HIV viral suppression and longevity among a cohort of children initiating antiretroviral therapy in Eastern Cape, South Africa

Abstract

IntroductionThere are limited data on viral suppression (VS) in children with HIV receiving antiretroviral therapy (ART) in routine care in low‐resource settings. We examined VS in a cohort of children initiating ART in routine HIV care in Eastern Cape Province, South Africa.MethodsThe Pediatric Enhanced Surveillance Study enrolled HIV‐infected ART eligibility children zero to twelve years at five health facilities from 2012 to 2014. All children received routine HIV care and treatment services and attended quarterly study visits for up to 24 months. Time to VS among those starting treatment was measured from ART start date to first viral load (VL) result <1000 and VL <50 copies/mL using competing risk estimators (death as competing risk). Multivariable sub‐distributional hazards models examined characteristics associated with VS and VL rebound following suppression among those with a VL >30 days after the VS date.ResultsOf 397 children enrolled, 349 (87.9%) started ART: 118 (33.8%) children age <12 months, 122 (35.0%) one to five years and 109 (31.2%) six to twelve years. At study enrolment, median weight‐for‐age z‐score (WAZ) was −1.7 (interquartile range (IQR):−3.1 to −0.4) and median log VL was 5.6 (IQR: 5.0 to 6.2). Cumulative incidence of VS <1000 copies/mL at six, twelve and twenty‐four months was 57.6% (95% CI 52.1 to 62.7), 78.7% (95% CI 73.7 to 82.9) and 84.0% (95% CI 78.9 to 87.9); for VS <50 copies/mL: 40.3% (95% CI 35.0 to 45.5), 63.9% (95% CI 58.2 to 69.0) and 72.9% (95% CI 66.9 to 78.0). At 12 months only 46.6% (95% CI 36.6 to 56.0) of children <12 months had achieved VS <50 copies/mL compared to 76.9% (95% CI 67.9 to 83.7) of children six to twelve years (p < 0.001). In multivariable models, children with VL >1 million copies/mL at ART initiation were half as likely to achieve VS <50 copies/mL (adjusted sub‐distributional hazards 0.50; 95% CI 0.36 to 0.71). Among children achieving VS <50 copies/mL, 37 (19.7%) had VL 50 to 1000 copies/mL and 31 (16.5%) had a VL >1000 copies/mL. Children <12 months had twofold increased risk of VL rebound to VL >1000 copies/mL (adjusted relative risk 2.03, 95% CI: 1.10 to 3.74) compared with six to twelve year olds.ConclusionsWe found suboptimal VS among South African children initiating treatment and high proportions experiencing VL rebound, particularly among younger children. Greater efforts are needed to ensure that all children achieve optimal outcomes.

Rates and Correlates of Short Term Virologic Response among Treatment-Naïve HIV-Infected Children Initiating Antiretroviral Therapy in Ethiopia: A Multi-Center Prospective Cohort Study

“…Even though a high proportion of children initially achieved virological suppression, a substantial proportion (38.3%) subsequently registered at least one pVL ≥ 150 copies per mL, a rate that is similar to a study from South Africa [35]. Those who were classified as being WHO clinical stage 4 had an increased hazard of virologic rebound.…”

“…Moreover, in Ethiopia, there is no disaggregated national pediatric data on the rate of sustained virological suppression among HIV infected children who initiated cART (that is, the statistic represented by the third "90" of the UNAIDS 90-90-90 goal) [5]. Only an aggregate estimate of 86% virological suppression in 2016 has been reported, which is higher than the ESA regional average of 52% [33][34][35]. The current study revealed high initial rates of virological suppression -85.5% of participants achieved pVL <150 copies/mL at some point during study follow up -a rate that is comparable to reports by other studies [8,9,17,18].…”

Importance of support groups to the health and well-being of vulnerable children and young people living with HIV: a case study of the Kids Clubs program in Haiti

“…While children and young people's access to antiretroviral therapy (ART) has increased dramatically over the past decade, ART adherence and viral suppression remain challenges, especially among highly vulnerable populations in lower-and middle-income countries [1][2][3][4][5][6]. Nondisclosure and lack of routine have been identified as contributing to poor medication adherence and retention in care.…”

Safety and Efficacy of Starting Antiretroviral Therapy in the First Week of Life

“…A recent South African study that initiated very early ART reported just over 50% with HIV RNA < 400 copies/mL at 6 months, and > 10% mortality [ 34 ]. Similarly, in several earlier pediatric cohorts in Johannesburg, only 25%–49% achieved 6-month viral suppression to < 50 copies/mL [ 35 ], and only 29% achieved 6-month viral suppression to < 50 copies/mL among infants starting ART < 3 months of age in a cohort in Cape Town [ 36 ]. In contrast, 71% of infants in the EIT study had HIV-1 RNA < 40 copies/mL at the 24-week visit.…”