Pediatric HIV Research Articles

Epidemic Healthcare-Associated Pediatric HIV Infection from Parenteral Drug Administration, Pakistan 2019

Epidemic Healthcare-Associated Pediatric HIV Infection from Parenteral Drug Administration, Pakistan 2019

A Review and Analysis of Outcomes from Prevention of Mother-to-Child Transmission of HIV Infant Follow-up Services at a Pediatric Infectious Diseases Unit of a Major Tertiary Hospital in Nigeria: 2007-2020.

Background and Objective:Above 90% of childhood HIV infections result from mother-to-child transmission (MTCT). This study examined the MTCT rates of HIV-exposed infants enrolled in the infant follow-up arm of the prevention of mother-to-child transmission (PMTCT) program in a teaching hospital in Southeast Nigeria.Methods:This was a 14-year review of outcomes of infants enrolled in the infant follow-up arm of the PMTCT program of Nnamdi Azikiwe University Teaching Hospital Nnewi, Nigeria. The majority of subjects were enrolled within 72 hours of birth and were followed up until 18 months of age according to the National Guidelines on HIV prevention and treatment. At enrollment, relevant data were collected prospectively, and each scheduled follow-up visit was recorded both electronically and in physical copy in the client’s folders. Data were analyzed using SPSS version 20. The major outcome variable was final MTCT status.Results:Out of 3,784 mother-infant dyads studied 3,049 (80.6%) received both maternal and infant Antiretroviral (ARV) prophylaxis while 447 (11.8%) received none. The MTCT rates were 1.4%, 9.3%, 24.1%, and 52.1% for both mother and infant, mother only, infant only, and none received ARV prophylaxis respectively. There was no gender-based difference in outcomes. The MTCT rate was significantly higher among mixed-fed infants (p<0.001) and among those who did not receive any form of ARVs (p<0.001). Among dyads who received no ARVs, breastfed infants significantly had a higher MTCT rate compared to never-breastfed infants (57.9% vs. 34.8%; p<0.001). The MTCT rate was comparable among breastfed (2.5%) and never-breastfed (2.1%) dyads who had received ARVs. After logistic regression, maternal (p<0.001, OR: 7.00) and infant (p<0.001, OR: 4.00) ARV prophylaxis for PMTCT remained significantly associated with being HIV-negative.Conclusion and Global Health Implications:Appropriate use of ARVs and avoidance of mixed feeding in the first six months of life are vital to the success of PMTCT programs in developing countries. PMTCT promotes exclusive breastfeeding and reduces the burden of pediatric HIV infection, thereby enhancing child survival.

Improving PMTCT Coverage and Access in Communities with Unmet Needs in Jos, Nigeria by Adopting Task Shifting and Task Sharing Strategies

Towards achieving an AIDS-free generation, UNAIDS set the 90-90-90 target aiming at 90% of HIV positive persons knowing their status, 90% of positives receive sustained antiretroviral drugs and 90% of those receiving ARVs attain virologic suppression by 2020. The attainment are dependent on continual access, quality care and treatment retention, so efforts must address context specific barriers to accessing services. The ethnoreligious conflicts in Jos created barriers to accessing HIV/PMTCT services, even when treatment sites existed around the metropolis. Fifteen communities lacked comprehensive HIV services and residents could not access treatment facilities because of security challenges. A specialized strategy using community oriented resource persons (CORPs) and task shifting task sharing (TSTS) principles conceptualized by stakeholders was utilized to bridge personnel gaps and scale-up PMTCT. The HIV Lead Implementing Partner supported a faith based community organization to identify and scale-up PMTCT into 28 hospitals in 15 communities. Training and task devolution to Community Health workers (CHWs), expert patients and Traditional Birth Attendants (TBAs) was utilized. The facilities were networked for service delivery, referrals, supervision and commodity logistics. HIV testing was provided to pregnant women during ANC, labour and postnatal, and their children and spouses. All 28 facilities offered HCT and provided ARVs to those testing positive in labour, women testing positive during ANC were managed/referred to 8 PMTCT sites for evaluation and ARV commencement according to Nigerian HIV Guidelines. Infants received Nevirapine, early infant diagnosis and Cotrimoxazole. HIV positive children and non-pregnant adults were referred to three ART sites for evaluation and treatment. The twenty-eight facilities were activated for HCT/PMTCT/ART using MNCH structures and CHEWs, TBAs and PLHIV expert patients provided care, support and tracking. After the six-month pilot, of 3,293 women receiving ANC, 3,094 (93.9%) accepted HCT and received same-day results. Thirty-four tested positive, but 15 previously knew their status and on ARVs, but had challenges accessing care, while 17 of 19 newly diagnosed women commenced ARVs while 2 defaulters are being tracked. Five HIV exposed babies delivered received Nevirapine and cotrimoxazole, four were tested HIV-negative. Also 7193 adults and 23 children received HCT and results, 69 positive adults and 2 positive children enrolled care, among who 33 adults and 2 children commenced ARVs. PMTCT diagnostics must identify specific barriers communities experience and implement multipronged context specific scale-up efforts to improve access/uptake to eliminate Paediatric HIV infections. CORPs and TSTS strategies are critical to improve service-delivery and retention in care.

Unique genotypic features of HIV-1 C gp41 membrane proximal external region variants during pregnancy relate to mother-to-child transmission via breastfeeding.

Mother-to-child transmission (MTCT) through breastfeeding remains a major source of pediatric HIV-1 infection worldwide. To characterize plasma HIV-1 subtype C populations from infected mothers during pregnancy that related to subsequent breast milk transmission, an exploratory study was designed to apply next generation sequencing and a custom bioinformatics pipeline for HIV-1 gp41 extending from heptad repeat region 2 (HR2) through the membrane proximal external region (MPER) and the membrane spanning domain (MSD). MPER harbors linear and highly conserved epitopes that repeatedly elicits HIV-1 neutralizing antibodies with exceptional breadth. Viral populations during pregnancy from women who transmitted by breastfeeding, compared to those who did not, displayed greater biodiversity, more frequent amino acid polymorphisms, lower hydropathy index and greater positive charge. Viral characteristics were restricted to MPER, failed to extend into flanking HR2 or MSD regions, and were unrelated to predicted neutralization resistance. Findings provide novel parameters to evaluate an association between maternal MPER variants present during gestation and lactogenesis with subsequent transmission outcomes by breastfeeding.ImportanceHIV-1 transmission through breastfeeding accounts for 39% of MTCT and continues as a major route of pediatric infection in developing countries where access to interventions for interrupting transmission is limited. Identifying women who are likely to transmit HIV-1 during breastfeeding would focus therapies, such as broad neutralizing HIV monoclonal antibodies (bn-HIV-Abs), during the breastfeeding period to reduce MTCT. Findings from our pilot study identify novel characteristics of gestational viral MPER quasispecies related to transmission outcomes and raise the possibility for predicting MTCT by breastfeeding based on identifying mothers with high-risk viral populations.

926. Antibody Response to HPV Vaccination in Pediatric and Adolescent People Living with HIV (PLWH)

BackgroundImmune dysfunction related to HIV infection is associated with an inability to clear HPV infection and may compromise the immunogenicity of quadrivalent HPV vaccine Gardasil® (4v HPV).MethodsBetween 2005 and 2017, males and females 7 to 20 years old age, were offered 3-dose 4v HPV vaccine. Plasma IgG titers to HPV 6 (H6), 11 (H11), 16 (H16) and 18 (H18) were measured using multiplex VLP-based ELISA. For the 36 patients, median interval from 1st dose to 2nd and 3rd doses were 73 and 216 days. Plasma sample 1 was collected at median of 91 days after dose 1, sample 2, 169 and sample 3, 740 after respective vaccine doses. A 4th sample was available for 26 patients, median 2327 days after dose 1. Rank-sum test, Χ 2 or Fisher’s Exact Test were employed.ResultsBefore vaccination, 10 (28%) were seropositive to 1 or more HPV types. The baseline seropositives were older than seronegatives (16 years vs 11; p=0.007). After dose 3 all participants had an Ab response to at least 1 HPV type and 32 (89%) were seropositive for 4 HPV types. Seroconversions were H18, 87%; H16 97%; H11, 100%; H6, 97%. Seroconversions after 1 dose of 4v HPV among the baseline seronegatives were 61%, 90%, 86% and 86%, respectively and 22 became seropositive for all 4 types. The 4 baseline seronegative PLWH with partial seroconversion had higher median HIV viral load (VL) compared to baseline seronegative group with full seroconversion (12,920 vs 101 copies/ml; p = 0.052), but had comparable CD4 counts. The rate of post vaccination seropositivity and baseline to peak titer response for each HPV type was not significantly different for baseline sero-groups. Among baseline seronegative, all 19 sampled distant from vaccination remained seropositive to at least 1 HPV type (84% to 3 or more types) and 6 (32%) became seronegative (sero-reversion). Those showing sero-reversion had higher VL compared to the 14 who remained seropositive (9100 vs 48; p =0.015). Time from last dose of 4v HPV to sample 4, CD4%, age, gender, and race/ethnicity were similar between the groups.Bar Graphs representing Ab response to the 4 HPV types following each dose of 4v HPV vaccine ConclusionIn the complex environment of a pediatric HIV specialty clinic, most PLWH mounted Ab responses to 4v HPV that were durable. H18 was least immunogenic. Patients with higher HIV VL were less likely to seroconvert for all types and were more likely to sero-revert.Disclosures All Authors: No reported disclosures

Monoolein-based nanoparticles containing indinavir: a taste-masked drug delivery system

Objective This study developed a novel child-friendly drug delivery system for pediatric HIV treatment: a liquid, taste-masked, and solvent-free monoolein-based nanoparticles formulation containing indinavir (0.1%). Significance Adherence to antiretroviral therapy by pediatric patients is difficult because of the lack of dosage forms adequate for children. Methods Monoolein-based nanoparticles were developed. The particle size, zeta potential, pH, drug content, small angle X-ray scattering, stability, in vitro drug release profile, biocompatibility, toxicity, and taste-masking properties were evaluated. Results Monoolein-based formulations containing indinavir had nanosized particles with 155 ± 7 nm, unimodal particle size distribution, and polydispersity index of 0.16 ± 0.03. The zeta potential was negative (−31.3 ± 0.3 mV) and pH was neutral (7.78 ± 0.01). A 96% drug incorporation efficiency was achieved, and the indinavir concentration remained constant for 30 days. Polarized light microscopy revealed isotropic characteristics. Transmission electron microscopy images showed spherical shaped morphology. Small-angle X-ray scattering displayed a form factor broad peak. Indinavir had a sustained release from the nanoparticles. The system was nonirritant and was able to mask drug bitter taste. Conclusions Monoolein-based nanoparticles represent a suitable therapeutic strategy for antiretroviral treatment with the potential to reduce the frequency of drug administration and promote pediatric adherence.

Factors Associated with HIV Status Disclosure to Orphans and Vulnerable Children Living with HIV: Results from a Longitudinal Study in Tanzania.

Background The Tanzanian national guideline for pediatric HIV disclosure recommends beginning disclosure as early as age 4–6 years; full disclosure is recommended at the age of 8–10 years. Despite clear procedures, the disclosure rate in Tanzania remains relatively low. This study assessed the factors associated with HIV status disclosure to orphans and vulnerable children living with HIV (OVCLHIV). Methods Data for this analysis come from the USAID-funded Kizazi Kipya program in Tanzania that provides health and social services to OVC and caregivers of HIV-affected households. Data were collected between January 2018 and March 2019. Disclosure status was self-reported by caregivers of children aged 8 years or above. Beneficiary characteristics were included as independent variables. Generalized estimating equations took into account the clustering effect of the study design. Results Of the 10673 OVCLHIV, most were females (52.43%), and 80.67% were enrolled in school. More than half (54.89%) were from households in rural areas. Caregivers were mostly females (70.66%), three quarters were between 31 and 60 years old and had a complete primary education (67.15%), and 57.75% were HIV-infected. Most of the OVCLHIV (87.31%) had a disclosed HIV status. Greater OVCLHIV age (p < 0.001), school enrollment (OR = 1.22; 95% CI 1.06, 1.41), urban location of household (OR = 1.64; 95% CI 1.44, 1.86), caregivers' higher education level (p < 0.001), and caregiver HIV-positive status (OR = 1.25; 95% CI 1.09, 1.43) were positively associated with disclosure status. OVCLHIV of female caregivers were 27% less likely to have been disclosed than those of male caregivers. Conclusion The disclosure rate among OVCLHIV in this study was high. Disclosure of HIV status is crucial and beneficial for OVCLHIV continuum of care. Caregivers should be supported for the disclosure process through community-based programs and involvement of health volunteers. Policymakers should take into consideration the characteristics of children, their caregivers, and location of households in making disclosure guidelines as adaptable as possible.

Barriers and Facilitators Along the HIV Care Cascade Among Hospitalized Adolescents in Western Kenya

Background/Objective: There are 1.7 million adolescents living with HIV (ALHIV) globally, the majority of whom live in Eastern and Southern Africa. Despite increasing access to antiretroviral therapy (ART), ALHIV experience poorer HIV-related outcomes at each stage of the care cascade relative to other age groups. We sought to investigate barriers and facilitators experienced at each stage of the HIV “care cascade” – testing, linkage to care, retention in care, and adherence to and viral suppression on ART – among a cohort of hospitalized adolescents. &#x0D; &#x0D; Methods: This qualitative study used semi-structured interviews of hospitalized ALHIV and their caregivers to investigate if crucial delays occurred at each stage of the HIV care cascade. Interviews explored barriers and facilitators at each stage, and were guided by a framework that considered adolescent- or family-level factors, developmental and mental health needs, society-level, programmatic, and health system factors. Interviews were audio-recorded, transcribed and translated. Members of the study team independently coded each transcript after inter-coder reliability was established. &#x0D; &#x0D; Results: Hospitalized ALHIV experienced critical delays in care, most frequently at the stages of HIV diagnosis and ART adherence. Common barriers to testing related to lack of awareness around perinatal HIV and unknown maternal HIV status. Barriers to adherence were complex and heterogeneous. Common barriers included lack of HIV disclosure or problematic disclosure to the adolescent; intense stigma and challenges coming to terms with one’s HIV status; and issues related to ART side effects and tolerance. Facilitators to adherence included family supervision and support in ART taking, and HIV education and adherence counseling provided at the clinic. &#x0D; &#x0D; Conclusion and Policy Impact: Hospitalized adolescents experienced significant delays in care, most frequently at the stages of pediatric HIV diagnosis and ART adherence. Barriers to adherence are particularly complex. Interventions to address adolescent ART adherence are urgently needed.

Mental health, substance use and viral suppression in adolescents receiving ART at a paediatric HIV clinic in South Africa.

IntroductionMental health problems are prevalent in adolescents living with HIV (ALHIV), often remain untreated, and may negatively affect antiretroviral therapy (ART) adherence and viral suppression. We implemented routine mental health screening at a paediatric ART clinic to improve the identification and management of mental health problems in ALHIV. In this report, we examine screening outcomes, associated patient characteristics and the odds of unsuppressed viral load in ALHIV screening positive for mental disorders.MethodsAdolescents aged 10 to 19 years attending Rahima Moosa Hospital in Johannesburg, South Africa between February 1, 2018, and January 1, 2020, were offered mental health screening at each routine HIV care visit. The screening included four pre‐screening questions followed by full screening (conditional on positive pre‐screening) for depression (Patient Health Questionnaire‐9 [PHQ‐9]), suicide (Adolescent Innovations Project [AIP]‐handbook), anxiety (Generalized Anxiety Disorder‐7 [GAD‐7]), post‐traumatic stress disorder (PTSD) (Primary Care PTSD Screen [PC‐PTSD‐5]) and substance use (CAGE Adapted to Include Drugs [CAGE‐AID]). We assessed screening outcomes and calculated adjusted odds ratios for associations between positive screening tests at the first screen and unsuppressed viral load (>400 copies/mL) at the measurement taken closest to the date of screening, within hundred days before and one day after screening.ResultsOut of 1203 adolescents who attended the clinic, 1088 (90.4%) were pre‐screened of whom 381 (35.0%) underwent full screening, 48 (4.4%) screened positive for depression (PHQ‐9 ≥10), 29 (2.8%) for suicidal concern, 24 (2.2%) for anxiety (GAD‐7 ≥10), 38 (3.2%) for PTSD (PC‐PTSD‐5 ≥3), 18 (1.7%) for substance use (CAGE‐AID ≥2) and 97 (8.9%) for any of these conditions. Positive screening for depression (aOR 2.39, 95% CI 1.02 to 5.62), PTSD (aOR 3.18, 95% CI 1.11 to 9.07), substance use (aOR 7.13, 95% CI 1.60 to 31.86), or any condition (aOR 2.17, 95% CI 1.17 to 4.02) were strongly associated with unsuppressed viral load.ConclusionsALHIV affected by mental health problems have increased rates of unsuppressed viral load and need specific clinical attention. The integration of routine mental health screening in paediatric ART programmes is a feasible approach for identifying and referring adolescents with mental health and adherence problems to counselling and psychosocial support services and if needed to psychiatric care.

Second line anti-retroviral therapy failure in a pediatric cohort of an Ethiopian tertiary hospital: A retrospective observational study

Background: Sub-Saharan Africa carries the largest burden of pediatric HIV infection. The extent and factors affecting the success of second line anti-retroviral treatment in the region have not been well-studied. This study aimed to determine the rate and determinants of failure of second line anti-retroviral treatment among children and adolescents on follow-up at an Ethiopian tertiary teaching hospital. Methods and materials: A retrospective observational cohort study was conducted at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. Structured data abstraction forms were used to collect socio-demographic, clinical and diagnostic data. Descriptive statistics and bivariate analysis were used to describe the magnitude of the problem and its associations. Results: A total of 76 children and adolescents who were taking second line anti-retroviral treatment and had at least a single viral load determination while under care were analyzed. Their mean age was 16.1 years. Failure of second line anti-retroviral drugs was seen in 14 of the 76 while 4 of them fulfilled eligibility criteria for a switch to third line anti-retroviral treatment. The mean duration till virologic failure was 17.6 months. The mean CD4 and viral load upon requirement of a third line regimen was 612.2/mm3 and 82,131.3 copies/ml. Second line antiretroviral treatment virologic failure was significantly associated with the age of the child or adolescent. Conclusion: There was a high rate of virologic failure among children and adolescents under second line anti-retroviral drugs in our hospital. Our findings also highlight the need for provision of third line second line anti-retroviral drugs. Challenges for delivering a standard care were infrequent viral load testing and delayed initiation of second line treatment after confirming failure of first line regimens.

Using the critical path method to rollout and optimise new PMTCT guidelines to eliminate mother-to-child transmission of HIV in Zimbabwe: a descriptive\xa0analysis

BackgroundAchievement of the elimination target for mother-to-child transmission (MTCT) of HIV in selected countries has increased hope to end the HIV epidemic in children across the world. However, MTCT rates remain well above the 5% elimination target in most sub-Saharan Africa countries. These countries require innovative strategies to scale-up their interventions to end paediatric HIV. We describe how the Elizabeth Glaser Paediatric AIDS Foundation (EGPAF) consortium and the Children’s Investment Fund Foundation (CIFF) used the critical path method to facilitate rapid expansion and optimization of 2010 and 2013 WHO PMTCT guidelines to reduce Zimbabwe’s MTCT rate from 22% in 2010 to 6.4% in 2015.MethodsWe analysed activities implemented and PMTCT programme data for the period before and during the EGPAF-CIFF project. The critical path method involved a cycle of collecting and analysing quarterly PMTCT indicator data and planning and implementing targeted activities to improve the PMTCT indicators. We performed a graphical trend analysis of data that measured availability of PMTCT services. Using Pearson’s Chi2 test, we compared results of PMTCT uptake indicators at the start and end of the EGPAF-CIFF project and used regression discontinuity analysis to assess effectiveness of activities implemented to improve the PMTCT service uptake indicators.ResultsZimbabwe rolled out WHO 2010 and 2013 PMTCT guidelines in less than 1 year during the EGPAF-CIFF project, yet it took more than 4 years to roll-out previous guidelines. All PMTCT indicators increased significantly (p < 0.001) comparing the five-year periods before and during the EGPAF-CIFF project. Critical path activities implemented increased five of the seven PMTCT uptake indicators.ConclusionZimbabwe rapidly rolled-out and optimised new WHO PMTCT guidelines and drastically reduced its MTCT rate using the critical path method. We recommend wider use of the critical path method in public health programmes.

Rethinking the challenges of paediatric HIV diagnosis

Rethinking the challenges of paediatric HIV diagnosis

Harnessing early life immunity to develop a pediatric HIV vaccine that can protect through adolescence.

Harnessing early life immunity to develop a pediatric HIV vaccine that can protect through adolescence.

Optimizing Disclosure of HIV Status to a Diverse Population of HIV-Positive Youth at an Urban Pediatric HIV Clinic

PurposeThe purpose of the study was to increase the proportion of youth living with HIV (YLWH) aged ≥11 years who undergo developmentally appropriate disclosure about their HIV status. MethodsA quality improvement project was initiated at an urban pediatric HIV clinic between July 2018 and March 2020. The primary outcome measure was the proportion of YLWH aged ≥11 years who were disclosed to about their HIV status. The proportion of undisclosed YLWH who had documented nondisclosure status was also assessed as a process measure. Plan-Do-Study-Act (PDSA) cycles for change included monthly clinic staff check-ins to discuss new disclosures, quarterly team meetings to discuss strategies to improve disclosure, and modifying a clinic note template to prompt providers to document disclosure status. Annotated run charts were used to analyze the data. ResultsBefore the first PDSA cycle, 26/46 (57%) of the target population of YLWH aged ≥11 years had their HIV status disclosed to them, and none of the undisclosed youth had disclosure status documented in their medical record. After 20 months and six PDSA cycles, the proportion of YLWH aged ≥11 years disclosed to about their HIV status increased to 80% and the proportion of undisclosed YLWH with documentation of their disclosure status increased to 100%. ConclusionsSeveral interventions integrated throughout the pediatric HIV care process were associated with an increase in the proportion of YLWH with developmentally appropriate HIV disclosure and documentation of disclosure status, an important psychosocial aspect of care in these individuals.

Addressing the challenges and relational aspects of index-linked HIV testing for children and adolescents: insights from the B-GAP study in Zimbabwe

IntroductionIndex-linked HIV testing, targeted at sexual contacts or children of individuals with HIV, may improve yield and efficiency. The B-GAP study evaluated index-linked testing approaches in health facility and community-based settings. This paper reports on a qualitative study to understand factors that affect uptake of index-linked HIV testing for children and adolescents.MethodsWe conducted four focus group discussions (FGDs) with caregivers who had their children tested through B-GAP and one FGD with providers who offered index-linked HIV testing to indexes. We aimed to understand enabling and inhibiting factors in the decision-making process. Translated and transcribed transcripts were read for familiarisation. Following initial coding, analytical memos were written to identify emerging key themes across the data.ResultsOur findings showed there was inadequate emphasis on paediatric HIV in routine care which had a negative impact on subsequent uptake of testing for children. Once the decision to test had been made, access to facilities was sometimes challenging and alleviated by community-based testing. A key finding was that HIV testing is not a discrete event but a process that was influenced by relationships with other family members and children themselves. These relationships raised complex issues that could prevent or delay the testing process.ConclusionThere is a need to improve messaging on the importance of HIV testing for children and adolescents and to provide support to caregivers and their families in order to improve testing uptake. Addressing access barriers through the provision of community-based testing and implementing a family-centred approach can optimise index-linked testing.

Paediatric HIV: we are not done yet!

Paediatric HIV: we are not done yet!

Palliative Care Training in Residency

Features| November 2020 Palliative Care Training in Residency Mgbechi U. Erondu, MD, MFA Mgbechi U. Erondu, MD, MFA Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor November 2020, Vol. 84, 29. https://doi.org/10.1097/01.ASM.0000722140.82851.5e Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Mgbechi U. Erondu; Palliative Care Training in Residency. ASA Monitor 2020; 84:29 doi: https://doi.org/10.1097/01.ASM.0000722140.82851.5e Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search After my 11-month experience with the Botswana-Baylor International Pediatric HIV initiative (BIPAI), I published a short story titled “Rabid Morula Seed” about a young mother coming to terms with her 3-year-old daughter's diagnosis of rhabdomyosarcoma (The Examined Life. 1:2, 2011). As a student of anthropology, I have always been interested in the illness experience. Nowhere was this more evident than in my observation of children suffering from chronic conditions like cancer and HIV, and yet who shared hospital quarters with other children who had TB and measles. The program at the Botswana Baylor Children's Clinical Centre of Excellence in Gaborone is revolutionary among international programs for its emphasis on encouraging happiness and wellness for children outside of their medical diagnoses. In some ways, this was my first encounter with pediatric palliative care and it has motivated me to address disparities in hospice and palliative care in the U.S. and abroad.... You do not currently have access to this content.

Optimizing viral load suppression in Kenyan children on antiretroviral therapy (Opt4Kids)

BackgroundAs many as 40% of the 1 million children living with HIV (CLHIV) receiving antiretroviral treatment (ART) in resource limited settings have not achieved viral suppression (VS). Kenya has a large burden of pediatric HIV with nearly 140,000 CLHIV. Feasible, scalable, and cost-effective approaches to ensure VS in CLHIV are urgently needed. The goal of this study is to determine the feasibility and impact of point-of-care (POC) viral load (VL) and targeted drug resistance mutation (DRM) testing to improve VS in children on ART in Kenya. MethodsWe are conducting a randomized controlled study to evaluate the use of POC VL and targeted DRM testing among 704 children aged 1–14 years on ART at health facilities in western Kenya. Children are randomized 1:1 to intervention (higher frequency POC VL and targeted DRM testing) vs. control (standard-of-care) arms and followed for 12 months. Our primary outcome is VS (VL < 1000 copies/mL) 12 months after enrollment by study arm. Secondary outcomes include time to VS and the impact of targeted DRM testing on VS. In addition, key informant interviews with patients and providers will generate an understanding of how the POC VL intervention functions. Finally, we will model the cost-effectiveness of POC VL combined with targeted DRM testing. DiscussionThis study will provide critical information on the impact of POC VL and DRM testing on VS among CLHIV on ART in a resource-limited setting and directly address the need to find approaches that maximize VS among children on ART. Trials registrationNCT03820323.

The Comparison of Teen Clubs vs. Standard Care on Treatment Outcomes for Adolescents on Antiretroviral Therapy in Windhoek, Namibia.

Background Adolescents living with HIV (ALHIV) are challenged to adhere to antiretroviral therapy (ART) and achieve and maintain virologic suppression. Group-based adherence support interventions, such as adherence clubs, have been shown to improve long-term adherence in ART patients. The teen club intervention was introduced in 2010 in Namibia to improve treatment outcomes for ALHIV by providing adherence support in a peer-group environment. Adolescents who have completed the full HIV disclosure process can voluntarily join the teen clubs. The current study compared treatment outcomes of ALHIV receiving ART at a specialized paediatric HIV clinic between 1 July 2015 and 30 June 2017 in Windhoek, Namibia. Methods A retrospective cohort analysis was conducted on routine patient data extracted from the electronic Patient Monitoring System, individual Patient Care Booklets, and teen club attendance registers. A sample of 385 adolescents were analysed: 78 in teen clubs and 307 in standard care. Virologic suppression was determined at 6, 12, and 18 months from study start date, and compared by model of care, age, sex, disclosure status, and ART regimen. Comparisons between adolescents in teen clubs and those receiving standard care were performed using the chi-square test, and risk ratios were calculated to analyze differences in ART adherence and virologic suppression. Results The average clinician-measured ART adherence was 89% good, 6% fair, and 5% poor amongst all adolescents, with no difference between teen club members and adolescents in standard care (p = 0.277) at 3 months. Virologic suppression over the 2-year observation period was 87% (68% fully suppressed <40 copies/ml and 19% suppressed between 40–999 copies/ml), with no difference between teen club members and those in standard care. However, there were statistically significant differences in virologic suppression levels between the younger (10–14 years) adolescents and older (15–19 years) adolescents at 6 months (p = 0.015) and at 12 months (p = 0.021) and between adolescents on first-line and second-line ART regimen at 6 months (p = 0.012), 12 months (p = 0.004), and 18 months (p = 0.005). Conclusion The teen club model delivering psychosocial support only did not improve adherence and virologic suppression levels for adolescents in a specialized paediatric ART clinic, neither were they inferior to standard care. Considering the limitations of this study, teen clubs may still hold potential for improving adherence and virologic suppression levels for older adolescents, and more robust research on adherence interventions for adolescents with higher methodological quality is required.

A Review to Identify the Gaps in Prevention of Mother to Child Transmission of HIV Services in Nigeria

Background: Nigeria has the second largest burden of maternal to child transmission of HIV (MTCT) in the world at a rate of 30% and has the largest burden of paediatric HIV infection globally at the rate of 10%. Effective prevention of mother to child transmission of HIV (PMTCT) can drastically reduce the paediatric HIV infection to 2%. However, recent evidence reveals yawning gaps in the PMTCT services in Nigeria, where out of estimated 9.2 million pregnancies, only about 3 million received HIV counselling and testing (HCT). This review is to unravel the unmet needs for PMTCT of HIV services in Nigeria.&#x0D; Methods: Keywords from objectives of review are MTCT and PMTCT which were used to search for related literatures through online libraries of national and international journals; Medline and PubMed including google. 62 related literatures/studies were initially generated and then narrowed down to 19 literatures were selected which met the inclusion criteria- less than 10 year and related to objective of review.&#x0D; Findings: There are unmet needs for PMTCT of HIV services in Nigeria due to challenges like low HCT/PMTCT service uptake (35.5%), low HCT/PMTCT service delivery facilities (27%), low ANC (58%) and low (35%) delivery in formal health setting.&#x0D; Conclusion: PMTCT target in Nigeria has not been met. Regular training of existing health workforce including the TBAs and the adoption of the recommendations for an HIV-free generation will bridge the HCT / PMTCT of HIV services gap identified in this review.