Clinical, Virologic, Immunologic Outcomes and Emerging HIV Drug Resistance Patterns in Children and Adolescents in Public ART Care in Zimbabwe

Abstract

ObjectiveTo determine immunologic, virologic outcomes and drug resistance among children and adolescents receiving care during routine programmatic implementation in a low-income country.MethodsA cross-sectional evaluation with collection of clinical and laboratory data for children (0-<10 years) and adolescents (10–19 years) attending a public ART program in Harare providing care for pediatric patients since 2004, was conducted. Longitudinal data for each participant was obtained from the clinic based medical record.ResultsData from 599 children and adolescents was evaluated. The participants presented to care with low CD4 cell count and CD4%, median baseline CD4% was lower in adolescents compared with children (11.0% vs. 15.0%, p<0.0001). The median age at ART initiation was 8.0 years (IQR 3.0, 12.0); median time on ART was 2.9 years (IQR 1.7, 4.5). On ART, median CD4% improved for all age groups but remained below 25%. Older age (≥ 5 years) at ART initiation was associated with severe stunting (HAZ <-2: 53.3% vs. 28.4%, p<0.0001). Virologic failure rate was 30.6% and associated with age at ART initiation. In children, nevirapine based ART regimen was associated with a 3-fold increased risk of failure (AOR: 3.5; 95% CI: 1.3, 9.1, p = 0.0180). Children (<10y) on ART for ≥4 years had higher failure rates than those on ART for <4 years (39.6% vs. 23.9%, p = 0.0239). In those initiating ART as adolescents, each additional year in age above 10 years at the time of ART initiation (AOR 0.4 95%CI: 0.1, 0.9, p = 0.0324), and each additional year on ART (AOR 0.4, 95%CI 0.2, 0.9, p = 0.0379) were associated with decreased risk of virologic failure. Drug resistance was evident in 67.6% of sequenced virus isolates.ConclusionsDuring routine programmatic implementation of HIV care for children and adolescents, delayed age at ART initiation has long-term implications on immunologic recovery, growth and virologic outcomes.

Patterns of detectable viral load in a cohort of HIV‐positive adolescents on antiretroviral therapy in South Africa

“…Our results show a clear trend of increasing rates of detectable VL as the cohort ages. This is in keeping with findings from other studies that show older adolescents to be at higher risk of detectable VL . Detectable VL was not sustained throughout the follow‐up period in a majority of adolescents, and showed a dynamic pattern of adherence and virological outcomes.…”

Patterns of detectable viraemia among children and adults with HIV infection taking antiretroviral therapy in Zimbabwe

“…The incidence of LLV and VF after reaching VL suppression was also significantly higher in children than in adults. Furthermore, in the present study, adolescents (those aged !10 years) were more likely to experience VF compared to younger children, a finding that has also been reported by other studies conducted in Africa (Makadzange et al, 2015). Adolescence is a period of particularly high risk for poor adherence (Mukui et al, 2016;Nachega et al, 2009).…”

“…The rate of VF in children who reached VL suppression is lower than those reported by other studies (Makadzange et al, 2015;Salou et al, 2016). A possible reason for the higher VF rates reported in other studies is the cross-sectional design of studies and lack of information regarding initial VL suppression prior to inclusion in the study (Fokam et al, 2017;Salou et al, 2016).…”

Drug Resistance Among Adolescents and Young Adults with Virologic Failure of First-Line Antiretroviral Therapy and Response to Second-Line Treatment

“…[28][29][30] In 2015 in Zimbabwe, VF rates were nearly 40% among 15-19year-olds. 1,31 Policy and guidelines support service delivery to improve adherence, viral suppression, and clinical outcomes among adolescents. 32 Similarly, the WHO guidelines encourage EAC before switching to a new regimen.…”