Abstract
BackgroundAntiretroviral treatment (ART) options for young children co-infected with HIV and tuberculosis are limited in resource-poor settings due to limited data on the use of efavirenz (EFV). Using available pharmacokinetic data, an EFV dosing schedule was developed for young co-infected children and implemented as the standard of care at Macha Hospital in Southern Province, Zambia. Treatment outcomes inchildren younger than 3 years of age or weighing less than 10 kg receiving either EFV-based ART plus anti-tuberculous treatment or nevirapine-based (NVP) ART were compared.MethodsTreatment outcomes were measured in a cohort of HIV-infected children seeking care at Macha Hospital in rural Zambia from 2007 to 2010. Informationon the diagnosis and treatment of tuberculosis was abstracted from medical records.ResultsForty-five children treated for tuberculosis initiated an EFV-based regimen and 69 children initiated a NVP-based regimen, 7 of whom also were treated for tuberculosis. Children receiving both regimens were comparable in age, but children receiving EFV started ART with a lower CD4+ T-cell percentage and weight-for-age z-score. Children receiving EFV experienced increases in both CD4+ T-cell percentage and weight-for-age z-score during follow-up, such that levels were comparable to children receiving NVP after two years of ART. Cumulative survival after 12 months of ART did not differ between groups (NVP:87%;EFV:80%;p = 0.25). Eleven children experienced virologic failure during follow-up.The adjusted hazard ratio of virologic failure comparing EFV to NVP was 0.25 (95% CI:0.05,1.24) and 0.13 (95% CI:0.03,0.62) using thresholds of 5000 and 400 copies/mL, respectively.Five children receiving EFV were reported to have had convulsions after ART initiation compared to only one child receiving NVP (p = 0.04).ConclusionsDespite poorer health at ART initiation, children treated for tuberculosis and receiving EFV-based regimens showed significant improvements comparable to children receiving NVP-based regimens. EFV-based regimens should be considered for young HIV-infected children co-infected with tuberculosis in resource-limited settings.
Highlights
The dual burden of human immunodeficiency virus (HIV) infection and tuberculosis represents a significant threat to the health of children in sub-Saharan Africa
An estimated 3.4 million children worldwide are infected with HIV [1], the majority of whom live in sub-Saharan Africa.In areas of high HIV prevalence, as many as half of incident pediatric tuberculosis cases occur in children infected with HIV [2]
Because of the poor prognosis in young children infected with HIV and tuberculosis, there is no alternative to concurrent treatment of both infections [6]
Summary
The dual burden of human immunodeficiency virus (HIV) infection and tuberculosis represents a significant threat to the health of children in sub-Saharan Africa. Because of the poor prognosis in young children infected with HIV and tuberculosis, there is no alternative to concurrent treatment of both infections [6]. Simultaneous initiation of both therapies increases the risk of immune reconstitution syndrome, but extensive delays in starting antiretroviral therapy (ART) should be avoided. Antiretroviral treatment (ART) options for young children co-infected with HIV and tuberculosis are limited in resource-poor settings due to limited data on the use of efavirenz (EFV). Treatment outcomes inchildren younger than 3 years of age or weighing less than 10 kg receiving either EFV-based ART plus anti-tuberculous treatment or nevirapine-based (NVP) ART were compared
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