Missed opportunities of inclusion in a cohort of HIV‐infected children to initiate antiretroviral treatment before the age of two in West Africa, 2011 to 2013

Abstract

IntroductionThe World Health Organization (WHO) 2010 guidelines recommended to treat all HIV-infected children less than two years of age. We described the inclusion process and its correlates of HIV-infected children initiated on early antiretroviral therapy (EART) at less than two years of age in Abidjan, Côte d'Ivoire, and Ouagadougou, Burkina Faso.MethodsAll children with HIV-1 infection confirmed with a DNA PCR test of a blood sample, aged less than two years, living at a distance less than two hours from the centres and whose parents (or mother if she was the only legal guardian or the legal caregiver if parents were not alive) agreed to participate in the MONOD ANRS 12206 project were included in a cohort to receive EART based on lopinavir/r. We used logistic regression to identify correlates of inclusion.ResultsAmong the 217 children screened and referred to the MONOD centres, 161 (74%) were included and initiated on EART. The main reasons of non-inclusion were fear of father's refusal (48%), mortality (24%), false-positive HIV infection test (16%) and other ineligibility reasons (12%). Having previously disclosed the child's and mother's HIV status to the father (adjusted odds ratio (aOR): 3.20; 95% confidence interval (95% CI): 1.55 to 6.69) and being older than 12 months (aOR: 2.05; 95% CI: 1.02 to 4.12) were correlates of EART initiation. At EART initiation, the median age was 13.5 months, 70% had reached WHO Stage 3/4 and 57% had a severe immune deficiency.ConclusionsFear of stigmatization by the father and early competing mortality were the major reasons for missed opportunities of EART initiation. There is an urgent need to involve fathers in the care of their HIV-exposed children and to promote early infant diagnosis to improve their future access to EART and survival.

The value of confirmatory testing in early infant HIV diagnosis programmes in South Africa: A cost-effectiveness analysis

“…The primary finding was that, when confirmatory testing was not used in the model, more than 10% of infants who initiated ART reflected false-positive diagnoses. These model results are comparable to empirical data from Africa: when records of infants receiving positive EID results and/or initiating ART were reviewed in detail, the proportion found to be truly HIV-uninfected was 2.5% in Kenya, 6.3% in South Africa, 14.6% in Malawi, and 16% in Côte d’Ivoire and Burkina Faso [ 72 – 75 ]. HIV-uninfected infants incorrectly initiating ART not only receive unnecessary medication exposure and treatment costs, but may also experience long-term medication toxicities and the substantial stigma associated with HIV diagnosis [ 7 ].…”

Pharmacokinetics of Efavirenz at a High Dose of 25 Milligrams per Kilogram per Day in Children 2 to 3 Years Old

“…Between May 2011 and January 2013, 156 children were initiated on cART at age 13.7 months (median) (21). After 12 to 15 months on cART, 13 infants had died, 2 were lost to follow-up, 3 were withdrawn from the treatment, 32 virologically failed, and 106 (68%) (54 in the LPV arm and 52 in the EFV arm) were randomized for participation in the study.…”

Survival of HIV-1 vertically infected children

“…Infants are at the highest risk with nearly 30% mortality with bacteriologically confirmed tuberculosis [101]. While cART reduces tuberculosis-related mortality substantially [99,102], delays in cART initiation remain challenging [100,103]. Unlike in adults [104,105], there are no RCTs on the optimal timing of cART initiation in tuberculosis co-infected children.…”