Clinical standards for drug-susceptible TB in children and adolescents

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

Suboptimal lopinavir exposure in infants on rifampicin treatment receiving double-dosed or semi-superboosted lopinavir/ritonavir: time for a change

BACKGROUND

While super-boosted lopinavir/ritonavir (LPV/r; ratio 4:4 instead of 4:1) is recommended for infants living with HIV and receiving concomitant rifampicin, in clinical practice many different LPV/r dosing strategies are applied due to poor availability of paediatric separate ritonavir formulations needed to super-boost. We evaluated LPV pharmacokinetics in infants with HIV receiving LPV/r dosed according to local guidelines in various sub-Saharan African countries with or without rifampicin-based tuberculosis (TB)-treatment.

METHODS

This was a 2-arm pharmacokinetic sub-study nested within the EMPIRICAL trial (#NCT03915366). Infants aged 1-12 months recruited into the main study were administered LPV/r according to local guidelines and drug availability either with or without rifampicin-based TB-treatment; during rifampicin co-treatment they received double-dosed (ratio 8:2) or semi-superboosted LPV/r (adding a ritonavir 100mg crushed tablet to the evening LPV/r dose). Six blood samples were taken over 12 hours after intake of LPV/r.

RESULTS

In total, 14/16 included infants had evaluable pharmacokinetic curves; 9/14 had rifampicin co-treatment (5 received double-dosed and 4 semi-superboosted LPV/r). The median (IQR) age was 6.4 months (5.4-9.8), weight 6.0kg (5.2-6.8) and 10/14 were male. Of those receiving rifampicin, 6/9 (67%) infants had LPV C trough <1.0mg/L compared to 1/5 (20%) in the control arm. LPV apparent oral clearance was 3.3-fold higher for infants receiving rifampicin.

CONCLUSION

Double-dosed or semi-superboosted LPV/r for infants aged 1-12 months receiving rifampicin resulted in substantial proportions of subtherapeutic LPV levels. There is an urgent need for data on alternative antiretroviral regimens in infants with HIV/TB co-infection, including twice-daily dolutegravir.

Monitoring and evaluation of HIV screening and testing of hospitalized infants and their mothers

SETTING

Improved HIV monitoring and evaluation (M&E) is urgently needed to help close gaps in inpatient infant provider-initiated testing and counseling (PITC) and pediatric case identification. A revised reporting system was piloted on the Breastfeeding Ward at Hospital Central de Maputo in Maputo, Mozambique.

OBJECTIVE

To demonstrate how a simplified reporting system designed for pediatric inpatient ward registers can be used to easily calculate key PITC indicators, including testing coverage, HIV status, linkage to antiretroviral therapy, maternal testing, and point-of-care nucleic acid testing.

DESIGN

This was a retrospective review of PITC data documented in the ward discharge register for all inpatient infants with charts closed from January 1 to June 30, 2020.

RESULTS

At chart closure, 97.7% of infants (477/488) had known serostatus: 76.3% were not exposed (364/477), 15.3% were exposed (73/477), 1.9% definitively non-infected (9/477), and 6.5% infected (31/477). There was a 26.9% positivity rate (14/52) for infant point-of-care nucleic acid testing. Of all HIV-infected infants, 80.6% (25/31) were linked to antiretroviral therapy by the time of discharge. Preferred maternal testing was done in 80.5% of eligible mothers (276/343), with 3.0% newly positive (8/276).

CONCLUSION

This straightforward PITC reporting system enabled simple calculation of key indicators needed for standard M&E, contributed to quality improvement efforts to increase testing coverage, and could be easily adapted for use in other settings.

Clinical and operational factors associated with low pediatric inpatient HIV testing coverage in Mozambique

Setting

Eleven pediatric wards in Maputo Province, Mozambique.

Objective

1) To determine provider-initiated testing and counseling (PITC) coverage, the rate of human immunodeficiency virus (HIV) positivity, and the clinical and facility-level variables associated with PITC; and 2) to assess the care cascade for HIV-exposed and -infected children.

Design

This was a cross-sectional, retrospective review of inpatient charts, selected via systematic randomization, of patients aged 0-4 years, admitted between July and December 2015.

Results

Among the 800 patients included, the median age was 23 months and median duration of hospitalization was 3 days. HIV testing was ordered in 46.0% of eligible patients (known HIV-infected at admission excluded), with results documented for 35.7%, of whom 8.3% were positive. The patient hospitalization diagnoses with the highest PITC rates were malnutrition (73.8%), sepsis (71.4%) and tuberculosis (58.3%), with positivity rates of respectively 16.1%, 20.0%, and 28.6%. Longer hospitalization, weekday admission, and PITC training for staff were significantly associated with better PITC performance. Antiretroviral treatment was initiated during hospitalization for 29.6% of eligible patients.

Conclusion

PITC coverage was low, with high HIV positivity rates, highlighting missed opportunities for diagnosis and linkage to treatment. Strengthened routine testing on wards with consideration of inpatient ART initiation are needed to help achieve pediatric 90-90-90 goals.

Risk factors for mortality in Malawian children with human immunodeficiency virus and tuberculosis co-infection

SETTING

A large urban pediatric human immunodeficiency virus (HIV) clinic in Lilongwe, Malawi.

OBJECTIVE

To identify demographic and clinical risk factors for mortality in children co-infected with HIV and tuberculosis (TB).

DESIGN

A retrospective cohort study of HIV-infected children (aged <18 years) enrolled between October 2004 and October 2010 with at least one current or historical TB diagnosis. Descriptive statistics and logistic regression analyses were performed to determine factors associated with mortality.

RESULTS

A total of 1561 patients met the inclusion criteria, representing 32% of patients ever enrolled. Median age at TB diagnosis was 3.8 years (interquartile range 1.5-7.4); 60.9% had severe immune suppression and 47.6% of those with available data had some degree of acute malnutrition at TB diagnosis. Of the 1113 patients with known outcomes, 225 (20.2%) died. Children with TB-HIV co-infection not initiated on antiretroviral therapy (ART) at any time were 8.8 times more likely to die compared to those initiated on ART 0-2 months after initiation of anti-tuberculosis treatment (adjusted OR 8.83, 95%CI 4.42-17.63). Severe immunosuppression and World Health Organization Stage IV were also associated with mortality.

CONCLUSIONS

Pediatric TB-HIV co-infection is common and mortality is high in this cohort of Malawian children. Prompt initiation of ART should be emphasized in this high-risk patient population.