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Khamadi SA, Bahemana E, Dear N, Mavere C, George F, Kapene R, Papianus G, Willoughby W, Chambers J, Ganesan K, Mwakabanje I, Bacha JM, Desai P, Almas S, Coakley PD, Wolfman V, Lee EH, Hickey PW, Livezey J, Agaba PA. Factors associated with viral suppression and drug resistance in children and adolescents living with HIV in care and treatment programs in southern Tanzania. J Pediatric Infect Dis Soc 2023:7190157. [PMID: 37279560 DOI: 10.1093/jpids/piad040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Achieving viral suppression (VS) for persons living with HIV is key to reaching epidemic control. We assessed the prevalence of VS and the frequency of HIV drug resistance mutations (HIVDRM) among children and adolescents living with HIV (CALHIV) in the Southern Highland zone of Tanzania. METHODS From 2019-2021, we enrolled CALHIV aged 1-19 years on ART for >6 months in a cross-sectional study. Participants had viral load (VL) testing; those with VL ≥1000 copies/mL underwent HIVDRM testing. VS (<1000 copies/mL) prevalence estimates were calculated, and robust Poisson regression was used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for associations with potential predictors of VS. RESULTS Of 707 participants, 595 had VS (PR:0.84, 95% CI:0.81-0.87). Use of an integrase strand transfer inhibitor-containing regimen (aPR 1.15, 95% CI:0.99-1.34), age 5-9 years (aPR 1.16, 95% CI: 1.07-1.26) and seeking care at a referral center (aPR 1.12, 95% CI:1.04-1.21) were associated with VS. Factors inversely associated with VS included having one (aPR 0.82, 95% CI: 0.72-0.92) or two or more (aPR 0.79, 95% CI: 0.66-0.94) referrals for adherence counselling, and self-reporting missing one to two (aPR 0.88, 95% CI: 0.78-0.99) or three or more (aPR 0.77, 95% CI: 0.63-0.92) doses of ART in the past month. Of 74 participants with PRRT and INT sequencing done, 60 (81.1%) had HIVDRMs at the following frequencies: 71.6%, 67.6%, 1.4% and 4.1% for major NNRTI, NRTI, PI and INSTI respectively. CONCLUSION Higher rates of VS were observed in this cohort, and HIVDRMs were common in those without VS. This evidence supports ART optimization using dolutegravir-based regimens. However, better strategies to improve adherence are needed.
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Affiliation(s)
- Samoel A Khamadi
- Walter Reed Program/HJF Medical Research International, Mbeya, Tanzania
| | - Emmanuel Bahemana
- Walter Reed Program/HJF Medical Research International, Mbeya, Tanzania
| | - Nicole Dear
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Caroline Mavere
- Walter Reed Program/HJF Medical Research International, Mbeya, Tanzania
| | - Fredy George
- Walter Reed Program/HJF Medical Research International, Mbeya, Tanzania
| | - Razack Kapene
- Walter Reed Program/HJF Medical Research International, Mbeya, Tanzania
| | - Grace Papianus
- Walter Reed Program/HJF Medical Research International, Mbeya, Tanzania
| | - Walidah Willoughby
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Jillian Chambers
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Kavitha Ganesan
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Iman Mwakabanje
- Walter Reed Program/HJF Medical Research International, Mbeya, Tanzania
| | - Jason M Bacha
- Baylor College of Medicine, Department of Pediatrics, Houston, TX, USA
- Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Baylor College of Medicine Children's Foundation - Tanzania, Mbeya, Tanzania
| | - Priyanka Desai
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Shaban Almas
- Walter Reed Program/HJF Medical Research International, Mbeya, Tanzania
| | - Peter D Coakley
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Vanessa Wolfman
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Elizabeth H Lee
- The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Patrick W Hickey
- The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jeffrey Livezey
- The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Patricia A Agaba
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
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2
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Campbell LR, Silverstein A, Peckham-Gregory E, Kamiyango W, Villiera J, McAtee CL, Bacha JM, Kovarik CL, Mehta PS, Chanroo T, Kapesa A, Malingoti B, Mzikamanda R, Ozuah NW, Allen CE, Scheurer ME, El-Mallawany NK. Divergent clinical presentations and outcomes among children and adolescents with Kaposi sarcoma in Malawi and Tanzania. HIV Med 2023. [PMID: 36627111 DOI: 10.1111/hiv.13455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The Kaposi sarcoma (KS) T0 versus T1 staging classification does not address the unique clinical features of paediatric KS in human gammaherpesvirus 8 (HHV-8) endemic regions of Africa. This study seeks to define patterns of childhood KS using a paediatric-specific approach. METHODS The Lilongwe paediatric KS staging classification categorizes disease based on clinical phenotype: stage 1 = mild/moderate KS limited to cutaneous/oral involvement, stage 2 = primarily lymphadenopathic disease, stage 3 = woody edema KS, stage 4 = visceral and/or severe/disseminated mucocutaneous disease. Characteristics and outcomes were evaluated from paediatric referral centres in Lilongwe, Malawi, and Mbeya, Tanzania. RESULTS Among 171 patients, the median age was 9.3 years, 37% (n = 63) were female, and 87% (n = 149) had HIV. Breakdown by stage was as follows: 18% (n = 31) stage 1, 33% (n = 56) stage 2, 19% (n = 33) stage 3, and 30% (n = 51) stage 4. Age (younger stage 2 and older stage 3), severe CD4 count suppression (lower CD4 for stages 1 and 4), and presence of severe anaemia and thrombocytopenia (worse for stages 2 and 4) differed across stages. Estimated 2-year event-free survival/progression-free survival/overall survival by stage was as follows: stage 1, 81%/81%/87%; stage 2, 50%/50%/63%; stage 3, 24%/49%/81%; and stage 4, 29%/34%/54%. Sub-analysis of stage 2 lymphadenopathic KS demonstrated superior long-term 6-year event-free survival of 70% (95% confidence interval [CI] 49-83) for younger children (aged <7 years) versus 27% (95% CI 8-51) for older children. CONCLUSIONS This paediatric-specific staging classification categorizes patients with distinct characteristics and patterns of treatment response. This platform may guide clinicians to provide risk-stratified treatment with the hope of improving survival among children with KS.
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Affiliation(s)
- Liane R Campbell
- Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Baylor College of Medicine Children's Foundation-Tanzania, Mbeya, Tanzania
| | - Allison Silverstein
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi.,Department of Hospice and Palliative Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Erin Peckham-Gregory
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Center for Epidemiology and Population Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - William Kamiyango
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
| | - Jimmy Villiera
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
| | - Casey L McAtee
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - Jason M Bacha
- Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Baylor College of Medicine Children's Foundation-Tanzania, Mbeya, Tanzania
| | | | - Parth S Mehta
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - Toni Chanroo
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
| | - Asulwisye Kapesa
- Baylor College of Medicine Children's Foundation-Tanzania, Mbeya, Tanzania
| | - Beatrice Malingoti
- Baylor College of Medicine Children's Foundation-Tanzania, Mbeya, Tanzania
| | - Rizine Mzikamanda
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
| | - Nmazuo W Ozuah
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - Carl E Allen
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - Michael E Scheurer
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Center for Epidemiology and Population Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Nader K El-Mallawany
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
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3
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Bacha JM, Dlamini S, Anabwani F, Gwimile J, Kanywa JB, Farirai J, Bvumbwe M, Steffy T, Nguyen D, Wanless RS, Haq H. Achieving Antiretroviral Therapy Uptake and Viral Suppression Among Children and Adolescents Living With HIV in the UNAIDS 90-90-90 Era Across Six Countries in Eastern and Southern Africa-Lessons From the BIPAI Network. J Acquir Immune Defic Syndr 2022; 90:300-308. [PMID: 35364599 DOI: 10.1097/qai.0000000000002957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although achievements have been made globally since the UNAIDS 90-90-90 targets were announced, paediatric data remain sparse. We describe achievements toward antiretroviral therapy (ART) uptake and viral load (VL) suppression, existing gaps, and potential best practices among children and adolescents living with HIV (CALHIV) across 6 Eastern and Southern African countries. SETTING Baylor College of Medicine International Paediatric AIDS Initiative Network sites in Botswana, Eswatini, Lesotho, Malawi, Tanzania, and Uganda. METHODS We performed retrospective data analysis among CALHIV ages 0-19 years between 2014 and 2019. RESULTS A total of 25,370 CALHIV received care, 85.8% (21,773/25,370) received ART, 84.4% (18,376/21,773) had documented VL results, and 74.6% (13,715/18,376) had VL < 1000 cps/mL. By 2019, the pooled proportion of CALHIV receiving ART and having viral suppression increased to 99.8% [95% confidence interval (CI): 98.1 to 100.0] and 89.8% (95 CI: 88.2 to 91.5) respectively. Lower rates of viral suppression and higher lost to follow-up (LTFU) were seen in the 0-4-year and 15-19-year cohorts. CALHIV on ART not achieving viral suppression were younger, received care in Malawi or Mbeya, had a history of tuberculosis, lower rates of integrase-strand inhibitor-based ART, and were on ART for shorter durations. Best practices reported included adopting universal ART, ART optimization with protease inhibitor-based and/or dolutegravir-based regimens, peer-supported activities, child/adolescent friendly services, community-supported activities, and technology-driven quality improvement activities and digital solutions. CONCLUSIONS High rates of CALHIV receiving ART and having viral suppression can be achieved in settings in Eastern and Southern Africa through using pediatric best practices. Increased efforts must be made to address LTFU and to support under-fives and adolescents.
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Affiliation(s)
- Jason M Bacha
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine Children's Foundation-Tanzania, Mbeya, Tanzania
| | - Sandile Dlamini
- Department of Pediatrics, Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | - Florence Anabwani
- Department of Pediatrics, Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | - Judith Gwimile
- Department of Pediatrics, Baylor College of Medicine Children's Foundation-Tanzania, Mwanza, Tanzania
| | | | - John Farirai
- Department of Pediatrics, Botswana-Baylor Children's Clinical Centre of Excellence Trust, Gaborone, Botswana
| | - Menard Bvumbwe
- Department of Pediatrics, Baylor College of Medicine Children's Foundation-Malawi, Lilongwe, Malawi
| | - Teresa Steffy
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine Children's Foundation-Lesotho, Maseru, Lesotho; and
| | - Diane Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX
- Department of Education, Innovation, and Technology, Baylor College of Medicine, Houston, TX
| | - Richard S Wanless
- Department of Pediatrics, Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Heather Haq
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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4
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Campbell LR, El-Mallawany NK, Slone JS, Malingoti BM, Mehta PS, Scheurer ME, Bacha JM, Peckham-Gregory EC. Clinical characteristics and successful treatment outcomes of children and adolescents with Kaposi sarcoma in Southwestern Tanzania. Pediatr Hematol Oncol 2022; 39:28-47. [PMID: 34243680 DOI: 10.1080/08880018.2021.1936315] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The HIV/AIDS epidemic has driven the rise in cases of Kaposi sarcoma (KS) among children and adolescents living with HIV in countries with high Human gammaherpesvirus 8 (HHV-8) seroprevalence, such as Tanzania, where specialized oncology programs are sparse. Consequently, descriptions of successful treatment of KS in children and adolescents by general pediatricians are important. A retrospective analysis was performed of children and adolescents diagnosed with KS and treated with chemotherapy and combination antiretroviral therapy (cART) at the Baylor College of Medicine Children's Foundation Tanzania Center of Excellence - Mbeya between 2011 and 2017. Sixty-one patients were diagnosed with KS with a median age of 12.6 years (interquartile range (IQR) 9.4 - 15.5). Diagnosis was confirmed by histopathology in 36% (22/61). Among HIV positive patients (59/61), 78% (46/59) were on cART at KS diagnosis. Severe immunosuppression was present in 63% (35/56) of those with CD4 data and 44% (27/61) had SAM. Advanced-stage T1 disease was present in 64% (39/61), including 28% (17/61) with visceral/disseminated KS. Two-year estimated overall survival (OS) was 72% (95% Confidence Interval (CI): 58%-82%) and median follow up for survivors was 25.7 months (IQR 14.2-53.8). No patients were lost to follow up. Two-year OS was 63% (95% CI: 44%-77%) in patients with severe immune suppression and 60% (95% CI: 37%-76%) in patients with SAM. Among patients with visceral/disseminated KS, 53% (9/17) survived. This retrospective analysis demonstrated favorable outcomes in a complex cohort of children and adolescents with KS treated with chemotherapy by general pediatricians in Tanzania.
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Affiliation(s)
- L R Campbell
- Baylor College of Medicine International Pediatric AIDS Initiative at, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - N K El-Mallawany
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - J S Slone
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - B M Malingoti
- Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - P S Mehta
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - M E Scheurer
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA.,Center for Epidemiology and Population Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - J M Bacha
- Baylor College of Medicine International Pediatric AIDS Initiative at, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - E C Peckham-Gregory
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA.,Center for Epidemiology and Population Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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5
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Mandalakas AM, Kay AW, Bacha JM, Devezin T, Golin R, Simon KR, Dhillon D, Dlamini S, DiNardo A, Matshaba M, Sanders J, Thahane L, Amuge PM, Ahmed S, Sekadde MP, Fida NG, Lukhele B, Chidah N, Damba D, Mhango J, Chodota M, Matsoso M, Kayabu A, Wanless RS, Schutze GE. Tuberculosis among Children and Adolescents at HIV Treatment Centers in Sub-Saharan Africa. Emerg Infect Dis 2021; 26. [PMID: 33219815 PMCID: PMC7706926 DOI: 10.3201/eid2612.202245] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
HIV-infected children and adolescents are at increased risk for tuberculosis (TB). Antiretroviral therapy (ART) reduces TB risk in HIV-infected adults, but its effectiveness in HIV-infected children and adolescents is unknown. We analyzed data from 7 integrated pediatric HIV/TB centers in 6 countries in sub-Saharan Africa. We used a Bayesian mixed-effect model to assess association between ART and TB prevalence and used adaptive lasso regression to analyze risk factors for adverse TB outcomes. The study period encompassed 57,525 patient-years and 1,160 TB cases (2,017 cases/100,000 patient-years). Every 10% increase in ART uptake resulted in a 2.33% reduction in TB prevalence. Favorable TB outcomes were associated with increased time in care and early ART initiation, whereas severe immunosuppression was associated with death. These findings support integrated HIV/TB services for HIV-infected children and adults and demonstrate the association of ART uptake with decreased TB incidence in high HIV/TB settings.
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6
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Haq H, Elyanu P, Bulsara S, Bacha JM, Campbell LR, El-Mallawany NK, Keating EM, Kisitu GP, Mehta PS, Rees CA, Slone JS, Kekitiinwa AR, Matshaba M, Mizwa MB, Mwita L, Schutze GE, Wanless SR, Scheurer ME, Lubega J. Association between Antiretroviral Therapy and Cancers among Children Living with HIV in Sub-Saharan Africa. Cancers (Basel) 2021; 13:cancers13061379. [PMID: 33803641 PMCID: PMC8003101 DOI: 10.3390/cancers13061379] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/02/2021] [Accepted: 03/14/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Most children infected with HIV live in Sub-Sahara Africa (SSA). These children are at risk of cancers related to HIV infection, but the degree of this risk and how it is influenced by antiretroviral therapy (ART) is unknown. In this study, we determined the subtypes, incidence, and risk factors of cancers in children with HIV in SSA and receiving ART with the goal of learning how we may prevent these cancers. We found that Kaposi sarcoma and lymphoma are the most common, comprising about 77% and 19% of cancers in these children, respectively. For every 100,000 person-years, 47.6 children developed cancer. Waiting to start ART until after 2 years old and having had severe immunosuppression were the two biggest risk factors for cancer that we identified. The findings justify the recommendations to start children on ART as soon as they are diagnosed with HIV regardless of their CD4 immune status. Abstract Approximately 91% of the world’s children living with HIV (CLWH) are in sub-Saharan Africa (SSA). Living with HIV confers a risk of developing HIV-associated cancers. To determine the incidence and risk factors for cancer among CLWH, we conducted a nested case-control study of children 0–18 years from 2004–2014 at five centers in four SSA countries. Incident cases of cancer and HIV were frequency-matched to controls with HIV and no cancer. We calculated the incidence density by cancer type, logistic regression, and relative risk to evaluate risk factors of cancer. The adjusted incidence density of all cancers, Kaposi sarcoma, and lymphoma were 47.6, 36.6, and 8.94 per 100,000 person-years, respectively. Delayed ART until after 2 years of age was associated with cancer (OR = 2.71, 95% CI 1.51, 4.89) even after adjusting for World Health Organization clinical stage at the time of enrolment for HIV care (OR = 2.85, 95% CI 1.57, 5.13). The relative risk of cancer associated with severe CD4 suppression was 6.19 (p = 0.0002), 2.33 (p = 0.0042), and 1.77 (p = 0.0305) at 1, 5, and 10 years of ART, respectively. The study demonstrates the high risk of cancers in CLWH and the potential benefit of reducing this risk by the early initiation of ART.
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Affiliation(s)
- Heather Haq
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
- Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children’s Hospital, Houston, TX 77030, USA;
| | - Peter Elyanu
- Baylor College of Medicine Children’s Foundation-Uganda, Kampala, Uganda; (P.E.); (G.P.K.); (A.R.K.)
| | - Shaun Bulsara
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
| | - Jason M. Bacha
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
- Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children’s Hospital, Houston, TX 77030, USA;
- Baylor College of Medicine Children’s Foundation-Tanzania, Mbeya, Tanzania;
| | - Liane R. Campbell
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
- Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children’s Hospital, Houston, TX 77030, USA;
- Baylor College of Medicine Children’s Foundation-Tanzania, Mbeya, Tanzania;
| | - Nader K. El-Mallawany
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
| | - Elizabeth M. Keating
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
- Baylor College of Medicine Children’s Foundation-Lesotho, Maseru, Lesotho
| | - Grace P. Kisitu
- Baylor College of Medicine Children’s Foundation-Uganda, Kampala, Uganda; (P.E.); (G.P.K.); (A.R.K.)
| | - Parth S. Mehta
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
- Global Hematology Oncology Pediatric Excellence Program, Texas Children’s Cancer and Hematology Centers, Houston, TX 77030, USA
| | - Chris A. Rees
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
- Baylor College of Medicine Children’s Foundation-Malawi, Lilongwe, Malawi
| | - Jeremy S. Slone
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
- Global Hematology Oncology Pediatric Excellence Program, Texas Children’s Cancer and Hematology Centers, Houston, TX 77030, USA
| | - Adeodata R. Kekitiinwa
- Baylor College of Medicine Children’s Foundation-Uganda, Kampala, Uganda; (P.E.); (G.P.K.); (A.R.K.)
| | - Mogomotsi Matshaba
- Botswana-Baylor Children’s Clinical Centre of Excellence, Gabarone, Botswana;
| | - Michael B. Mizwa
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
- Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children’s Hospital, Houston, TX 77030, USA;
| | - Lumumba Mwita
- Baylor College of Medicine Children’s Foundation-Tanzania, Mbeya, Tanzania;
| | - Gordon E. Schutze
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
- Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children’s Hospital, Houston, TX 77030, USA;
| | - Sebastian R. Wanless
- Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children’s Hospital, Houston, TX 77030, USA;
| | - Michael E. Scheurer
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
| | - Joseph Lubega
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (H.H.); (S.B.); (J.M.B.); (L.R.C.); (N.K.E.-M.); (E.M.K.); (P.S.M.); (C.A.R.); (J.S.S.); (M.B.M.); (G.E.S.); (M.E.S.)
- Global Hematology Oncology Pediatric Excellence Program, Texas Children’s Cancer and Hematology Centers, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-8328224242
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Vonasek B, Kay A, Devezin T, Bacha JM, Kazembe P, Dhillon D, Dlamini S, Haq H, Thahane L, Simon K, Matshaba M, Sanders J, Minde M, Wanless S, Nyasulu P, Mandalakas A. Tuberculosis symptom screening for children and adolescents living with HIV in six high HIV/TB burden countries in Africa. AIDS 2021; 35:73-79. [PMID: 33048868 PMCID: PMC7752241 DOI: 10.1097/qad.0000000000002715] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 08/31/2020] [Accepted: 09/15/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The WHO recommends that children and adolescents living with HIV (CALHIV) complete TB symptom screening at every clinical encounter but evidence supporting this recommendation is limited. We evaluated the performance of the recommended TB symptom screening in six high-burden TB/HIV countries. DESIGN Retrospective longitudinal cohort. METHODS We extracted data from electronic medical records of CALHIV receiving care from clinics in Botswana, Eswatini, Lesotho, Malawi, Tanzania, and Uganda from January 2014 to June 2017. We defined incident TB cases as those prescribed TB treatment within 30 days of TB diagnosis. We analyzed the most recent symptom screen preceding a TB diagnosis. In accordance with WHO guidelines, positive screens were defined as current fever, cough, poor weight gain, or recent TB contact. Odds of TB disease was modeled by screen result and age at which screening was conducted. RESULTS Twenty thousand seven hundred and six patients collectively had 316 740 clinic visits, of which 240 161 (75.8%) had documented TB symptom screens. There were 35 701 (14.9%) positive TB symptom screens, and 1212 incident TB diagnoses. Sensitivity and specificity of the TB symptom screen to diagnose TB were 61.2% (95% CI 58.4--64.0) and 88.8% (95% CI 88.7--88.9), respectively. Log odds of documented TB for positive or negative screens was statistically different only for screens conducted at ages 7--17. CONCLUSION Although specificity was high, the sensitivity of the TB symptom screen to detect TB in CALHIV was low. More accurate screening approaches are needed to optimally identify TB disease in CALHIV.
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Affiliation(s)
- Bryan Vonasek
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Alexander Kay
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation-Swaziland, Mbabane, Eswatini
| | - Tara Devezin
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jason M. Bacha
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation-Tanzania, Mbeya, Tanzania
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kazembe
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Dilsher Dhillon
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Sandile Dlamini
- Baylor College of Medicine Children's Foundation-Swaziland, Mbabane, Eswatini
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Heather Haq
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Lineo Thahane
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation-Lesotho, Maseru, Lesotho
| | - Katie Simon
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Mogomotsi Matshaba
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Botswana-Baylor Children's Clinical Center of Excellence, Gaborone, Botswana
| | - Jill Sanders
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation-Lesotho, Maseru, Lesotho
| | - Mercy Minde
- Baylor College of Medicine Children's Foundation-Tanzania, Mwanza, Tanzania
| | - Sebastian Wanless
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Phoebe Nyasulu
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Anna Mandalakas
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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8
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Bacha JM, El-Mallawany NK, Slone JS, Wilkinson JP, Mehta PS, Campbell LR. Recommendations for treating life-threatening Kaposi sarcoma during pregnancy in HIV-positive women in low income countries. Int J STD AIDS 2020; 31:724-734. [PMID: 32493141 DOI: 10.1177/0956462420920160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In areas of high HIV and human herpes virus 8 prevalence, life-threatening forms of Kaposi sarcoma (KS) can occur in HIV-positive women during pregnancy. Treating KS in pregnancy must balance both the well-being of the mother with the health of the fetus, yet data and recommendations on the best treatment approach for KS during pregnancy are limited. Without effective treatment, which can be difficult to obtain in low income countries (LICs), the mother and infant are at risk for poor outcomes. A successful case report is used as teaching example, followed by a detailed review of the literature that culminates in recommendations for treating KS during pregnancy among HIV-positive women in LICs. A 31-year-old HIV-positive woman presented for care in April 2016 at 28 weeks gestation with extensive KS skin lesions, KS lymphadenopathy, and a large oropharynx KS lesion causing partial airway obstruction. She had initiated antiretroviral therapy (ART) months prior and was virally suppressed, suggesting KS-immune reconstitution inflammatory syndrome. Due to the severity of KS and her third trimester status, combination chemotherapy was initiated using bleomycin, vincristine, and doxorubicin followed by maintenance therapy with paclitaxel. She showed remarkable response to the chemotherapy and had a normal vaginal delivery of a healthy baby at full term. Full clinical remission was achieved, and her baby was HIV-negative with no negative health effects of the KS or the chemotherapy. Review of the sparse existing literature demonstrates the importance, safety, and effectiveness of treating KS during pregnancy. We offer simple adaptable treatment recommendations for use in treating HIV-positive women with KS during pregnancy in LICs. Life-threatening KS can be treated using chemotherapy and ART in resource-limited settings, allowing for good outcomes in mother and infant. While monotherapy with liposomal doxorubicin or paclitaxel is preferred, these are often not available in LICs. As alternatives, bleomycin, vincristine, and doxorubicin can be safely used during the second and/or third trimesters for treating KS. Following a simple treatment approach can be an effective way to treat KS in pregnancy for pregnant women living with HIV in an LIC setting.
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Affiliation(s)
- Jason M Bacha
- Baylor College of Medicine Children's Foundation - Tanzania, Mbeya, Tanzania.,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Nader K El-Mallawany
- Baylor College of Medicine - Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Jeremy S Slone
- Baylor College of Medicine - Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Jeffrey P Wilkinson
- Baylor College of Medicine, Department of Obstetrics and Gynecology, Global Women's Health, Houston, TX, USA
| | - Parth S Mehta
- Baylor College of Medicine - Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Liane R Campbell
- Baylor College of Medicine Children's Foundation - Tanzania, Mbeya, Tanzania.,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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9
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McCormick DW, Bacha JM, El-Mallawany NK, Kovarik CL, Slone JS, Campbell LR. Disseminated cysticercosis and Kaposi sarcoma in a child with HIV/AIDS: A case report. BMC Infect Dis 2020; 20:309. [PMID: 32334521 PMCID: PMC7183726 DOI: 10.1186/s12879-020-05039-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/16/2020] [Indexed: 12/22/2022] Open
Abstract
Background Clinical manifestations of extraneural infection with the pork tapeworm Taenia solium typically affect the muscles, eyes, alimentary canal, and/or subcutaneous tissues. Children living with HIV are at increased risk for more widespread and severe manifestations of food-borne opportunistic infections, including T. solium, due to fluctuating levels of immunosuppression. We present a case of disseminated T. solium in a HIV-positive child with Kaposi sarcoma living in Tanzania with cysticercosis presenting as widespread subcutaneous nodules. Case presentation A 4-year-old HIV-positive boy in Southern Tanzania presented for evaluation of > 30 violaceous skin lesions, few subcutaneous nodules, and a circumferential violaceous penile lesion which rapidly grew after initiation of ART. The patient was clinically diagnosed with Kaposi sarcoma and started on chemotherapy with bleomycin, vincristine, and doxorubicin. He completed 10 cycles of chemotherapy, with full resolution of the violaceous skin and penile lesions but persistence of his subcutaneous nodules, thus paclitaxel was added. After 12 additional cycles of paclitaxel, his subcutaneous nodules enlarged, and biopsy of a scapular subcutaneous nodule was performed. Histopathology revealed a cystic structure with a central larval scolex and serrated spiral canal consistent with T. solium, which confirmed a diagnosis of disseminated cysticercosis. He completed a 10-day course of praziquantel and albendazole with resolution of the subcutaneous nodules. Conclusions Disseminated cysticercosis is an unusual opportunistic infection which can present as subcutaneous nodules without other typical cysticercosis symptoms. Immunosuppression – from HIV and/or chemotherapy – may unmask cysticercosis in children in endemic regions and result in more severe manifestations of this disease. Cysticercosis should remain on a clinician’s differential for subcutaneous nodules, especially in children living with HIV. Cysticercosis can mimic Kaposi sarcoma, and histopathology is essential to accurately diagnose and manage patients with concerning skin lesions.
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Affiliation(s)
- David W McCormick
- Baylor College of Medicine, 1 Baylor Plaza BCM 620, Houston, TX, 77030-3411, USA.
| | - Jason M Bacha
- Baylor College of Medicine, 1 Baylor Plaza BCM 620, Houston, TX, 77030-3411, USA.,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Baylor College of Medicine Children's Foundation - Tanzania, Pediatrics, Mbeya, Tanzania
| | - Nader K El-Mallawany
- Baylor College of Medicine - Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Carrie L Kovarik
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - J S Slone
- Baylor College of Medicine - Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Liane R Campbell
- Baylor College of Medicine, 1 Baylor Plaza BCM 620, Houston, TX, 77030-3411, USA.,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Baylor College of Medicine Children's Foundation - Tanzania, Pediatrics, Mbeya, Tanzania
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10
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Bacha JM, Aririguzo LC, Mng'ong'o V, Malingoti B, Wanless RS, Ngo K, Campbell LR, Schutze GE. The Standardized Pediatric Expedited Encounters for ART Drugs Initiative (SPEEDI): description and evaluation of an innovative pediatric, adolescent, and young adult antiretroviral service delivery model in Tanzania. BMC Infect Dis 2018; 18:448. [PMID: 30176821 PMCID: PMC6122709 DOI: 10.1186/s12879-018-3331-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As countries scale up antiretroviral therapy (ART) for children, innovative strategies to deliver quality services to children are needed. Differentiated ART delivery models have been successful in adults, but no such program has been described in children. We describe the Standardized Pediatric Expedited Encounters for ART Drugs Initiative (SPEEDI). METHODS Descriptive analysis of patients eligible for SPEEDI was done via retrospective review of children, adolescents, and young adults on ART at the Baylor Centre of Excellence (COE) in Mbeya, Tanzania between January 2013 and December 2015. Eligibility for SPEEDI visits included the following: stable children, adolescents, and young adults on ART for approximately 3 months or longer, no medical or social complications, good adherence to ART, and presence of reliable caregiver. During a SPEEDI visit, patients were fast tracked in triage to collect medications directly without physically seeing a clinician. SPEEDI patients came to clinic every two months, and alternated SPEEDI visits with standard visits. Baseline characteristics, mortality, and lost-to-follow up rates of SPEEDI patients were analyzed. RESULTS One thousand one hundred sixty-four patients utilized SPEEDI, totaling 3493 SPEEDI visits. SPEEDI reached 51.3% (1164/2269) of pediatric ART patients, accounting for 7.7% (3493/44489) of total patient encounters. SPEEDI patients were 52% (605/1164) female, median age of 11.7 years (range 1.2-25.5 yr), median time on ART of 21 months (range 4-130 months) and 83.5% (964/1155) categorized as no or mild HIV-associated immunodeficiency. SPEEDI patients had good outcomes (98.8%), low LTFU (0.1%) and low mortality rates (0.61 deaths per 100 patient-years). CONCLUSION SPEEDI was an effective model for delivering ART to children, adolescents, and young adults in our setting, leading to good clinical outcomes, low mortality, and low LTFU. The SPEEDI program safely and effectively expedited and spaced out ART visits for children, adolescents, and young adults, and can serve as an adaptable ART delivery model for other resource limited settings.
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Affiliation(s)
- Jason M Bacha
- Pediatrics, Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Box 2663, Mbeya, PO, Tanzania. .,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Lynda C Aririguzo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Veronica Mng'ong'o
- Pediatrics, Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Box 2663, Mbeya, PO, Tanzania
| | - Beatrice Malingoti
- Pediatrics, Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Box 2663, Mbeya, PO, Tanzania
| | - Richard S Wanless
- Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Katherine Ngo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Liane R Campbell
- Pediatrics, Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Box 2663, Mbeya, PO, Tanzania.,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Gordon E Schutze
- Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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11
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Bacha JM, Ngo K, Clowes P, Draper HR, Ntinginya EN, DiNardo A, Mangu C, Sabi I, Mtafya B, Mandalakas AM. Why being an expert - despite xpert -remains crucial for children in high TB burden settings. BMC Infect Dis 2017; 17:123. [PMID: 28166728 PMCID: PMC5294844 DOI: 10.1186/s12879-017-2236-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 01/31/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As access to Xpert expands in high TB-burden settings, its performance against clinically diagnosed TB as a reference standard provides important insight as the majority of childhood TB is bacteriologically unconfirmed. We aim to describe the characteristics and outcomes of children with presumptive TB and TB disease, and assess performance of Xpert under programmatic conditions against a clinical diagnosis of TB as a reference standard. METHODS Retrospective review of children evaluated for presumptive TB in Mbeya, Tanzania. Baseline characteristics were compared by TB disease status and, for patients diagnosed with TB, by TB confirmation status using Wilcoxon rank sum test for continuous variables and the Chi-square test for categorical variables. Sensitivity and specificity were calculated to assess the performance of Xpert, smear, and culture against clinical TB. Kappa statistics were calculated to assess agreement between Xpert and smear to culture. RESULTS Among children (N = 455) evaluated for presumptive TB, 70.3% (320/455) had Xpert and 62.8% (286/455) had culture performed on sputa. 34.5% (157/455) were diagnosed with TB: 80.3% (126/157) pulmonary TB, 13.4% (21/157) bacteriologically confirmed, 53.5% (84/157) HIV positive, and 48.4% (76/157) inpatients. Compared to the reference standard of clinical diagnosis, sensitivity of Xpert was 8% (95% CI 4-15), smear 6% (95% CI 3-12) and culture 16% (95% CI 9-24), and did not differ based on patient disposition, nutrition or HIV status. CONCLUSION Despite access to Xpert, the majority of children with presumptive TB were treated based on clinical diagnosis. Reflecting the reality of clinical practice in resource limited settings, new diagnostics such as Xpert serve as important adjunctive tests but will not obviate the need for astute clinicians and comprehensive diagnostic algorithms.
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Affiliation(s)
- Jason M Bacha
- Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Mbeya, Tanzania. .,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Katherine Ngo
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
| | - Petra Clowes
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Heather R Draper
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
| | - Elias N Ntinginya
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Andrew DiNardo
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
| | - Chacha Mangu
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Issa Sabi
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Bariki Mtafya
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
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12
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Bacha JM, Appugliese D, Coleman S, Kaciroti N, Bradley RH, Corwyn RF, Lumeng JC. Maternal perception of neighborhood safety as a predictor of child weight status: The moderating effect of gender and assessment of potential mediators. ACTA ACUST UNITED AC 2010; 5:72-9. [PMID: 19606373 DOI: 10.3109/17477160903055911] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine if there is a relationship between maternal perception of neighborhood safety in 3(rd) grade and weight status in 5(th) grade children, to test if gender moderates this relationship, and to identify potential mediators. METHOD Data from 868 children and their mothers involved in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (NICHD-SECCYD) were used to examine the relationship between maternal perception of neighborhood safety in the 3(rd) grade and child body mass index (BMI) z-score in the 5(th) grade. Multiple regression models tested this relationship, the effect of gender, and potential mediating variables (time outdoors in neighborhood, television viewing, child behavior problems and puberty status). RESULTS Neighborhood safety ratings in the least safe tertile, compared with the safest tertile, were associated with an increased risk of obesity independent of gender, race and income-to-needs ratio (OR=1.59; 95% confidence interval [CI]: 1.03, 2.46), and higher child BMI z-scores among girls, but not boys, compared with the safest tertile (beta=0.33; 95% CI: 0.09, 0.57). Neither amount of time spent outdoors in the neighborhood, television viewing, child behavior problems (internalizing or externalizing), nor puberty status altered the relationship. CONCLUSIONS Maternal perception of the neighborhood as unsafe in 3(rd) grade independently predicted a higher risk of obesity, and a higher BMI z-score among girls, but not boys, in the 5(th) grade. The relationship was not explained by several potential mediators. Further investigation is needed to explore these gender differences and potential mediators.
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Affiliation(s)
- Jason M Bacha
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
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