Pediatric HIV Research Articles

Time to Viral Suppression in Perinatally HIV-Infected Infants Depends on the Viral Load and CD4 T-Cell Percentage at the Start of Treatment.

Interventions aiming for an HIV cure would benefit from rapid elimination of virus after the onset of antiretroviral therapy (ART), by keeping the latent HIV reservoir small. We investigated HIV suppression in 312 perinatally infected infants starting ART within 6 months after birth from the EPPICC (European Pregnancy and Paediatric HIV Cohort Collaboration). To better understand kinetic differences in HIV suppression among infants, we investigated their individual viral load (VL) decay dynamics. We identified VL decay patterns and determined times to viral suppression (TTS). For infants with strictly declining VLs (n = 188), we used parameter fitting methods to estimate baseline VLs, decay rates, and TTS. We subsequently identified the parameters determining TTS by linear modeling. The majority of infants suppress HIV VL after the onset of ART. Some children experienced a long TTS due to an "erratic" VL decay pattern. We cannot exclude that this is partly due to treatment complications and subsequent treatment changes, but these children were characterized by significantly lower CD4 percentages (CD4%) at start of treatment compared with those with a "clean" VL decline. Focusing on this "clean" subset, the TTS could be predicted by mathematical modeling, and we identified baseline VL and CD4% as the major factors determining the TTS. As VL steeply increases and CD4% constantly decreases in untreated HIV-infected infants, the progression of an HIV infection is largely determined by these 2 factors. To prevent a further disease progression, treatment should be initiated early after contracting HIV, which consequently shortens TTS.

Prevalence of latent tuberculosis infection in HIV-1-infected children on antiretroviral therapy in Jos, Nigeria.

There are few studies investigating the prevalence of latent tuberculosis infection (LTBI) in HIV-1-infected children on antiretroviral therapy (ART), but no data from Nigeria. This study determined the prevalence of LTBI in HIV-1-infected children on ART in our clinic. Knowing the prevalence and thus the burden of LTBI could help improve HIV care by enabling targeted isoniazid (INH) prophylaxis. This observational study was carried out from September 2016 to August 2017 at the pediatric HIV clinic of the Jos University Teaching Hospital among HIV-1-infected children on ART, aged 6 months-15 years. LTBI was diagnosed using an interferon-gamma release assay, the ELISpot test, T-SPOT®.TB assay (Oxford Immunotec, Abingdon, UK) on freshly collected whole blood samples within 2 h. Children with a positive test were treated with INH after first excluding TB by chest X-ray and clinical evaluation. Of the 90 children studied, 4 (4.4%) had LTBI diagnosed by ELISpot. Their median interquartile range (IQR) age was 10.4 years (7.9-12.5), the majority were male (54.4%) and most of them had originally received Bacille Calmette-Guérin (83/89, 93.3%). They had a median CD4 count of 694 cells/μL (472-1045). The median (IQR) CD4 count was higher in LTBI compared to non-LTBI children: 1286 cells/μL (953-1375) versus 683 cells/μL (465-1040), (P = 0.044). Although this study showed a very low prevalence of LTBI in our setting, it was still beneficial to the few children on ART identified with LTBI as it enabled treatment with INH. A larger study will be required to ascertain the actual burden of LTBI in such children in our setting.

Transition from Pediatric to Adult HIV Care for Young Women Living with HIV.

Transitioning from pediatric to adult care is a complicated process for youth with chronic illnesses. This study elucidates the unique factors affecting transition preparedness and perception of adult HIV care among a cohort of young women with HIV. Between 2013 and 2015, 48 women with HIV, who had experience with pediatric HIV care, were enrolled in a large Canadian cohort study. Variables were self-reported during peer-administered surveys. Only 60% reported feeling prepared for transition. Having never had contact with child protection services (P = .049), never been in foster care (P = .011), never been in a group home (P = .036), reporting a higher current CD4 count (P = .033), and reporting a younger ideal age for transition (P = .041) were associated with transition preparedness. Eighty-four percent reported equivalent or better HIV care following transition. Correlates of equivalent/better care following transition included lower personal income (P = .023), higher CD4 count (P = .021), care by an adult infectious diseases specialist (P = .002), and transition preparedness (P = .005). Our findings highlight the importance of adequate transition preparation and its effect on perception of care following transition.

Oral manifestations in pediatric HIV infection in developing countries based on published research between 2009-2019

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Mensana M, Nugraha A, Ernawati D. Oral manifestations in pediatric HIV infection in developing countries based on published research between 2009-2019. HIV & AIDS Review. International Journal of HIV-Related Problems. 2020;19(4):222-226. doi:10.5114/hivar.2020.101680. APA Mensana, M., Nugraha, A., & Ernawati, D. (2020). Oral manifestations in pediatric HIV infection in developing countries based on published research between 2009-2019. HIV & AIDS Review. International Journal of HIV-Related Problems, 19(4), 222-226. https://doi.org/10.5114/hivar.2020.101680 Chicago Mensana, Mario P., Alexander P. Nugraha, and Diah S. Ernawati. 2020. "Oral manifestations in pediatric HIV infection in developing countries based on published research between 2009-2019". HIV & AIDS Review. International Journal of HIV-Related Problems 19 (4): 222-226. doi:10.5114/hivar.2020.101680. Harvard Mensana, M., Nugraha, A., and Ernawati, D. (2020). Oral manifestations in pediatric HIV infection in developing countries based on published research between 2009-2019. HIV & AIDS Review. International Journal of HIV-Related Problems, 19(4), pp.222-226. https://doi.org/10.5114/hivar.2020.101680 MLA Mensana, Mario P. et al. "Oral manifestations in pediatric HIV infection in developing countries based on published research between 2009-2019." HIV & AIDS Review. International Journal of HIV-Related Problems, vol. 19, no. 4, 2020, pp. 222-226. doi:10.5114/hivar.2020.101680. Vancouver Mensana M, Nugraha A, Ernawati D. Oral manifestations in pediatric HIV infection in developing countries based on published research between 2009-2019. HIV & AIDS Review. International Journal of HIV-Related Problems. 2020;19(4):222-226. doi:10.5114/hivar.2020.101680.

Characterizing the double-sided cascade of care for adolescents living with HIV transitioning to adulthood across Southern Africa.

IntroductionAs adolescents and young people living with HIV (AYLH) age, they face a “transition cascade,” a series of steps associated with transitions in their care as they become responsible for their own healthcare. In high‐income countries, this usually includes transfer from predominantly paediatric/adolescent to adult clinics. In sub‐Saharan Africa, paediatric HIV care is mostly provided in decentralized, non‐specialist primary care clinics, where “transition” may not necessarily include transfer of care but entails becoming more autonomous for one's HIV care. Using different age thresholds as proxies for when “transition” to autonomy might occur, we evaluated pre‐ and post‐transition outcomes among AYLH.MethodsWe included AYLH aged <16 years at enrolment, receiving antiretroviral therapy (ART) within International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA‐SA) sites (2004 to 2017) with no history of transferring care. Using the ages of 16, 18, 20 and 22 years as proxies for “transition to autonomy,” we compared the outcomes: no gap in care (≥2 clinic visits) and viral suppression (HIV‐RNA <400 copies/mL) in the 12 months before and after each age threshold. Using log‐binomial regression, we examined factors associated with no gap in care (retention) in the 12 months post‐transition.ResultsA total of 5516 AYLH from 16 sites were included at “transition” age 16 (transition‐16y), 3864 at 18 (transition‐18y), 1463 at 20 (transition‐20y) and 440 at 22 years (transition‐22y). At transition‐18y, in the 12 months pre‐ and post‐transition, 83% versus 74% of AYLH had no gap in care (difference 9.3 (95% confidence interval (CI) 7.8 to 10.9)); while 65% versus 62% were virally suppressed (difference 2.7 (−1.0 to 6.5%)). The strongest predictor of being retained post‐transition was having no gap in the preceding year, across all transition age thresholds (transition‐16y: adjusted risk ratio (aRR) 1.72; 95% CI (1.60 to 1.86); transition‐18y: aRR 1.76 (1.61 to 1.92); transition‐20y: aRR 1.75 (1.53 to 2.01); transition‐22y: aRR 1.47; (1.21 to 1.78)).ConclusionsAYLH with gaps in care need targeted support to prevent non‐retention as they take on greater responsibility for their healthcare. Interventions to increase virologic suppression rates are necessary for all AYLH ageing to adulthood.

The pattern of mucocutaneous disorders in pediatric HIV patients in a tertiary care center

Background: Dermatological manifestations constitute one of the most common clinical features in HIV-infected children. An early recognition of such features is important for an early diagnosis and also to assess the prognosis of HIV infection. Objective: The present study was conducted to determine the prevalence and pattern of mucocutaneous manifestations in HIV-infected children and also to assess the association between those manifestations and degree of cellular immune deficiency. Materials and Methods: This was a cross-sectional study conducted in the Outpatient Department of SKIN and STD between April 2017 to March 2018. A total of 100 HIV patients

Predictors of pediatric HIV disclosure among caregivers of HIV positive children attending special treatment clinic in dalhatu araf specialist hospital, Lafia, Nigeria.

HIV-infected children now live longer due to the availability of HIV counseling, testing, and treatment with highly active antiretroviral treatment (HAART). Efforts to help these children to know about the HIV infection and their status are important steps toward long-term disease management. This study was conducted to determine the factors associated with pediatric HIV disclosure among caregivers of children attending Special Treatment Clinic at Dalhatu Araf Specialist Hospital, Lafia. This was a descriptive cross-sectional study conducted among 160 caregivers of children attending the Special Treatment Clinic (STC) at DASH, Lafia, selected by systematic random sampling technique. Interviewer administered structured questionnaire was used to collect data, while bivariate and multivariate analyses were done with the Epi Info version 7. Pediatric HIV disclosure rate in this study was 33.8%. The mean age at pediatric HIV disclosure was 9.85 ± 1.86 years. The independent predictors for pediatric HIV disclosure following logistic regression were child's age, 10-14 years (AOR = 4.46; 95%CI 1.47-13.61), child knowledge of caregivers' HIV status (AOR = 51.18; 95%CI 13.40-195.66), and caregivers' age ≥40 years (AOR = 3.58; 95%CI 1.25-11.74). The pediatric HIV disclosure was low in this study due to the caregivers' and their wards' factors. Health care workers need to intensify health education on the benefit of pediatric HIV disclosure at the STC clinic.

Impact of a Maternal Prevention of Mother-to-child Transmission of HIV (PMTCT) Intervention on HIV-exposed Infants in Uganda.

Background:Uganda has successfully reduced pediatric HIV infections through prevention of mother-to-child transmission of HIV (PMTCT) programs, yet little is known about adherence to infant-specific components of interventions. We hypothesized that infants born to mothers receiving the WiseMama (WM) electronic drug monitoring (EDM)-based adherence intervention would have increased uptake of six-week post-natal nevirapine (NVP) infant prophylaxis and better adherence to six-week early infant diagnosis (EID) HIV testing.Methods:At two sites in Uganda, the Wise Infant Study (WIN) prospectively followed an infant cohort. Infants were born to women enrolled in an RCT testing the effect of real-time reminders delivered via EDM on maternal adherence to antiretroviral therapy. We assessed intrapartum and discharge receipt of NVP prophylaxis using pharmacy and infant HIV DNA testing laboratory data.Results:Of 121 women eligible for WIN, 97 (80%) consented and enrolled; 46 had been randomized to control and 51 to intervention. There were no differences in receipt of a six-week NVP supply (control 87%, intervention 82%, p = 0.53). Receipt of any NVP prophylaxis did not vary by delivery location (p = 0.35), and although 12% of infants were delivered at non-study health facilities, they were not less likely to receive NVP at discharge (p = 0.37). Among infants with a completed HIV test, there was no difference in mean time to first test (control 52 days (SD 18), intervention 51 days (SD 15), p = 0.86). Only one infant, in the control group, tested positive for HIV.Conclusion and Global Health Implications:We found no significant differences in adherence to infant PMTCT practices between intervention and control infants with relatively high rates of NVP receipt albeit with suboptimal adherence to six-week EID testing. Further work is needed to ensure improved access, uptake, and follow-up of HIV-exposed infants in the Option B+ era.

Paediatric HIV treatment outcome in Lagos: The Nigerian Institute of Medical Research experience

Paediatric HIV treatment outcome in Lagos: The Nigerian Institute of Medical Research experience

Caregivers/Patients Perception and Satisfaction with Outpatient HIV Services at the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria

Background: Patient perception and satisfaction is an indicator used to evaluate the quality of healthcare. This study aimed to assess patients’/caregivers’ perception and satisfaction with outpatient HIV services.&#x0D; Methodology: This was a cross sectional study carried out at the Paediatric HIV clinic of the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria. Purposive and convenient sampling methods were used to recruit 152 out patients just before they exit the outpatient department (OPD). Exit interviews were conducted with a three-point Likert scale using a Pretested self-administered questionnaire. Participation was voluntary and consent was obtained from all participants. Obtained data was analysed using epi info version 7, Chi-square test was used to test the association between the overall satisfaction level and sociodemographic characteristics of the patients. Statistical significance for the chi-square test was set at p&lt; 0 .05.&#x0D; Results: A total of 152 caregivers/patients participated in the study, only 31 (20.4%) were patients, aged 15-18years, 77 (50.7%) were aged from 26 and 41 years, 111(73%) were females, 99 (65.1%) were married and 76(50.0% had secondary level of education. Majority of the patients (130, 85.53%) were satisfied with the provider interpersonal skills followed by the physical environment at the OPD (118, 77.63%). However, only 53.29% were satisfied with the waiting and consulting time. The overall satisfaction rate was 73. 68% based on the three domains measured. The results showed a statistically significant association between the overall level of satisfaction and the female gender (X2= 4.67, p = 0.0306) and those with tertiary educational level (X2= 14.48, p= 0.0001) of the patients/caregivers.&#x0D; Conclusion: The level of satisfaction with outpatient HIV services at the UPTH is high. Program managers review of patients’ appointment time and use of electronic consultation tool will reduce the consulting and waiting time and further improve patient’s satisfaction.

HIV infection predominantly affecting children in Sindh, Pakistan, 2019: a cross-sectional study of an outbreak

In April 2019, an HIV screening camp for all ages was established in response to a report of an unusually large number of paediatric HIV diagnoses in Larkana, Pakistan. We aimed to understand the clinical profile of the children who registered for HIV care. In this cross-sectional study, we review the outbreak response from the government, academia, and UN agencies in Larkana, Sindh, Pakistan. We report age-stratified and sex-stratified HIV prevalence estimated among individuals screened. For children who registered for HIV care, clinical history of previous injections and blood transfusions, HIV disease stage, hepatitis B and hepatitis C status, and CD4 count was abstracted from clinical records from Sindh AIDS Control Program HIV Clinic (Shaikh Zayed Childrens Hospital, Larkana, Pakistan) and analysed using percentages, χ2 tests, and weight-for-age Z scores. We also analysed data for parents who were tested for HIV. Between April 24, and July 15, 2019, 31 239 individuals underwent HIV testing, of whom 930 (3%) tested positive for HIV. Of these, 763 (82%) were younger than 16 years and 604 (79%) of these were aged 5 years and below. Estimated HIV prevalence was 3% overall; 7% (283 of 3803) in children aged 0-2 years, 6% (321 of 5412) in children aged 3-5 years, and 1% (148 of 11 251) in adults aged 16-49 years. Of the 591 children who registered for HIV care, 478 (81%) were 5 years or younger, 379 (64%) were boys, and 315 (53%) of 590 had a weight-for-age Z score of -3·2. Prevalence of hepatitis B surface antigen was 8% (48 of 574) and hepatitis C antibody positivity was 3% (15 of 574). Of children whose mothers tested for HIV, only 39 (11%) of 371 had HIV-positive mothers. Most children (404 [89%] of 453) reported multiple previous injections and 40 (9%) of 453 reported blood transfusions. This HIV outbreak is unprecedented among children in Pakistan: a 54% increase in paediatric HIV diagnoses over the past 13 years. The outbreak was heavily skewed towards young children younger than 5 years, with a predominance of boys. Epidemiological and molecular studies are needed to understand the full extent of the outbreak and its drivers to guide HIV control strategies. None.

Pattern of Otorhinolaryngological Disorders in HIV Positive Paediatric Patients at the University of Port Harcourt Teaching Hospital (UPTH)

Background: HIV is a worldwide disease and affects all systems of the body. Despite the high burden of Paediatric HIV in Nigeria, few studies have been done on Otolaryngological disorders in children living with HIV. This study aimed to determine the pattern and prevalence of Otorhinolaryngological disorders among HIV positive paediatric patients and to compare them with age and sex-matched control.&#x0D; Methods: This was a descriptive cross-sectional case-control study carried out among 130 HIV positive and 130 HIV negative children aged 6 to 15 years at the University of Port Harcourt Teaching Hospital (UPTH). Eligible patients were recruited via a systematic sampling method and matched with HIV negative controls and an interviewer-administered questionnaire was used to extract relevant information. All patients had Otorhinolaryngological examination and CD4 count determination, while children with tonsillar enlargement underwent X-ray of the post nasal space. HIV patients were graded for severity using WHO clinical Staging.&#x0D; Results: A higher proportion of the HIV positive patients had allergic rhinitis (66.9% vs.30.8%, p=0.01), pharyngitis (40.8% vs.18.5%, p=0.01), tonsillitis (34.6% vs.20.8%, p=0.013), adenotonsilar disease (24.6% vs. 13.8%, p=0.028), cervical lymphadenopathy (15.4% vs. 5.4%, p=0.001) and otitis media (5.4% vs. 0.8%, p=0.031). There was a significantly higher prevalence of ORL disorders among HIV positive children (95.4%) compared to HIV negative children (78.5%). (P=0.001).&#x0D; Conclusion: Pattern of ORL disorder appeared similar in both HIV-positive and -negative children. However, the overall high prevalence of the findings among the HIV-positive children required regular ORL assessment in these children.

HIV-1 low-level viremia affects T cell activation rather than T cell development in school-age children, adolescents, and young adults during antiretroviral therapy

ObjectivesGiven the improvements in antiretroviral therapy (ART) in recent years, more pediatric HIV patients receiving ART are reaching adolescence and adulthood. This study investigated the influence of poor virological response (low-level viremia (LLV) and virological failure (VF)) on the immune system of these patients. MethodsHIV-infected, ART-experienced pediatric patients (n=206) were enrolled in this cross-sectional study. The patients were subdivided into school-age children/early adolescents, middle adolescents, and late adolescents/young adults according to their age, and further classified into virological suppression (VS), LLV, and VF groups according to plasma viral load (pVL) measurement. Thymic output, T cells subsets, and immune activation were analyzed by flow cytometry. ResultsCompared with VS patients, VF patients displayed decreased CD4+ T cell counts, while LLV and VS patients had comparable CD4+ T cell counts regardless of age. Compared with VS patients, LLV and VF patients had higher percentages of CD8+HLA-DR+ and CD8+CD38high T cells, and the immune activation was positively correlated with pVL in VF and LLV patients. Thymic output levels (CD31+) and regulatory T cell subpopulations in LLV and VF patients were comparable to those in VS patients. LLV patients showed comparable percentages of T cell subsets (TN, TCM, TEMRA, and TEM) as VS patients in all age groups. ConclusionsLLV causes excessive immune activation although it does not impair T cell recovery or naïve-to-memory T cell conversion in pediatric patients living with HIV. Therefore, T cell immune activation should be monitored at the management of LLV during ART.

Outcome of Prevention of Mother to Child Transmission (PMTCT) of HIV Services at the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria

Background: Mother to Child Transmission (MTCT) of HIV causes over 90% of Paediatric HIV and its prevention must be targeted to curb this scourge.&#x0D; Objective: To determine the associated risk factors and outcome (HIV status) of HIV-exposed babies at the University of Port Harcourt Teaching Hospital (UPTH).&#x0D; Methodology: This was a prospective study carried out at the Paediatric HIV clinic of UPTH. Information on sociodemographic data of the babies, age at referral, when the mother’s HIV status was diagnosed, HAART use status of the mother, place of ANC and delivery, method of delivery, feeding option, duration of breast feeding and HIV status of the babies were obtained. Obtained data was analysed and a p- value of &lt; 0.05 was considered significant at 95% confidence interval.&#x0D; Result: A total of two hundred and sixty HIV exposed children were seen over the study period, with a male: female ratio of 1.4:1. The overall MTCT rate was 6.2%. Among the mothers that had the complete PMTCT intervention, an MTCT rate of 1.1% was observed, while it was 28.6% among mothers who had no form of PMTCT. Identified statistically significant risk factors to MTCT include; lack of use of HAART (χ2 =116.2, p=0.0001); No infant ARV prophylaxis (p=0.0001); Mixed feeding (p=0.0001); Prolonged breast feeding (χ 2 = 7.09, P= 0.0287); TBA supervised pregnancy (χ2 =31.9, P= 0.0001) and delivery (χ2 =61.47, P= 0.0001).&#x0D; Conclusion: PMTCT interventions in the control of MTCT of HIV is effective. To eliminate MTCT of HIV, promoting PMTCT services must be encouraged.

The impact of health programmes to prevent vertical transmission of HIV. Advances, emerging health challenges and research priorities for children exposed to or living with HIV: Perspectives from South Africa.

Over the past three decades, tremendous global progress in preventing and treating paediatric HIV infection has been achieved. This paper highlights the emerging health challenges of HIV-exposed uninfected (HEU) children and the ageing population of children living with HIV (CLHIV), summarises programmatic opportunities for care, and highlights currently conducted research and remaining research priorities in high HIV-prevalence settings such as South Africa. Emerging health challenges amongst HEU children and CLHIV include preterm delivery, suboptimal growth, neurodevelopmental delay, mental health challenges, infectious disease morbidity and mortality, and acute and chronic respiratory illnesses including tuberculosis, pneumonia, bronchiectasis and lymphocytic interstitial pneumonitis. CLHIV and HEU children require three different categories of care: (i) optimal routine child health services applicable to all children; (ii) routine care currently provided to all HEU children and CLHIV, such as HIV testing or viral load monitoring, respectively, and (iii) additional care for CLHIV and HEU children who may have growth, neurodevelopmental, behavioural, cognitive or other deficits such as chronic lung disease, and require varying degrees of specialised care. However, the translation thereof into practice has been hampered by various systemic challenges, including shortages of trained healthcare staff, suboptimal use of the patient-held child's Road to Health book for screening and referral purposes, inadequate numbers and distribution of therapeutic staff, and shortages of assistive/diagnostic devices, where required. Additionally, in low-middle-income high HIV-prevalence settings, there is a lack of evidence-based solutions/models of care to optimise health amongst HEU and CLHIV. Current research priorities include understanding the mechanisms of preterm birth in women living with HIV to optimise preventive interventions; establishing pregnancy pharmacovigilance systems to understand the short-, medium- and long-term impact of in utero ART and HIV exposure; understanding the role of preconception maternal ART on HEU child infectious morbidity and long-term growth and neurodevelopmental trajectories in HEU children and CLHIV, understanding mental health outcomes and support required in HEU children and CLHIV through childhood and adolescence; monitoring HEU child morbidity and mortality compared with HIV-unexposed children; monitoring outcomes of CLHIV who initiated ART very early in life, sometimes with suboptimal ART regimens owing to medication formulation and registration issues; and testing sustainable models of care for HEU children and CLHIV including later reproductive care and support.

HIV research in South Africa: Advancing life.

South African (SA) researchers have made both national and global contributions to HIV prevention and treatment. Research conducted in SA has contributed markedly to improved survival in HIV-infected infants, children and adults. The translation of clinical research into practice has enabled the curtailment of paediatric HIV in SA. Along with international collaborators, SA has made pivotal contributions to biomedical prevention modalities including medical male circumcision and oral and topical microbicides, and is undertaking pivotal HIV vaccine research. Research into the structural and psychosocial drivers of HIV infection will be critical for sustaining biomedical interventions, and necessary to end AIDS.

Cascade Analysis: An Adaptable Implementation Strategy Across HIV and Non-HIV Delivery Platforms.

Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement. The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV. CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW. CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.

Cost-effectiveness of integrating postpartum antiretroviral therapy and infant care into maternal & child health services in South Africa.

BackgroundPoor engagement in postpartum maternal HIV care is a challenge worldwide and contributes to adverse maternal outcomes and vertical transmission. Our objective was to project the clinical and economic impact of integrated postpartum maternal antiretroviral therapy (ART) and pediatric care in South Africa.MethodsUsing the CEPAC computer simulation models, parameterized with data from the Maternal and Child Health–Antiretroviral Therapy (MCH-ART) randomized controlled trial, we evaluated the cost-effectiveness of integrated postpartum care for women initiating ART in pregnancy and their children. We compared two strategies: 1) standard of care (SOC) referral to local clinics after delivery for separate standard ART services for women and pediatric care for infants, and 2) the MCH-ART intervention (MCH-ART) of co-located maternal/pediatric care integrated in Maternal and Child Health (MCH) services throughout breastfeeding. Trial-derived inputs included: 12-month maternal retention in care and virologic suppression (SOC: 49%, MCH-ART: 67%), breastfeeding duration (SOC: 6 months, MCH-ART: 8 months), and postpartum healthcare costs for mother-infant pairs (SOC: $50, MCH-ART: $69). Outcomes included pediatric HIV infections, maternal and infant life expectancy (LE), lifetime HIV-related per-person costs, and incremental cost-effectiveness ratios (ICERs; ICER <US$903/YLS considered “cost-effective”).ResultsCompared to SOC, MCH-ART increased maternal LE (SOC: 25.26 years, MCH-ART: 26.20 years) and lifetime costs (SOC: $9,912, MCH-ART: $10,207; discounted). Projected pediatric outcomes for all HIV-exposed children were similar between arms, although undiscounted LE for HIV-infected children was shorter in SOC (SOC: 23.13 years, MCH-ART: 23.40 years). Combining discounted maternal and pediatric outcomes, the ICER was $599/YLS.ConclusionCo-located maternal HIV and pediatric care, integrated in MCH services throughout breastfeeding, is a cost-effective strategy to improve maternal and pediatric outcomes and should be implemented in South Africa.

Quantifying pediatric patient need for second- and third-line HIV treatment: A tool for decision-making in resource-limited settings

As national HIV programs across the world mature and continue to scale up towards UNAIDS’ 90-90-90 targets, it is increasingly important to accurately estimate HIV treatment needs in pediatric patient populations to prepare for anticipated increases in demand. This is particularly vital in sub-Saharan Africa, where the bulk of the global pediatric HIV burden remains concentrated, and for treatment-experienced populations, for which data are severely limited. This article discusses the conceptual framework behind and application of a five-year country-level quantification and decision-making tool aimed at providing national HIV programs and their partners with a better understanding of their evolving national HIV treatment and programming needs for second-and third-line pediatric populations. The conceptual framework of the algorithm which undergirds the tool is the patient pathway, along which key influencing factors that determine whether pediatric HIV patients are linked to care, remain in treatment, and are appropriately switched to later lines of treatment are accounted for quantitatively. Excel-based and arithmetic, the algorithm is designed to use available national, regional, and global data for factors impacting patient estimates including treatment coverage; routine viral load testing; viral load non-suppression; confirmed treatment failure; and patient loss to follow up—outcomes for which data are generally very limited in this patient population. The ultimate output of the tool is an estimate of the aggregate annual number of patients by treatment line. Given the limitations in available data for pediatric HIV, particularly for patients on second- and third-line treatments, this tool may help fill a data gap by providing a mechanism for policymakers to scenario plan, thus aiding resource allocation decisions for pediatric HIV program scale-up. The tool may be used to streamline national antiretroviral procurement of later lines of treatment, especially in resource-limited settings, and may also be used to add value to broader HIV policy and planning processes at the national level.

Nutritional, clinical and immunological status of children at HIV diagnosis in the continental region of Equatorial Guinea.

To evaluate the nutritional, clinical and immunological status of children at HIV diagnosis in the continental region of Equatorial Guinea. Children <18years diagnosed with HIV between 2009 and 2017 were included. Clinical, immunological and nutritional data were collected. Weight-for-height, weight-for-age and height-for-age Z-scores were calculated using WHO Child Growth Standards. The population was assessed in two equal periods (2009-2013 and 2014-2017) from the time of diagnosis. A total of 213 children were diagnosed with HIV (49.3% males), median age 3.8years (IQR: 1.5-8.2). A total of 121 cases (56.8%) were at WHO clinical stage III, and 53 (24.9%) were at WHO clinical stage IV. CDC immunological stage II was diagnosed in 51/130 (39.2%) and CDC stage III in 44/130 (33.8%). About 56.2% of children were underweight (weight-for-age <-2 SD); 20.1% moderately and 36.1% severely so. About 27.6% of children were wasted (weight-for-height <-2 SD); 11.9% moderately and 15.7% severely so. About 56.3% of children were stunted (height-for-age <-2 SD); 20.7% moderately and 35.6% severely so. The prevalence of wasting was higher in children ≤5years than in children >5years (36.4% vs. 19.1%, P=0.026). In the second period, the prevalence of moderate-severe immunodeficiency decreased (87.2% to 67.0%, P=0.018), without significant differences in the other nutritional or clinical data. Severe underweight was a risk factor for moderate-severe immunodeficiency (aOR: 4 [95% CI: 1.4-11.4], P=0.010). We highlight a high proportion of malnutrition at the time of HIV diagnosis in Guinea´s paediatric population. Early diagnosis of HIV infection is a priority, achievable by training Guinea´s physicians to suspect HIV early, introducing HIV molecular diagnostic techniques and ensuring intensive nutritional treatment.