Poor Clinical Outcomes for HIV Infected Children on Antiretroviral Therapy in Rural Mozambique: Need for Program Quality Improvement and Community Engagement

Vermund, Sten H.; Blevins, Meridith; Moon, Troy D.; José, Eurico; Moiane, Linda; Tique, José A.; Sidat, Mohsin; Ciampa, Philip J.; Shepherd, Bryan E.; Vaz, Lara M. E.

doi:10.1371/journal.pone.0110116

Cited by 51 publications

(63 citation statements)

References 151 publications

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“…Our challenges are not unique, and are experienced in both high- and low-income settings. 38–39 The management of a chronic, lifelong, incurable infectious disease in the context of stigma and poverty is challenging for parents and practitioners alike; innovative approaches are needed in the Americas and the Caribbean. 40–44 …”

Section: Discussionmentioning

confidence: 99%

Mortality in Children with Human Immunodeficiency Virus Initiating Treatment: A Six-Cohort Study in Latin America

Luque¹,

Jenkins

Shepherd

et al. 2017

The Journal of Pediatrics

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Objectives To assess the risks of and factors associated with mortality, loss to followup, and changing regimens after perinatally HIV-infected children initiate combination antiretroviral therapy (cART) in Latin America and the Caribbean. Study design This 1997–2013 retrospective cohort study included 1174 ART-naïve perinatally-infected children who started cART age<18 years (median 4.7 years; interquartile range [IQR] 1.7–8.8) at one of six cohorts from Argentina, Brazil, Haiti, and Honduras, within the Caribbean, Central and South America Network for HIV Epidemiology (CCASAnet). Median follow-up was 5.6 years (interquartile range [IQR] 2.3 to 9.3). Study outcomes were all-cause mortality, loss to followup, and major changes/interruption/stopping of cART. We used Cox proportional hazards models stratified by site to examine the association between predictors and times to death or changing regimens. Results Only 52% started cART <5 years of age; 19% began a protease inhibitor. At cART initiation, median CD4 count was 472 cells/mm3 (IQR: 201–902); median CD4% was 16% (IQR:10–23). Probability of death was high in the first year of cART: 0.06 (95% confidence interval [CI] 0.04–0.07). Five years after cART initiation, the cumulative mortality incidence was 0.12 (CI 0.10–0.14). Cumulative incidences for loss to followup and regimen change after five years were 0.16 (CI 0.14–0.18) and 0.30 (CI 0.26–0.34), respectively. Younger children had the highest risk of mortality, whereas older children had the highest risk of being lost to followup or changing regimens. Conclusions Innovative clinical and community approaches are needed for quality improvement for HIV pediatric care in the Americas.

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Section: Discussionmentioning

confidence: 99%

Mortality in Children with Human Immunodeficiency Virus Initiating Treatment: A Six-Cohort Study in Latin America

Luque¹,

Jenkins

Shepherd

et al. 2017

The Journal of Pediatrics

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“…Indeed, better survival in children with greater adherence to placebo in co-trimoxazole prophylaxis trial suggests that good adherence may be a surrogate for overall better child care [37]. Mortality at ≥2 years on cART from routine programs in RLS ranges from 3.7 to 29% [38,39] and rates vary from 1.3–6.0/100 CY [40,41]. Children still initiate treatment with severe disease with mortality remaining higher in the first year (Figure 3)[42].…”

Section: Survival On Cart In Routine Carementioning

confidence: 99%

Survival of HIV-1 vertically infected children

Davies

Gibb

Turkova

2016

Current Opinion in HIV and AIDS

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Purpose of review It is 20 years since the start of the combination antiretroviral therapy (cART) era and >10 years since cART scale-up began in resource-limited settings. We examined survival of vertically HIV-infected infants and children in the cART era. Recent findings Good survival has been achieved on cART in all settings with up to ten-fold mortality reductions compared to before cART availability. Although mortality risk remains high in the first few months after cART initiation in young children with severe disease, it drops rapidly thereafter even for those who started with advanced disease, and longer term mortality risk is low. However, suboptimal retention on cART in routine programs threatens good survival outcomes and even on treatment children continue to experience high comorbidity risk; infections remain the major cause of death. Interventions to address infection risk include co-trimoxazole prophylaxis, isoniazid preventive therapy, routine childhood and influenza immunization and improving maternal survival. Summary Pediatric survival has improved substantially with cART and HIV-infected children are aging into adulthood. It is important to ensure access to diagnosis and early cART, good program retention and optimal co-morbidity prophylaxis and treatment to achieve the best possible long-term survival and health outcomes for vertically infected children.

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“…Early detection of HIV infection, linking and retaining them on anti-retroviral therapy (ART) is essential for reducing the morbidity and improving survival. However, globally only 43% of children living with HIV received ART in 2016 [2] and the attrition (loss to follow-up and/or death) of children on ART is higher in resource limited settings when compared to developed countries [3,4]. Many studies in Africa and Asia have shown that it is challenging to enrol and retain paediatric patients on ART care [5–7].…”

Section: Introductionmentioning

confidence: 99%

Attrition among HIV positive children enrolled under integrated HIV care programme in Myanmar: 12 years cohort analysis

Minn¹,

Kyaw²,

Aung³

et al. 2018

Global Health Action

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Background: In Myanmar, HIV seropositive children are being enrolled in an integrated HIV care (IHC) Program for HIV treatment and care since 2005. Objectives: To assess the: (a) attrition (death or loss-to-follow-up) rates among children (aged ≥ 18 months to < 15 years) enrolled into the programme before and after initiation of anti-retroviral therapy (ART) (pre-ART and ART periods); (b) demographic and clinical factors associated with attrition during these two periods. Methods: Children enrolled in IHC Programme and their status (death, lost to follow-up, regular follow-up or transferred out) was assessed as on 30 June 2017. Attrition rates (per 100 person-years) at pre – ART and ART periods were calculated and the association between demographic and clinical characteristics with attrition was assessed using Cox proportional hazards model. Results: Among 2,736 children enrolled, pre-ART attrition rate was 19 per 100 person-years of follow-up (95% CI: 17–21) and ART attrition rate was 4 per 100 person-years of follow-up (95% CI: 3–4) with higher levels during the initial few months of enrolment. The 36-month retention rates during pre-ART period was 75% (95% CI: 72–78) and during ART period was 87% (95% CI: 86–88). The children ‘at enrolment’ with relatively lower levels of haemoglobin, immune deficiency, underweight for age, higher WHO clinical stages, presence of hepatitis B infection had higher hazards of attrition in both periods. Conclusion: The attrition rates are high particularly among children with relatively poorer clinical, nutritional profiles at enrolment. The study suggests the urgent need for improving adherence counselling especially during the initial few months of enrolment and early ART initiation.

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Poor Clinical Outcomes for HIV Infected Children on Antiretroviral Therapy in Rural Mozambique: Need for Program Quality Improvement and Community Engagement

Cited by 51 publications

References 151 publications

Mortality in Children with Human Immunodeficiency Virus Initiating Treatment: A Six-Cohort Study in Latin America

Mortality in Children with Human Immunodeficiency Virus Initiating Treatment: A Six-Cohort Study in Latin America

Survival of HIV-1 vertically infected children

Attrition among HIV positive children enrolled under integrated HIV care programme in Myanmar: 12 years cohort analysis

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