Pediatric HIV in Kano, Nigeria

Prevalence and outcome of HIV infected children admitted in a tertiary hospital in Northern Tanzania

Background

Provider Initiated Testing and Counseling (PITC) among hospitalized children have shown to increase the probability of identifying HIV-infected children and hence be able to link them to HIV care. We aimed at determining the prevalence, clinical characteristics and outcome of HIV-infected children admitted at Bugando Medical Centre (BMC) after active provision of PITC services.

Methods

A cross-sectional study with follow up at three months post enrollment was done. Children with unknown HIV status were tested for HIV infection as per 2012 Tanzanian algorithm. Questionnaires were used to collect demographic, clinical and follow up information. Data was statistically analyzed in STATA v13.

Results

A total of 525 children were enrolled in the study. Median [IQR] age was 28 [15–54] months. Males consisted of 60.2% of all the participants. HIV prevalence was 9.3% (49/525). Thirty-three (67.3%) of HIV-infected children were newly diagnosed at enrolment. Thirty-nine (79.6%) of all HIV-infected patients had WHO HIV/AIDS clinical stage four disease, 10 (20.4%) had WHO clinical stage three and none qualified in stage one or two. About 84% (41/49) of HIV infected children had severe immunodeficiency at the time of the study. Factors that were independently associated with HIV infection were, cough (OR 2.40 [1.08–5.31], p = 0.031), oral thrush (OR 20.06[8.29–48.52], p < 0.001), generalized lymphadenopathy (OR 5.61 [1.06–29.56], p = 0.042), severe acute malnutrition (OR 6.78 [2.28–20.12], p = 0.001), severe stunting (OR 9.09[2.80–29.53], p = 0.034) and death of one or both parents (OR 3.62 [1.10–11.87], p = 0.034). The overall mortality (in-hospital and post-hospital) was 38.8% among HIV-infected children compared with 14.0% in HIV-uninfected children. Within three months period after discharge from the hospital, 71.4% (25/35) of discharged HIV-infected children reported to have attended HIV clinic at least once and 60.0% (21/35) were on antiretroviral medications.

Conclusion

PITC to all admitted children identified significant number of HIV-infected children. Mortality among HIV-infected children is high compared to HIV-uninfected. At the time of follow up about 30% of discharged HIV-infected children did not attend to any HIV care and treatment clinics. Therefore effective efforts are needed to guarantee early diagnosis and linkage to HIV care so as to reduce morbidity and mortality among these children.

Cost-effectiveness of Routine Provider-Initiated Testing and Counseling for Children With Undiagnosed HIV in South Africa

BACKGROUND

We compared the cost-effectiveness of pediatric provider-initiated HIV testing and counseling (PITC) vs no PITC in a range of clinical care settings in South Africa.

METHODS

We used the Cost-Effectiveness of Preventing AIDS Complications Pediatric model to simulate a cohort of children, aged 2-10 years, presenting for care in 4 settings (outpatient, malnutrition, inpatient, tuberculosis clinic) with varying prevalence of undiagnosed HIV (1.0%, 15.0%, 17.5%, 50.0%, respectively). We compared "PITC" (routine testing offered to all patients; 97% acceptance and 71% linkage to care after HIV diagnosis) with no PITC. Model outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs) from the health care system perspective and the proportion of children with HIV (CWH) diagnosed, on antiretroviral therapy (ART), and virally suppressed. We assumed a threshold of $3200/year of life saved (YLS) to determine cost-effectiveness. Sensitivity analyses varied the age distribution of children seeking care and costs for PITC, HIV care, and ART.

RESULTS

PITC improved the proportion of CWH diagnosed (45.2% to 83.2%), on ART (40.8% to 80.4%), and virally suppressed (32.6% to 63.7%) at 1 year in all settings. PITC increased life expectancy by 0.1-0.7 years for children seeking care (including those with and without HIV). In all settings, the ICER of PITC vs no PITC was very similar, ranging from $710 to $1240/YLS. PITC remained cost-effective unless undiagnosed HIV prevalence was <0.2%.

CONCLUSIONS

Routine testing improves HIV clinical outcomes and is cost-effective in South Africa if the prevalence of undiagnosed HIV among children exceeds 0.2%. These findings support current recommendations for PITC in outpatient, inpatient, tuberculosis, and malnutrition clinical settings.

The burden of vaccine-preventable diseases among HIV-infected and HIV-exposed children in sub-Saharan Africa: a systematic review and meta-analysis

There are knowledge gaps regarding evidence-based research on the burden of vaccine-preventable diseases among human immunodeficiency virus (HIV)-infected and HIV-exposed children aged <18 years in sub-Saharan Africa. It is therefore essential to determine the trend and burden of vaccine-preventable diseases. We completed a systematic review and meta-analysis to identify the incidence, prevalence and case-fatality rates (CFR) attributed to various vaccine-preventable diseases among HIV-infected and HIV-exposed children in sub-Saharan Africa. The trends in the prevalence of vaccine-preventable diseases among HIV-infected and HIV-exposed children were also determined. Nine studies on tuberculosis (TB) were pooled to give an overall incidence rate estimate of 60 (95% confidence interval [CI] 30-70) per 1,000 child-years. The incidence of pneumococcal infections varied between 109-1509 per 100,000 while pertussis was between 2.9 and 3.7 per 1000 child-year. Twenty-two TB prevalence studies reported an estimated prevalence of 16%. Fifteen prevalence studies on hepatitis B infection were pooled together with an estimated prevalence of 5%. The pooled prevalence for pneumococcal infections was 2% while rotavirus diarrhoea reported a prevalence of 13%. Twenty-nine studies on TB were pooled to give an overall CFR estimate of 17% while pneumococcal infections in HIV-infected and exposed children were pooled together with a resultant rate of 15%. Some of the vaccine-preventable diseases still have high incidences, prevalence and CFR among HIV-infected and HIV-exposed children. There is also a dearth of research data on the burden of several vaccine-preventable diseases among HIV-infected and exposed children and a need for more studies in this area.

Acute kidney injury in HIV-infected children: comparison of patients according to the use of highly active antiretroviral therapy

OBJECTIVE

To assess clinical and laboratory data, and acute kidney injury (AKI) in HIV-infected children using and not using highly active antiretroviral therapy (HAART) prior to admission.

METHODS

A retrospective study was conducted with HIV-infected pediatric patients (<16 years). Children who were using and not using HAART prior to admission were compared.

RESULTS

Sixty-three patients were included. Mean age was 5.3±4.27 years; 55.6% were females. AKI was observed in 33 (52.3%) children. Patients on HAART presented lower levels of potassium (3.9±0.8 vs. 4.5±0.7mEq/L, p=0.019) and bicarbonate (19.1±4.9 vs. 23.5±2.2mEq/L, p=0.013) and had a higher estimated glomerular filtration rate (102.2±36.7 vs. 77.0±32.8mL/min/1.73m², p=0.011) than those not on HAART. In the multivariate analysis, the use of HAART prior to the admission was a protective factor for AKI (p=0.036; OR=0.30; 95% CI=0.097-0.926).

CONCLUSION

AKI is a common complication of pediatric HIV infection. Use of HAART prior to the admission preserved glomerular filtration and was a protective factor for AKI, but increased medication side effects, such as hypokalemia and renal metabolic acidosis.

Epidemiology of children with acquired immune deficiency syndrome (stage 3): A referral hospital-based study in Iran

Lack of recognition of human immunodeficiency virus (HIV) infection especially in children and delayed implementation of effective control programs makes HIV infection as a major cause for concern. Information on HIV epidemiology in Iran as well as other Islamic countries is limited. The aim of our study was to describe the clinical manifestation and laboratory finding of HIV infected children who were admitted to a referral Children Medical Center (CMC) in Tehran, Iran, during 11 years from January 2002 to January 2013. This was a retrospective study carried out over a period of 11 years. The records of all patients attending to the CMC with confirmed acquired immunodeficiency syndrome (AIDS) were screened. The patients were evaluated for social circumstance, family history, age, gender, clinical, and laboratory features. Clinical data including fever, respiratory distress, diarrhea, rash, etc. as well as laboratory tests including complete blood count, serum glucose level, electrolytes, liver function test, cultures, CD4 lymphocyte count were evaluated. During the study period, 32 HIV positive children were enrolled. The majority of patients were presented with weight loss, prolonged fever, respiratory infection and chronic diarrhea. In this study, salmonella infections as well as streptococcal pneumonia and candida infections followed by, tuberculosis and Pseudomonas aeruginosa infections were the predominant opportunistic infections. Since the number of HIV-positive children has been alarmingly increasing in recent years and perinatal transmission is the most common route of HIV infection in children, essential recommendations for prenatal HIV testing as well as appropriate antiretroviral therapy by HIV infected mothers are needed.

Paediatric HIV testing beyond the context of prevention of mother-to-child transmission: a systematic review and meta-analysis

BACKGROUND

Many HIV-positive children in low-income and middle-income countries remain undiagnosed. Although HIV testing in children at health facilities is recommended by WHO, it is not well implemented. This systematic review and meta-analysis examines the case-finding benefit of HIV screening in children aged 0-5 years in low-income and middle-income countries.

METHODS

We did this systematic review and meta-analysis in accordance with an a-priori protocol. We searched PubMed, MEDLINE, WHO Global Index Medicus, Web of Science, Médecins Sans Frontières, Cochrane, Embase, CABS Abstracts, and LILACS databases for articles published between Jan 1, 2004, and April 30, 2016, that reported the quantitative prevalence of HIV detected through screening in four key contexts (paediatric inpatient settings, paediatric outpatient settings, nutrition centres, and expanded programme on immunisation centres) in paediatric populations in low-income and middle-income countries. Articles were identified and data were extracted in duplicate. The primary outcome was HIV prevalence, for which we used a DerSimonian-Laird random-effects meta-analysis to pool prevalence data and 95% CIs. We did stratified analyses according to geographical context and testing strategy. This study is registered with PROSPERO, number CRD42014014372.

FINDINGS

Our search found 2996 studies, of which 26 met the inclusion criteria. Paediatric HIV prevalence across all settings was 15·6% (95% CI 11·8-19·5). HIV prevalence by setting was highest in paediatric inpatient settings (21·1%, 95% CI 14·9-27·3), followed by nutrition centres (13·1%, 95% CI 3·4-22·7), expanded programme on immunisation centres (3·3%, 95% CI 0-6·9), and paediatric outpatient settings (2·7%, 95% CI 0·3-5·2). Universal testing and testing triggered by symptoms had similar diagnostic yield in the inpatient setting (21·3%, 95% CI 11·6-31·0 in triggered testing vs 20·9%, 95% CI 13·5-28·3 in universal testing).

INTERPRETATION

HIV testing in paediatric populations in low-income and middle-income countries outside the context of prevention of mother-to-child transmission programmes provides an important opportunity to identify HIV-positive children. For countries wishing to prioritise interventions, the highest diagnostic yields were obtained from inpatient wards and nutrition centres. Universal testing might be the preferred approach since it did not have a substantially lower diagnostic yield than triggered testing

FUNDING

None.

Prevalence and risk factors of undernutrition among antiretroviral-therapy-naïve subjects aged under 5 years old in Makurdi, Nigeria: a retrospective study

Background

Undernutrition is common in human immunodeficiency virus (HIV) infection and it contributes significantly to its morbidity and mortality. However, as far as we are aware, few studies have described the risk factors of undernutrition among HIV-infected Nigerian children. The study reported here aimed to determine the prevalence and risk factors of undernutrition among HIV-infected, antiretroviral therapy (ART)-naïve children aged under 5 years old in Makurdi, Nigeria.

Methods

A retrospective, cross-sectional study was undertaken at the Federal Medical Centre, Makurdi, between June 2010 and June 2011. Logistic regression modelling was used to determine the risk factors of undernutrition.

Results

Data on 182 HIV-infected children (88 males and 94 females), aged between 6 weeks and 59 months were studied. The prevalence of undernutrition was 12.1%, 33.5%, and 54.4% for underweight, wasting, and stunting, respectively. In multivariate regression analyses, being female (adjusted odds ratio [AOR] 0.292, 95% [confidence interval] CI 0.104–0.820, P=0.019), the child’s caregiver being on ART (AOR 0.190, 95% CI 0.039–0.925, P=0.04), and the absence of tuberculosis in the child (AOR 0.034, 95% CI 0.003–0.357, P=0.005) were independently protective against underweight. Subjects who were exclusively breastfed in the first 6 months of life were protected from stunting (AOR 0.136, 95% CI 0.032–0.585, P=0.007). No factor impacted significantly on wasting in multivariate analyses.

Conclusion

Undernutrition among HIV-infected, ART-naïve children aged under 5 years old may be reduced if programmatic interventions are guided toward early initiation of ART among eligible HIV-infected caregivers and the promotion of HIV/tuberculosis coinfection control efforts. Also, the importance of exclusive breastfeeding in reducing undernutrition cannot be overemphasized.