated with changes in weight-, height-, or head circumference-for-age z scores (P = 0.86, n = 235; P = 0.07, n = 226; and P = 0.09, n = 165, respectively) in children <30 months of age or with changes in weight- or height-for-age z scores (P = 0.27, n = 259; P = 0.11, n = 251) in older children.

CONCLUSIONS

Height growth velocity predicted survival independently of age, viral load and CD4+ cell count. Weight, height and head circumference growth velocities were not significantly associated with viral load in symptomatic HIV-infected children in this large prospective trial of nucleoside reverse transcriptase therapy.

Delayed onset of pubertal development in children and adolescents with perinatally acquired HIV infection

OBJECTIVE

To examine whether greater severity of HIV infection is associated with delayed initiation of pubertal development among perinatally HIV-infected children, and to compare sexual maturation of perinatally HIV-infected children with children in the general US population using the National Health and Nutrition Examination Survey III.

METHODS

In a prospective cohort study, the authors studied 983 HIV-infected children aged 6 to 18 years, who had Tanner stage assessed on at least two occasions between 1995 and 2000. Analyses were conducted separately for girls and boys to identify factors associated with onset of puberty or adrenarche (progression beyond Tanner stage 1).

RESULTS

Among children who were in Tanner stage 1 at their first assessment, 185 of 413 (45%) girls and 144 of 434 (33%) boys entered puberty during the observation period. In multivariate longitudinal regression analyses adjusted for age, race/ethnicity, time interval between study visits, and other clinical factors, girls with severe immunosuppression (CD4% <15) were significantly less likely to enter adrenarche (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.29-0.83) and puberty (OR, 0.57; 95% CI, 0.33-0.96) compared with girls who were not immunosuppressed (CD4% > or =25). For boys, those with severe immunosuppression were significantly less likely to enter adrenarche (OR, 0.52; 95% CI, 0.28-0.96) and tended to be less likely to begin puberty (OR, 0.69; 95% CI, 0.39-1.22) compared with boys who were not immunosuppressed. Qualitative comparisons suggested that HIV-infected children may experience delayed puberty and adrenarche compared with similarly aged children in the general US population.

CONCLUSIONS

Immunosuppression was associated with delayed pubertal onset in perinatally HIV-infected children. Further studies of perinatally HIV-infected and uninfected children are needed to better quantify the delay in pubertal onset and to compare the pace of pubertal maturation.

Nutritional aspects of HIV-infected children receiving highly active antiretroviral therapy

The presentation of the nutritional problems of HIV-infected children is changing over time with improved antiretroviral regimens. Early reports of HIV infection in the 1980s, included such problems as malnutrition and wasting. However, as treatment and prophylactic regimens improve, the current nutritional problems of HIV-infected children in developed countries include truncal obesity and insulin resistance in addition to malnutrition. Background data on the wasting syndrome, etiology of malnutrition, nutritional effects of highly active antiretroviral therapies, and nutritional intervention strategies for HIV-infected children will be presented.

Height, weight, and growth in children born to mothers with HIV-1 infection in Europe

OBJECTIVES

Little is known about the independent long-term effect on growth of exposure to maternal human immunodeficiency virus (HIV) infection. Growth patterns in uninfected children who are born to infected mothers have not been described in detail previously beyond early childhood, and patterns over age for infected and uninfected children have not been based on appropriate general population standards. In vertically HIV-infected children, poor growth has been suggested to be an early marker of infection or progression of disease. However, whether growth faltering is an independent HIV-related symptom or caused indirectly by other HIV clinical symptoms requires clarification. This information is needed to inform the debate on a possible effect of antiretroviral combination therapy on the height of infected children and would provide evidence for the use of specific interventions to improve height. The objective of this study was to describe growth (height and weight) patterns in infected and uninfected children who are born to HIV-infected mothers with respect to standards from a general population and to assess age-related differences in height and weight by infection status, allowing for birth weight, gestational age, gender, HIV-related clinical status, and antiretroviral therapy (ART).

METHODS

Since 1987, children who were born to HIV-infected mothers in 11 centers in 8 European countries were enrolled at birth in the European Collaborative Study and followed prospectively according to a standard protocol. Height and weight were measured at every visit, scheduled at birth; 3 and 6 weeks; 3, 6, 9, 12, 15, 18, and 24 months; and every 6 months thereafter. Serial measurements of height and weight from birth to 10 years of age of 1403 uninfected and 184 infected children were assessed. We fitted linear mixed effects models allowing for variance changes over age and within-subject correlation using fractional polynomials and natural cubic splines. Growth patterns were compared with British 1990 growth standards and by infection status.

RESULTS

Of the 1587 children enrolled, 810 were male and 777 were female; 1403 were not infected (681 boys, 722 girls), and 184 were infected (88 boys, 96 girls). Neither height nor weight was associated significantly with the main effects of HIV infection status at birth, but differences between infected and uninfected children increased with age. Uninfected children had normal growth patterns from early ages. Infected children were estimated to be significantly shorter and lighter than uninfected children with growth differences increasing with age. Differences in growth velocities between the infected and uninfected children increased after 2 years of age for height and after 4 years of age for weight and were more marked in the latter. Between 6 and 12 months, uninfected children grew an estimated 1.6% faster in height and 6.2% in weight than infected children; between ages 8 and 10 years, these figures were 16% and 44%, respectively. By 10 years, uninfected children were on average an estimated 7 kg heavier and 7.5 cm taller than infected children. Growth in uninfected children who were born before 1994, before the widespread use of ART prophylaxis to reduce vertical transmission, did not substantially differ from that of children who were born after 1994. To investigate whether the growth differences between infected and uninfected children were associated with HIV disease progression, we analyzed growth of infected children using the Centers for Disease Control and Prevention (CDC) clinical classification, in 3 groups: no symptoms, mild or moderate symptoms (A and B), and severe symptoms (C or death). Infected children with mild or serious symptoms lagged behind asymptomatic children in both height and weight, and these differences increased with age. Infected children who were born before availability of ART, before 1988, were more likely to reach a weight below the third centile for age than children who were born after 1994 when effective HIV treatment was widely available. Of the 184 infected children, 67 had been weighed and/or measured at least once while on combination (> or = 2 drugs) ART. Reflecting the longitudinal nature of the European Collaborative Study and the changing availability of HIV treatment, most of these measurements took place after 7 years of age, and therefore analyzing the possible effect of combination therapy on growth is difficult. The z scores for height and weight gain improved substantially in several children who received combination therapy regardless of their CDC clinical classification. To increase available information, we pooled all measurements according to CDC clinical classification and presence of combination therapy at the time of the observation. Weight and height significantly improved for severely ill children after combination therapy.

CONCLUSION

Using data from this large prospective European study, we investigated in comparison with general British standards growth patterns in the first 10 years of life of HIV-infected and uninfected children who were born to HIV-infected mothers. The duration of follow-up of uninfected as well as infected children makes this a unique data set. We allowed for repeated measurements for each child and the increase of variability in height and weight with age. Growth faltering may be related to the social environment, and our finding that uninfected children have normal growth, which is unaffected by exposure to maternal HIV infection, is consistent with observations that in Europe the HIV-infected population is more like the general population and less socioeconomically disadvantaged than that in the United States. However, HIV-infected children grew considerably slower, and differences between infected and uninfected children increased with age. Growth patterns in asymptomatic infected children were similar to those with only mild or moderate symptoms. However, compared with these 2 groups combined, severely ill children had poorer growth at all ages. Although limited by the small number of children who received combination therapy, severely ill children may benefit from such therapy in terms of improvements in weight and, to a smaller extent, in height. Growth faltering, particularly stunting, may adversely affect a child's quality of life, especially once they reach adolescence, and this should be taken into account when making decisions about starting and changing ART. Additional research will help to elucidate the relationship between combination therapy and improved growth, in particular regarding different regimens and the best timing of initiation for optimizing growth of infected children.

Effect of combination therapy including protease inhibitors on mortality among children and adolescents infected with HIV-1

BACKGROUND

Combination therapy including protease inhibitors has been shown to be effective in treating adults infected with human immunodeficiency virus type 1 (HIV-1), but there are only limited data regarding the treatment of children and adolescents.

METHODS

A cohort of 1028 HIV-1-infected children and adolescents, from birth through 20 years of age, who were enrolled in research clinics in the United States before 1996 was followed prospectively through 1999. We used proportional-hazards regression models to estimate the effect on mortality of combination therapy including protease inhibitors.

RESULTS

Seven percent of the subjects were receiving combination therapy including protease inhibitors in 1996; by 1999, 73 percent were receiving such therapy. In univariate analyses, a higher base-line percentage of lymphocytes that were CD4-positive, a higher weight for age, a higher height for age, black race, Hispanic ethnic background, younger age, and perinatally acquired infection were associated with a longer median time to the initiation of this type of therapy (P<0.001). After adjustment for covariates, the differences among racial and ethnic groups in the time to initiation were not statistically significant. Mortality declined from 5.3 percent in 1996 to 2.1 percent in 1997, 0.9 percent in 1998, and 0.7 percent in 1999 (P for trend <0.001). There were reductions in mortality in all subgroups defined according to age, sex, percentage of CD4+ lymphocytes, educational level of the parent or guardian, and race or ethnic background. In adjusted analyses, the initiation of combination therapy including protease inhibitors was independently associated with reduced mortality (hazard ratio for death, 0.33; 95 percent confidence interval, 0.19 to 0.58; P<0.001).

CONCLUSIONS

The use of combination therapy including protease inhibitors has markedly reduced mortality among children and adolescents infected with HIV-1.