Pediatric HIV Research Articles

Pruritic papular eruption in HIV-positive patients in Brazil

Pruritic papular eruption (PPE) is a mucocutaneous manifestation associated with HIV infection which was first described in the early years of the HIV epidemic [1]. PPE is characterized by erythematous papules or macules with symmetrical distribution mainly on the trunk and extremities in the absence of other causes of pruritus; intense itching is the most common symptom, leading to scratching, excoriation and postinflammatory hyperpigmentation [2]. PPE tends to be a chronic condition, but individual lesions will appear and disappear. Various aetiological factors have been explored in relation to PPE including immunological responses to insect bites, while infectious agents other than the primary HIV infection do not appear to be implicated [2]. Histopathological and haematological findings have been inconclusive and sometimes inconsistent, with most studies being small [2]. The salient feature of PPE is that it has been strongly and consistently associated with low CD4+ cell count, as described recently in paediatric and adult HIV patients [3,4]. Here, we report the associations that we found between PPE, CD4+ cell count and HIV viral load in HIV patients in Brazil who attended the Hospital Universitário Cassiano Antonio Moraes (HUCAM), Vitória (Espírito Santo) between 2004 and 2010. Patients had a dermatological examination and 4-mm punch skin biopsy, with diagnosis of PPE based on clinical and histopathologic findings to exclude differential diagnosis as scabies, prurigo caused by insect bites, cutaneous drug reactions, lichen planus, acne, demodicosis, eosinophilic folliculitis and bacterial folliculitis [2]. CD4+ cell count and viral load measurements at the time of examination, if available, were obtained from medical records. Ethical permission for use of these data was obtained from HUCAM research ethics committee. Of 370 patients [190 (51.4%) male, 180 (48.7%) female], median age 39 (range 15–82), 17.6% (65/370) had PPE, with no difference in prevalence by age (Pt test = 0.13) or sex (PChi-squared = 0.23). PPE was generalized (more than one body area) in 60.0% (39/65) of cases and PPE manifested mostly [76.9% (50/65)] as papules. Median CD4+ cell count was lower in patients with PPE [266 (interquartile range (IQR) 114–524) cells/μl, n = 45] than without PPE [400 (IQR 238–568) cells/μl, n = 159] (PKruskal–Wallis = 0.02) (Fig. 1a) and viral load was higher [1331 (IQR 5–171797, n = 40) copies/ml compared with 5 (IQR 5–569) copies/ml, n = 133] (PKruskal–Wallis = 0.001) (Fig. 1b); 32.5% (13/40) of patients with PPE had undetectable viral load (<10 copies/ml) compared with 51.9% (69/133) of patients without PPE (PChi-squared = 0.03). Ten patients with PPE were not taking antiretroviral therapy (ART) (15.4%) compared with 56 patients (18.4%) without PPE (PChi-squared = 0.57).Fig. 1: (a) CD4+ cell count in HIV patients with (n = 45) and without (n = 159) pruritic papular eruption [each box indicates the median (horizontal line) and interquartile range, whiskers include data points within 1.5 interquartile range of nearer quartile]; (b) Log10 HIV viral load in HIV patients with (n = 40) and without (n = 133) pruritic papular eruption (each point represents a single measurement, horizontal lines indicate medians).The strong association that we found between low CD4+ cell count and PPE replicates findings in most, but not all [5], previous studies of HIV-related dermatoses. PPE in the early years of the HIV epidemic was considered pathognomonic of AIDS and is potentially prognostic of ART failure [6,7]. Given that the prevalence of PPE has remained relatively unchanged among HIV patients even in the era of ART and that countries such as Brazil continue to see large numbers of new HIV cases each year (44 000 in 2018 http://www.aids.gov.br/pt-br/pub/2019/boletim-epidemiologico-de-hivaids-2019), more consideration needs to be given to identifying effective treatments to relieve debilitating and stigmatizing symptoms of HIV-related dermatological conditions and to improve patient quality of life [2]. Acknowledgements We thank Professor Elton Lucas and Professor Tania Reuter from the Hospital Universitário Cassiano Antonio Moraes (HUCAM) for their advice. This study received no specific funding. Conflicts of interest The authors have no conflicts of interest to declare.

Epidemiology of adolescents living with perinatally acquired HIV infection in a tertiary institution in Lagos State, Nigeria

Background: Nigeria is the only country with upward trend in HIV-related deaths in adolescents. Despite the high burden of adolescents with perinatally acquired HIV infection with increasing mortality solely in Nigeria, review of adolescents with perinatal HIV infection in sub-Saharan Africa by the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) Global Cohort Collaboration that excluded those in Nigeria creates a lacunae in knowledge that necessitates this current study.

Study of Clinical Manifestations of HIV Infected Children in Relation to CD4 Count

Aims: To study the clinical profile of HIV infected children and correlate them with the CD4 count at the time of presentation.&#x0D; Study Design: Hospital based observational study&#x0D; Place and Duration of Study: ART centre of SCBMCH and Department of Pediatrics, SVPPGIP, Cuttack, Odisha during the period October 2017 to September 2019.&#x0D; Methodology: All children aged between 1.5 to 15 years who were confirmed to be HIV positive by ELISA or immunocomb II, either at present or past were included in the study. They were subjected to CD4 count testing, along with nutritional assessment and screened for opportunistic infections, apart from their socio-demographic details. All quantitative variables including age, weight, height, were compared by unpaired t-test. Categorical variables like sex mode of transmission were compared by chi-square test. Variables like clinical staging, immunological staging and CD4 counts were measured at presentation and analyzed with repeated ANOVA at 5% level of significance to allow for multiple comparisons. P&lt;0.05 was considered significant and inferences were drawn.&#x0D; Results: Out of 103 cases, majority belonged to age 4- 7 years and 59.2% were malnourished. 24.3% were asymptomatic, with the most common clinical features noted were fever (65%), cough (47.8%), recurrent diarrhoea (41.8%) and weight loss (40.8%). The incidence of opportunistic infections was 24.3%, with tuberculosis (40%) and herpes zoster (36%) leading the list. Most cases (37.87%) came under WHO clinical stage-III. A significant correlation was found between CD4 count and age, WHO clinical staging, opportunistic infections in the population. Lower CD4 counts were associated with younger age, lower staging and less risk for symptoms and infections.&#x0D; Conclusion: CD4 count is a reliable market to assess the staging and risk for opportunistic infections in pediatric HIV and thus can be used as screening tool for complications/ deterioration in the child, for better management.

Longitudinal evaluation of adherence, retention, and transition patterns of adolescents living with HIV in Nigeria.

IntroductionAdherence to antiretroviral therapy (ART) and retention in treatment programs are required for successful virologic suppression and treatment outcomes. As the number of adolescents living with HIV continues to increase globally, more information about adherence and retention patterns during and through transition from child- to adult-centered care is needed to ensure provision of a high level of care and inform development of targeted interventions to improve patient outcomes in this vulnerable population. In this analysis, we sought to describe long-term trends in adherence, retention, and virologic suppression in adolescents receiving ART at a pediatric HIV clinic in Nigeria through transition to the adult clinic.SettingThe Jos University Teaching Hospital, United States President’s Emergency Plan for AIDS Relief (PEPFAR)-funded HIV clinic in Jos, Plateau State, Nigeria.MethodsWe conducted a retrospective observational longitudinal evaluation of data that had been collected during the course of care in a large pediatric ART program in Nigeria. We used descriptive statistics to define our patient population and quantify retention from ART initiation through adolescence and transition to adult-centered care. Logistic regression was used to evaluate predictors of loss to follow-up. We used medication possession ratio (MPR) to quantify adherence for each year a patient was on ART. To evaluate adherence and virologic suppression, we measured the proportion of patients with ≥95% MPR and the proportion with virologic suppression (viral load ≤400 copies/mL) within each age cohort, and used bivariate analyses to examine any association between MPR and VL suppression for all person-years observed.ResultsA total of 476 patients received at least one dose of ART as an adolescent (ages 10–19 years). The proportions of patients lost to follow-up were: 11.9% (71/597) prior to adolescence, 19.1% (31/162) during adolescence, and 13.7% (10/73) during transition to adult-centered care. While over 80% of patients had ≥95% medication adherence in all age groups, their viral load suppression rates through adolescence and post-transition were only 55.6%–64.0%. For patients that successfully transitioned to adult-centered care, we observed 87.7% (50/57) retention at month 12 post-transition, but only 34.6% (9/26) viral load suppression.ConclusionsOur evaluation found considerable proportions of adolescents lost to follow-up throughout the ART program cascade. We also found discrepancies between the proportions of patients with ≥95% MPR and the proportions with VL suppression, suggesting that true medication adherence in this population may be poor. Significant attention and targeted interventions to improve retention and adherence focused on adolescents are needed in order for global programs to achieve 90-90-90 goals.

Accès à la prise en charge de l’infection VIH pédiatrique – État des lieux de l’offre des soins au Cameroun en 2014

BackgroundIn Cameroon in 2012, the proportion (15%) of children eligible for antiretroviral treatment (ART) was one of the lowest among the 21 Global Fund priority countries. The objective of this study was to carry out a situational analysis of the existing care offer for pediatric HIV in Cameroon. MethodsA descriptive cross-sectional study was conducted over a 4-month period (April to August 2014) in 12 healthcare facilities in 7 regions of Cameroon selected by systematic sampling. The data were collected in a self-administered questionnaire filled out by the caregiving and administrative personnel included in the study. ResultsAll in all, 142 persons in charge of pediatric HIV treatment were included in the study, of whom 115 were working at the operational level: 59 (51.2%) health personnel, 44 (38.3%) community agents and 12 (10.4%) department heads; the other 27 exercised responsibilities at the regional (19) and the local (8) levels. An overwhelming majority of the caregivers involved in pediatric VIH treatment were nurses, a factor necessitating the delegation of medical tasks institutionalized in Cameroon. Few standardized nationwide documents take into account these treatment modalities. Inadequate dissemination of the documents at all levels of the healthcare pyramid may justify the non-compliance with the care protocols that has been observed in the training programs dedicated to the subject. ConclusionThe updating and large-scale dissemination of standardized nationwide documents taking into account the specificities of HIV-infected children are required to improve implementation at the operational level of the Cameroonian healthcare system of the existing guidelines for pediatric HIV treatment.

Trends of the HIV/AIDS Phenomenon Dynamics in Romania from 2017-2027

HIV infection remains of major public health importance in all world and in Romania. In Romania there are a large number of long-term survivors coming from the 1987-1990 generation, the circumstances are due to the fact that an increased number of HIV-infected persons receive a specific therapy. The study was conducted using sociological analysis methods such as comparative analysis, statistical analysis, and with the help of the method of regression analysis, to capture the dynamics of the HIV / AIDS phenomenon in Romania, as well as forecasting the dynamics of the phenomenon over the next decade. This longitudinal analysis of the statistical data provided by the Matei Bals Institute of Romania during the period 2004-2016, shows a progressive increase 1.4 times higher in 2016 compared to 2004, the prediction of the extension of the HIV / AIDS phenomenon for the period 2017-2027, in Romania being almost constant. Regarding the prognosis of the number of persons affected by HIV / AIDS in Romania, for the next 10 years an upward dynamic is predicted with an increasing annual rate of 506 new persons taken into evidence. As the prediction function shows, the trend the access to treatment is increasing for the next decade. After 2006 in Romania, the deaths dynamics is an exponential decreasing one, keeping the same rate of decrease, until 2015. The HIV/AIDS pandemic has changed considerably in the past 27 years. AIDS incidence and mortality in industrialised countries have fallen, and paediatric HIV disease has almost been eliminated as a public health issue, largely through antiretroviral drugs.

Nurse- and Midwife-Led HIV Services in Eastern and Southern Africa: Challenges and Opportunities for Health Facilities.

In eastern and southern Africa, much is unknown about implementation of nurse-initiated and managed antiretroviral therapy (NIMART). The purpose of this study was to identify perceived barriers and facilitators of NIMART for the prevention of mother-to-child transmission and pediatric HIV services in high-volume, high HIV-burden health facilities across this region. A total of 211 nurses, midwives, and nurse midwives and 62 supervisors from 30 health facilities in 11 countries participated in this mixed-methods evaluation. The findings show that although nurses, midwives, and nurse midwives clearly had the authority to provide NIMART services, they did not necessarily feel that they were well prepared and supported to do so. Deficits in supportive supervision and clinical mentorship were viewed as substantial challenges to effective provision of NIMART for the prevention of mother-to-child transmission and pediatric HIV services-particularly with respect to pediatric HIV services. Health facilities have important opportunities to advance NIMART practice through strengthening these aspects of in-service support.

Human Immunodeficiency Virus Infection among Exposed Infants in Selected Primary Health-Care Facilities in Nigeria: A Retrospective Cohort Study

BACKGROUND: Nigeria is the second largest country with paediatric HIV infections. Mother to Child transmission of HIV remains a major source of paediatric infection in Nigeria. This study was conducted to determine the outcomes of HIV exposed infants in selected Primary Health Care Centres.METHODS: A retrospective cohort study on HIV exposed infants between January 2015 to July 2016. A proforma was used to abstract information from clinic records on socio-demographics characteristics, ARV prophylaxis, mode of delivery, birth weight, infant prophylaxis, early infant diagnosis (EID), referral to ART. Descriptive and multivariate analysis was done to determine predictors of HIV infection among exposed infants.RESULTS: 170 exposed infants were recruited, and more than two-third of the infants were males (74.1%) with median age 4±3months ranging from (0 -11months). One hundred and fifty (88.2%) received infant prophylaxis and 116 (68.2%) had EID done at 6weeks. Of the 170 exposed infants 19(11.1%) were positive at 18months. Predictors of HIV infection were age of mothers ≥30years (Adjusted Odd’s Ratio = 2.5,95%CI 1.9 – 16.93), Vaginal tear (Adjusted OR= 2.7,95%CI 2.1- 19.21), infants whose maternal CD4 count &lt; 500(Adjusted OR= 3.5,95%CI 1.7 -15.02) and infant received prophylaxis other than daily Nevirapine for 6weeks (Adjusted OR=3.0,95%CI 2.4-12.74).CONCLUSION: The positivity rate among studied exposed infants was high. Continuous placement of younger HIV positive mothers and exposed infants on recommended prophylaxis and timely early infant diagnosis will go a long way in reducing the burden of paediatric HIV.

Impact of Sickle Cell Disease on the Treatment and Progression of Pediatric HIV

Impact of Sickle Cell Disease on the Treatment and Progression of Pediatric HIV

Modified Integrated Algorithm for Detection of HIV Among Sick Children Aged 0–14 Year Seeking Care at Healthcare Facilities in India

To test the ability and to identify unique criteria in a Modified Integrated Algorithm developed by Indian Council of Medical Research (ICMR) to detect HIV infection among sick children 0 to 14 years, seeking care in a health care facility. Facility based cross-sectional survey. Four talukas of Belgaum District, Karnataka, India during 2013-2014. Sick children 0-14 years seeking care at healthcare facilities in the study area. A total of 10 health care facilities were selected using specific criteria. Trained health care providers in these facilities used the WHO generic Integrated Management of Childhood Illnesses screening algorithm for HIV, applicable for children to 0-5 years and ICMR modified integrated algorithm for >5-14 years, to screen and test children for HIV, when they sought care in these facilities. Prevalence of HIV in children screened positive by the Modified Integrated Algorithm. Of the total 33342 children who visited the 10 health care facilities, 24342 were screened by the physician. Of the 527 screened positive sick children with suspected signs/ symptoms, 509 consented and were tested with age appropriate HIV testing. 97 children tested positive (HIV prevalence 19.1%: 5% in <5yrs and 28% in ≥5-14 years). The result of Classification and Regression Tree and logistics regression consistently identified parents with HIV and orphan child, as important predictor of HIV infection. ICMR Modified integrated algorithm may be used as a screening tool in the public and private health care facilities to increase case detection of pediatric HIV.

Impact of Sickle Cell Disease on the Treatment and Progression of Pediatric HIV

Background HIV and sickle cell disease (SCD) are significant causes of morbidity and mortality among pediatric populations in sub-Saharan Africa. They both, individually, adversely impact the immune system heightening the risk for severe infections. However, little is known on how these two chronic inflammatory illnesses interact. Objective To determine how SCD affects the HIV treatment outcomes including immunological, nutritional, hematological, change to 2nd line treatment and overall survival. Methods We did a retrospective cohort study on pediatric patients less than 19 years …

Using Social Media and Technology to Communicate in Pediatric HIV Research: Qualitative Study With Young Adults Living With or Exposed to Perinatal HIV.

BackgroundAs young adults living with perinatal HIV (PHIV) or perinatal HIV exposure but uninfected (PHEU) grow older and manage the challenges and competing demands of young adulthood, new approaches are needed to facilitate their retention in longitudinal research and clinical care beyond in-person clinic visits. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel virus that causes coronavirus disease (COVID-19), emerged in the United States in January 2020 and has underscored this need; studies are adapting to remote communication with and data collection from participants. However, there are limited data on communication preferences among young adults who are living with PHIV or PHEU.ObjectiveThe objectives of this qualitative study were to describe participants’ perceptions and use of social media and technology in their personal lives and in the context of participating in longitudinal pediatric HIV research and to describe the implications of the use of technology and social media for communication and retention purposes within a longitudinal pediatric study about HIV.MethodsWe conducted 6 focus group discussions with 31 young adults living with PHIV and 13 in-depth interviews with 6 young adults living with PHIV and 7 living with PHEU. We asked about their preferences for the use of social media and digital technology in the Adolescent Master Protocol, a US-based longitudinal cohort study of youth affected by HIV.ResultsParticipants’ willingness to use social media platforms, telephone calls, SMS text messages, and video calls within the context of HIV research varied due to fears of HIV stigma and inadvertent disclosure. However, trusting relationships with clinical staff positively impacted their willingness to use these platforms.ConclusionsOur findings offer insight into how pediatric studies and clinics can communicate with participants as they age, even as new technologies and social media platforms emerge and replace old ones. For optimal retention, pediatric clinical staff should consider communication approaches offering flexible and tailored options for young adults participating in HIV research.

Increasing pediatric HIV testing positivity rates through focused testing in high-yield points of service in health facilities-Nigeria, 2016-2017.

In 2017, UNAIDS estimated that 140,000 children aged 0-14 years are living with HIV in Nigeria, but only 35% have been diagnosed and are receiving antiretroviral therapy. Children are tested primarily in outpatient clinics, which show low HIV-positive rates. To demonstrate efficient facility-based HIV testing among children aged 0-14 years, we evaluated pediatric HIV-positivity rates in points of service in select health facilities in Nigeria. We conducted a retrospective analysis of HIV testing and case identification among children aged 0-14 years at all points of service at nine purposively sampled hospitals (November 2016-March 2017). Points of service included family index testing, pediatric outpatient department (POPD), tuberculosis (TB) clinics, immunization clinics, and pediatric inpatient ward. Eligibility for testing at POPD was done using a screening tool while all children with unknown status were eligible for HIV test at other points of service. The main outcome was HIV positivity rates stratified by the testing point of service and by age group. Predictors of an HIV-positive result were assessed using logistic regression. All analyses were done using Stata 15 statistical software. Of 2,180 children seen at all facility points of service with unknown HIV status, 1,822 (83.6%) were tested for HIV, of whom 43 (2.4%) tested HIV positive. The numbers of children tested by age group were <1 years = 230 (12.6%); 1-4 years = 752 (41.3%); 5-9 years = 520 (28.5%); and 10-14 years = 320 (17.6%). The number of children tested by point of service were POPD = 906 (49.7%); family index testing = 693 (38.0%); pediatric inpatient ward = 192 (10.5%); immunization clinic = 16 (0.9%); and TB clinic = 15 (0.8%). HIV positivity rates by point of service were TB clinic = 6.7% (95% Confidence Interval (CI): 0.9-35.2%); pediatric inpatient ward = 4.7% (95%CI: 2.5-8.8%); family index testing = 3.5% (95%CI: 2.3-5.1%); POPD = 1.0% (95%CI: 0.5-1.9%); and immunization clinic = 0%. The percentage contribution to total HIV positive children found by point of services was: family index testing = 55.8% (95%CI: 40.9-69.8%); POPD = 20.9% (95%CI: 11.3-35.6%); inpatient ward = 20.9 (95%CI: 11.3-35.6%) and TB Clinic = 2.3% (95%CI: 0.3-14.8%). Compared with the POPD, the adjusted odds ratio (95% CI) for finding an HIV positive child by point of service were TB clinic = 7.2 (95% CI: 0.9-60.9); pediatric inpatient ward = 4.9 (95% CI: 1.9-12.8); and family index testing = 3.7 (95% CI: 1.5-8.8). HIV-positivity rates did not significantly differ by age group. In Nigeria, to improve facility-based HIV positivity rates among children aged 0-14 years, an increased focus on HIV testing among children seeking care in pediatric inpatient wards, through family index testing, and perhaps TB clinics is appropriate.

The changing profile of paediatric HIV infection: An experience from the Middle East

ObjectiveTo describe the clinical and epidemiological profiles of HIV-infected Omani children before and after the implementation of the prevention of mother-to-child transmission of HIV (PMTCT) programme. MethodsA retrospective review of HIV-infected children seen at a national paediatric HIV unit between 1992 and 2015 was performed. ResultsNinety-one HIV-infected children were identified; 59 (65%) were ≤5 years of age at diagnosis, with 28 (47.5%) of these being <1 year old. The average annual incidence of infection per million children (≤14 years old) was 5.7, and the highest (11.6) was in 2010. At diagnosis, 48 (60%) patients had a CD4 count of ˂200cells/mm3. The median HIV viral load was 81600copies/ml at diagnosis and 5911copies/ml at 12 months after HIV treatment (p=0.015). The median CD4 count was 586cells/mm3 at diagnosis and 800cells/mm3 at 12 months after therapy (p=0.004). Compared to those diagnosed before 2009 (n=68), HIV-infected children diagnosed after 2009 (n=22) were more likely to be asymptomatic at the time of HIV diagnosis (23.5% (16/68) vs. 59.1% (13/22); p=0.002) and to have a favourable clinical outcome (42.6% (29/68) vs. 86.4% (19/22); p<0001). ConclusionsThe number of HIV-infected children in Oman has decreased substantially since the introduction of the PMTCT programme. Furthermore, the HIV-infected children diagnosed after 2009 had higher proportions of asymptomatic HIV infections at diagnosis and favourable clinical outcomes, in comparison to those diagnosed before 2009.

A cross-sectional study on caregivers\u2019 perspective of the quality of life and adherence of paediatric HIV patients to highly active antiretroviral therapy

BackgroundPoor compliance to highly active antiretroviral therapy (HAART) can result in the poor quality of life in children living with Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS) because of low plasma drug concentration and the possibility of drug resistance. This study evaluates the response of caregivers for determination of adherence and the four quality of life domains in children (aged 14 years and under) on HAART.MethodsWe conducted a cross-sectional study of 188 children, each accompanied by their caregivers at Ola During Children’s Hospital and Makeni Government Hospital between September and November 2016. Adherence to HAART and Quality of life was assessed using the WHO Quality of life summary questionnaire (WHOQOL-BREF). We obtained ethical approval from the Sierra Leone Ethics and Scientific Review Committee.ResultsThe study revealed 5.9% adherence amongst paediatric patients, and a strong association of adherent patients(p = 0.019*) to the physical health domain (mean = 64.61 SD = 8.1). Caregiver HIV status showed a strong association with the physical (mean = 58.3, SD = 11.7 and p = 0.024*), and psychological health domains (mean = 68.2, SD = 14.7 and p = 0.001). Caregiver type (mother/father/sibling) accompanying child to hospital also showed strong associated with the physical (mean = 58.0, SD = 10.6, p < 0.001), psychological (mean 68.2 SD = 14.81 p < 0.001) and environmental health domains (mean = 59.7, SD = 13.47, p < 0.001). Further regression analysis showed a strong association with physical health domain for HIV positive caregivers (p = 0.014) and adherent paediatric patients (p = 0.005). Nuclear family also showed a strong association with psychological (p < 0.001) and environmental (p = 0.001) health domains.ConclusionThis study showed a strong association between the quality of life domains and the involvement of nuclear family caregiver, HIV-positive caregiver and adherence to HAART. Our study suggests that the involvement of any member of the nuclear family, HIV positive parents and patient adherence to therapy can improve the quality of life of paediatric HIV/AIDS patients on highly active antiretroviral therapy in the two hospitals.

Active pediatric HIV case finding in Kenya and Uganda: A look at missed opportunities along the prevention of mother-to-child transmission of HIV (PMTCT) cascade.

BackgroundChildren living with HIV remain undiagnosed due to missed opportunities along the prevention of mother-to-child HIV transmission cascade. This study addresses programmatic gaps in the cascade by describing pregnancy and HIV-related services received by mothers of children newly identified as HIV-positive through active case finding.MethodsThis was a prospective observational cohort (2017–2018) of HIV-positive children <15 years of age newly diagnosed at study facilities and/or surrounding communities in Kenya and Uganda. At enrollment, caregivers were interviewed about maternal and child health and HIV history. Child medical and laboratory information was abstracted at two months post-diagnosis. Descriptive summary statistics were calculated; associations between selected factors and child age at HIV diagnosis were evaluated using generalized estimating equations.Results174 HIV-positive children (median age 2.4 years) were enrolled. Among maternal caregivers, 110/132 (83.3%) attended antenatal care and 60 (45.5%) reported testing HIV-negative in antenatal care. Of 41 and 56 women known to be HIV-positive during pregnancy and breastfeeding respectively, 17 (41.5%) and 15 (26.8%) did not receive antiretroviral drugs. Despite known maternal HIV-positive status during pregnancy, 39% of these children were not diagnosed until after two years of age; children were diagnosed at younger ages in Uganda (p = 0.0074) and if mother was the caregiver (p<0.0001). The most common HIV testing points identifying children were outpatient (44.3%) and maternal/child health departments (29.9%). Nearly all children initiated antiretroviral therapy within two weeks of diagnosis.ConclusionsMultiple missed opportunities for HIV prevention and delays in HIV testing of HIV-exposed children were identified in newly diagnosed children. Findings support critical prevention messaging and retesting of HIV-negative women during pregnancy and breastfeeding, strengthening HIV treatment initiation and follow-up systems and interventions to ensure HIV-positive women receive lifelong antiretroviral therapy throughout the cascade, and broader implementation of community case finding so children not engaged in care receive testing services.

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

Sub-Saharan Africa carries the largest burden of pediatric HIV infection. The success of second line anti-retroviral treatment and related factors among African children is not well-defined. Objectives: We aimed to identify the rate and determinants of second line anti-retroviral treatment failure among children and adolescents on follow-up at an Ethiopian tertiary teaching hospital. A retrospective observational cohort study was conducted at Tikur Anbessa Specialized Hospital, Addis Ababa. Structured 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. A total of 76 children and adolescents taking second line anti-retroviral treatment were analyzed (mean age: 16.1 years). Failure of therapy was seen in 14/76 while four were eligible for a switch to third line anti-retrovirals. Mean duration on second line treatment till virologic failure was diagnosed was 17.6 months while mean viral load upon requiring a third line regimen was 82,131.3 copies/ml. Second line antiretroviral treatment virologic failure was significantly associated with the age of the child or adolescent. A high rate of virologic failure exists among the study population. Findings underline need for provision of third line anti-retroviral drugs in Ethiopia. Challenges for delivering a standard care were irregular viral load testing and delayed initiation of second line treatment after failure of first line regimens.

Screening Algorithms to Reduce Burden of Pediatric HIV Testing: A Systematic Review and Meta-analysis.

The accuracy of symptom screening to identify children eligible for further HIV testing in generalized epidemics has been examined in several studies. We performed a systematic review and meta-analysis of these studies. We screened 5 databases and abstracts from 4 HIV/AIDS conferences. Studies were included if they were performed in clinical settings, included children of 0-15 years old, and used a signs/symptoms screen to determine eligibility for HIV testing. The primary outcomes were sensitivity and specificity of the screening tools. A meta-analysis was performed to evaluate the utility of a screening tool in the outpatient setting. Our search returned 5529 database results and approximately 6700 conference abstracts, of which 36 articles were reviewed and 7 met criteria for inclusion. All were prospective or cross-sectional studies that developed and/or validated a screening tool to identify children at higher risk for being HIV infected. Sensitivity of the screening tools ranged from 71% to 96%, whereas specificity ranged from 25% to 99%. Meta-analysis of studies evaluating outpatient screening tools revealed a sensitivity of 81.4%, with a specificity of 69.4% for detecting HIV infection. Few studies have evaluated the use of screening tools for HIV diagnosis in children. Screening tools that exist showed only moderate sensitivity and specificity and missed a substantial number of HIV-infected children in high-prevalence areas. In outpatient settings, the use of a screening tool may help reduce the number of HIV tests needed to identify an HIV-infected child, but at the cost of missed diagnoses. Further studies are needed to determine whether this represents a resource-saving mechanism.

Steep Declines in Pediatric AIDS Mortality in South Africa, Despite Poor Progress Toward Pediatric Diagnosis and Treatment Targets.

Few attempts have been made to monitor progress toward HIV diagnosis and antiretroviral treatment (ART) coverage targets in children, and the impact that ART and prevention of mother-to-child transmission (PMTCT) programs have had on pediatric HIV incidence and mortality. A multiparameter evidence synthesis approach was adopted to integrate South African pediatric HIV data sources. A previously developed model of HIV in South Africa was calibrated to household survey HIV prevalence data, routine antibody testing data, data on numbers and ages of children on ART, vital registration data and data on HIV diagnosis at death. The impact of ART and PMTCT was estimated by comparing validated model outputs against model predictions of the trends that would have been expected in the absence of ART and PMTCT. By mid-2018, the model estimated that 75.2% (95% CI: 73.9%-76.8%) of HIV-positive children were diagnosed, substantially lower than the corresponding estimates in HIV-positive adults (91.0%). ART coverage in children in 2018 (51.2%, 95% CI: 49.4%-52.7%) was also lower than that in adults (62.0%). In 2017-2018, the numbers of new cases of mother-to-child transmission and pediatric AIDS deaths were reduced by 84% and 94%, respectively, relative to what would have been expected in the absence of interventions, but reductions in mortality were driven largely by PMTCT. Although levels of AIDS mortality in children have declined dramatically in South Africa, this has mostly been due to successful PMTCT programs, and progress toward the 90-90-90 targets appears relatively poor when compared with that in adults.

Impact of WHO guidelines on trends in HIV testing and ART initiation among children living with HIV in Zambia

BackgroundAbout 13 years since the introduction of antiretroviral therapy (ART) for children living with HIV (CLHIV) in Zambia, HIV/AIDS testing and treatment guidelines for children have evolved over the years with limited documentation of long-term trends in the numbers testing HIV positive and initiating ART. We examined trends in HIV testing and ART initiation in Zambia.MethodsWe conducted a retrospective cohort study using routinely collected patient level data from 496 health facilities across Zambia. We used Poisson regression to derive incident rate ratios and 95% confidence intervals (95% CI) for background characteristics and used a Cuzick non-parametric test for trends to test the 13-year trends. Median time from testing to ART initiation in days and incidence rates were derived using life tables in survival analysis. We used multi-level random effects Poisson regression model to determine variations in time from HIV testing to ART initiation by facility.ResultsOverall, the cumulative proportion of the children who tested positive and initiated antiretroviral therapy (ART for HIV) from 2004 to 2017 was 69% (n = 99 592). During the period under review proportions of ART initiation increased from 52% in 2004–2006 to 97% in 2016–2017 (P < 0.001) and time from testing to ART initiation reduced from a median of 17 days IQR (1–161) in 2004 to one day IQR (1–14), P < 0.001 in 2016–2017. CLHIV were 15 times more likely to be initiated on ART in 2016-17 compared to period 2004-6 (IRR = 15.2, 95% CI 14.7–15.7). Time to ART initiation increased with age and was higher in rural health facilities compared to urban facilities. About 11% of the variability in time to ART initiation in children could be attributed to differences between facilities.ConclusionsThe substantial increase in ART initiation and reduction in time to ART initiation among CLHIV identified in this study, reflects improvements in the paediatric HIV programme in Zambia in relation to health care delivery and adherence to national testing and treatment guidelines that were adapted from WHO guidelines. However, age-related differentials in rates of ART initiation suggests that urgent interventions are needed to sustain and further improve programme performance.