Identifying HIV-infected children who may benefit from early initiation of antiretrovirals

Abstract

In resource-limited settings lacking laboratory testing, clinical staging criteria may not identify all human immuno- deficiency virus (HIV)-infected children who could benefit from antiretroviral therapy (ART). A retrospective analysis was conducted to identify clinical markers in children that could predict rapid progression and need for earlier ART. Pediatric HIV- infected patients receiving care at an outpatient clinic at the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania from November 2004-March 2006 were enrolled. Medical records were retrospectively reviewed for sociodemographic data, growth parameters, and medical information. Bivariable analysis was performed to identify predictors of clinical progression. Of 162 patients enrolled, 69 initially presented with mild clinical HIV disease and this analysis focuses on progression within this group. Twenty-one of those 69 progressed clinically to WHO Stage 3/4 during the 18 months of follow-up; 19 progressed within 2-9 months and two additional children were found to have progressed by the 9-18 months visit. Median (range) age at presentation among 69 patients with mild disease was 6.1 years (0.1-13.7 years), and 32 (46%) were female. Fourteen (20% of 69) patients were on ART at their first visit or started ART within the next 2 months (early ART), and an additional 20 (29% of 69) patients started ART in the following 2-18 months. Of initial visit clinical and laboratory criteria, lymphadenopathy (P = 0.046), chronic upper respiratory infections (P = 0.010), lower height-for-age z-score (P = 0.007), lower weight-for-age z-score ( P< 0.001), and CD4% (P = 0.016) were associated with clinical progression. Fewer patients receiving early ART progressed, as compared to patients receiving late ART (P = 0.004). Almost one third of children with clinically mild HIV disease progressed to Stage 3/4 disease within 2-18 months. In settings lacking CD4 cell counts, current guidelines would not have identified the majority of these children for treatment. Improved clinical criteria and low-tech modalities such as point-of-care CD4 testing may help improve identification of children for ART initiation.