Scaling up antiretroviral therapy for HIV-infected children in Côte d’Ivoire: determinants of survival and loss to programme

Abstract

Entry into the programmeThe Aconda programme adopted a comprehensive family-based approach. Health-care workers were trained to offer HIV testing to every pregnant woman attending antenatal clinics and to encourage HIV-infected mothers to bring their children and partners with them for testing and counselling. Each pregnant woman with an HIV infection was immediately referred for an adult consultation. She then received PMTCT therapy, either a short regimen or ART depending on her clinical and immunological status, and underwent assessment at both antenatal and adult clinics. 18Children aged ≤ 15 years entered the Aconda programme in one of two ways: (i) after referral for HIV testing at the age of ≥ 6 weeks because their mother had been diagnosed with HIV infection and had received PMTCT therapy, or (ii) after HIV testing at a paediatric clinic following presentation with AIDS-related symptoms, even if they had not been previously classified as exposed to or infected by HIV and even if their parents had not participated in the Aconda programme. Standardized paediatric follow-upThe Aconda paediatric HIV care package included systematic paediatric HIV testing which varied according to the child's age. In those aged ≥ 18 months, the standard serum testing algorithm comprised a series of two rapid HIV assays: the Determine ® HIV-1/2 assay (Inverness Medical, Bedford, United Kingdom of Great Britain and Northern Ireland) followed by the Genie II ® HIV-1/HIV-2 assay (Bio-Rad laboratories, MarneLa-Coquette, France). 19 Children aged < 18 months were diagnosed virologically using a TaqMan HIV-1, ribonucleic acid (RNA), real-time polymerase chain reaction test (Hoffmann-La Roche, Basel, Switzerland) with a threshold of 300 copies/ml. 20 Children were regarded as having HIV-1 infections if, at any age, they tested positive for HIV-1 RNA in plasma at least once or if, at age ≥ 18 months, they were positive for HIV-1 on serum testing. Children who tested negative but who were still breastfeeding were defined as HIV-undetermined and were retested 2 months after the cessation of breastfeeding or at 18 months. A negative diagnosis was regarded as definite if it was made at least 2 months after the cessation of breastfeeding and children with this diagnosis were excluded from the programme.All children with a confirmed HIV infection were seen monthly and had unrestricted free access to antiretroviral drugs and comprehensive care. 21 In all children, whether on ART or not, the CD4+ T lymphocyte (CD4 cell) count and CD4 cell percentage were measured every 6 months. Plasma viral load testing was not performed routinely after the diagnosis of HIV infection, even in children on ART. Pulmonary radiographs were available for children whose history and symptoms suggested tuberculosis.Children initiated ART if they were either at World Health Organization (WHO) HIV/AIDS clinical stage 3 or 4 or at clinical stage 1 or 2 with impaired immunity (i.e. a CD4 cell percentage ≥ 25 at age < 12 months, ≥ 20 at 12-35 months or ≥ 15 at ≥ 36 month...

Aderência ao seguimento no cuidado ao recém-nascido exposto à sífilis e características associadas à interrupção do acompanhamento

“…Williams et al 29 followed children with HIV in the United States and Puerto Rico and found that the abandonment of the follow-up occurred when they began attending school and/or their mothers returned to work. However, in Ivory Coast, Anaky et al 30 described the socioeconomic and cultural factors as responsible for the abandonment of follow-up in children infected with HIV. In Spain, families with very low socioeconomic and cultural levels showed high risk of dropping out the follow-up in children with very low birth weight at birth before two years 31 .…”

Challenges of malnutrition care among HIV-infected children on antiretroviral treatment in Africa

“…They are also more at risk of being lost to follow-up [25]. Many authors have reported that the risk of death in the first month of treatment was an average 2 to 3 times higher in malnourished children than in non-malnourished children [19,25,35,36]. Likewise, a deterioration of the nutritional status in the first month of treatment comes with a 2 to 3 times higher risk of death [35].…”

“…And, at initiation of treatment, severely malnourished children have a higher risk of morbid events requiring hospitalization in the first weeks of treatment [34]. They are also more at risk of being lost to follow-up [25]. Many authors have reported that the risk of death in the first month of treatment was an average 2 to 3 times higher in malnourished children than in non-malnourished children [19,25,35,36].…”

“…Underweight has been reported in more than 50% of HIV-infected children at ART initiation in resource-limited countries [12,24,25]. Chronic malnutrition can affect more than two thirds of these children [31][32][33].…”

“…Consequently, their nutritional status can be improved also [23]. The HIV-related pediatric morbidity and mortality was significantly decreased after introducing antiretrovirals in resource-limited countries, in 2004 [3,24,25].…”