Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004–2012

Abstract

Background There is limited published data on the outcomes of infants starting antiretroviral therapy (ART) in routine care in Southern Africa. This study aimed to examine the baseline characteristics and outcomes of infants initiating ART. Methods We analysed prospectively collected cohort data from routine ART initiation in infants from 11 cohorts contributing to the International Epidemiologic Database to Evaluate AIDS in Southern Africa. We included ART naïve HIV-infected infants <12 months of age initiating ≥ three antiretroviral drugs between 2004 and 2012. Kaplan-Meier estimates were calculated for mortality, loss to follow-up (LTFU), transfer out and virological suppression. We used Cox Proportional Hazards models stratified by cohort to determine baseline characteristics associated with outcomes mortality and virological suppression. Results The median (interquartile range) age at ART initiation of 4945 infants was 5.9 months (3.7-8.7) with follow-up of 11.2 months (2.8-20.0). At ART initiation 77% had WHO clinical stage 3 or 4 disease and 87% were severely immunosuppressed. Three-year mortality probability was 16% and LTFU 29%. Severe immunosuppression, WHO stage 3 or 4, anaemia, being severely underweight and initiation of treatment before 2010 were associated with higher mortality. At 12 months after ART initiation 17% of infants were severely immunosuppressed and the probability of attaining virological suppression was 56%. Conclusion Most infants initiating ART in Southern Africa had severe disease with high probability of LTFU and mortality on ART. Although the majority of infants remaining in care showed immune recovery and virological suppression, these responses were suboptimal.

Short-term outcomes of down-referral in provision of paediatric antiretroviral therapy at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa: A retrospective cohort study

“…The results were consistent with those from larger studies in similar cohorts. [13,14] It has also shown important negative outcomes associated with the down-referral process, with 18.9% of the study cohort LTFU, 50.0% of whom never presented to PHC clinics, and a further 11.4% having >8 weeks between down-referral and presentation to PHC clinics.…”

“…For the 99 children who were admitted to hospital, the mean (SD) length of stay was 19 (14) days and the most common admission diagnoses were acute lower respiratory tract infection (52.5%) and diarrhoeal disease (36.4%). Most of the children were managed in general medical or acute short-stay wards (70.2%).…”

PrEP as Peri-conception HIV Prevention for Women and Men

“…For women considering PrEP use in pregnancy, these uncertain risks must be weighed against the increased risk of HIV acquisition during pregnancy and the subsequent increased risk of perinatal transmission during acute HIV infection. Observational analyses suggest that pregnancy-induced immune, hormonal, and behavioral changes may increase HIV susceptibility and acute HIV infection during pregnancy has significant consequences for the baby and mother [1, 2, 37-39]. Acute HIV infection during pregnancy and postpartum poses a double burden as acute maternal HIV infection accounts for 26% of perinatal HIV transmission [40, 41].…”

Contribution of Gag and Protease to HIV-1 Phenotypic Drug Resistance in Pediatric Patients Failing Protease Inhibitor-Based Therapy

“…Current guidelines recommend treatment of infants immediately upon a diagnosis of HIV infection, and treatment according to these guidelines has been associated with good clinical outcomes (6,7). Nevertheless, an analysis of children treated in South Africa showed that the probability of virological suppression at age 12 months was only 56% (8). This may be due to the higher viral loads and challenges associated with accurate dosing in infants, placing them at a potentially greater risk for developing PI drug resistance than adult patients (9).…”