Pediatric ART Research Articles

Updates to the Spectrum/Estimations and Projections Package model for estimating trends and current values for key HIV indicators.

The Spectrum model is used by national programs and UNAIDS to prepare annual estimates of the status of the HIV epidemic in 160 countries. The model and assumptions are updated regularly under the guidance of the UNAIDS Reference Group on Estimates, Modelling and Projections in response to new data, studies, and program needs. This study describes the most recent updates for the 2016 round of estimates. Meetings of the UNAIDS Reference Group include individuals with extensive knowledge of HIV programs, research, statistics, and public policy. The Reference Group also collaborates with other institutions (such as the United Nations Population Division and the US Census Bureau) and projects (such as the ALPHA Network and IeDEA Consortium) to ensure that latest methods and data are used in the preparation of the annual estimates. In the past year new methods and data have been introduced for pediatric estimates, incidence fitting, and ART mortality (described elsewhere in this supplement). The 2016 version of Spectrum includes a number of other enhancements, including updated demographic data from the United Nations Population Division, program options for treatment (treat all), and programs to prevent mother-to-child transmission (option B+), improved methods to aggregate uncertainty to regional and global levels, several options for generating incidence trends, adjustments to the Estimations and Projections Package model to better incorporate aging effects, adjustments to account for the changing bias in prevalence from antenatal clinic surveillance, and an option to fit incidence among all adults 15+ in addition to 15-49. The new methods and data implemented in the 2016 version of Spectrum allow national programs more flexibility in describing their programs and improve the estimates of key indicators and their uncertainty.

Clinico-Social and Immunological Profile of Antiretroviral Naïve Children Living With HIV In Tertiary Care Hospital, Delhi

Introduction: This study was undertaken to assess the clinical profile of children living with HIV at the time of their enrolment in an ART centre in Delhi. The study also attempts to understand association between clinical staging and immunological profile (CD4 count/percentage) in HIV infected children. The findings of this study may help policy makers to plan better health care of CLHIV in resource constrained country like India. The Objectives of the study were to assess the baseline clinico-social and immunological profile of HIV positive children before the start of Antiretroviral Therapy, to study clinicosocial and morbidity profile of HIV positive children at the time of their enrolment in ART centre and to study the association between immunodeficiency and clinical staging of CLHIV.Methodology: The present study, conducted between December 2012 and March 2013, is a retrospective case review of 83 antiretroviral naïve Children living with HIV aged 8 months to 13 years and attending paediatric ART clinic of a tertiary care hospital of Delhi. After the infection was established on serological grounds, information on socio-demographic, clinical and immunological profile was studied.Results: Majority (62.7%) of CLHIV were boys. Both parents of CLHIV were found to be positive in 63.9% while mother was found to be positive in 69.9%. The most common route of HIV infection was mother-to-child transmission (69.9%), followed by transmission though blood/blood products (12.0%). Every three out of four children (71.1%) were in WHO clinical stage III or IV. Three out of four (74.7%) children presented with fever, one in two with cough (56.6%). Diarrhoea (56.6%), pneumonia (41.0%), popular pruritic eruptions (18.1%), candidiasis (16.9%) and tuberculosis (14.5%) were the most common opportunistic infections in these children. The most common signs present were hepatomegaly (81.9%), anaemia (78.3%) and lymphadenopathy (72.3%).Conclusion: Mother to child transmission is the most common route of transmission in CLHIV. At enrolment more than half of the children were in clinical stage III&IV. Fever, cough, diarrhoea, weight loss, rashes were common morbidities of the children. Majority of the children had hepatomegaly, anaemia and lymphadenopathy.SAARC J TUBER LUNG DIS HIV/AIDS, 2016; XIII(1) p.32-38

Outcomes among HIV-infected children initiating HIV care and antiretroviral treatment in Ethiopia.

To describe pediatric ART scale-up in Ethiopia, one of the 21 global priority countries for elimination of pediatric HIV infection. A descriptive analysis of routinely collected HIV care and treatment data on HIV-infected children (<15years) enrolled at 70 health facilities in four regions in Ethiopia, January 2006-September 2013. Characteristics at enrollment and ART initiation are described along with outcomes at 1year after enrollment. Among children who initiated ART, cumulative incidence of death and loss to follow-up (LTF) were estimated using survival analysis. 11695 children 0-14years were enrolled in HIV care and 6815 (58.3%) initiated ART. At enrollment, 31.2% were WHO stage III and 6.3% stage IV. The majority (87.9%) were enrolled in secondary or tertiary facilities. At 1year after enrollment, 17.9% of children were LTF prior to ART initiation. Among children initiating ART, cumulative incidence of death was 3.4%, 4.1% and 4.8%, and cumulative incidence of LTF was 7.7%, 11.8% and 16.6% at 6, 12 and 24months, respectively. Children <2years had higher risk of LTF and death than older children (P<0.0001). Children with more advanced disease and those enrolled in rural settings were more likely to die. Children enrolled in more recent years were less likely to die but more likely to be LTF. Over the last decade large numbers of HIV-infected children have been successfully enrolled in HIV care and initiated on ART in Ethiopia. Retention prior to and after ART initiation remains a major challenge.

Is there a silver lining in this cloud? Future expectations of adolescents with human immunodeficiency virus

Background and Objective: The life span of the children living with Hiv/AIDS has increased with the invention of Retroviral drugs. As they are entering in to late adolescents and early adulthood, it becomes necessary to understand their expectations. The study aimed to explore the future expectations among the adolescents with HIV/AIDs. Materials and Methods: An exploratory study design was adopted for the study. Semi structured interviews were undertaken with adolescents and interpretative phenomenological analysis was used to analyze the results. The universe of the study were HIV infected adolescents who are registered in the Pediatric ART Centre and are coming for follow up in Indira Ghandhi Institute of Child Health Hospital, Bangaluru. Results: Emergent themes demonstrated that, the adolescent with HIV/AIDS are concerned regarding their future. The themes emerged from the study was knowledge about the illness, physical health, future expectations about career and relationship and social support. Conclusion: Lives of the children adolescents being infected by HIV/AIDS, unlike those of their counterparts are complicated with stigma, adjustment problems, and many other psychosocial issues. While studies done in India bring to light the adjustment problems of these children, they fail to look at their future expectations and their dreams for them.

Results from implementing updated 2012 World Health Organization Guidance on early-warning indicators of HIV drug resistance in Zimbabwe.

This study evaluated the performance of sentinel sites in preventing the emergence of HIVDR using Early Warning Indicators (HIVDR EWI) survey. Adult and paediatric patient data on: On time pill pick up, Retention in care, Pharmacy stock-outs, and Dispensing practices was collected. Information from pharmacy registers was verified using facility-held cards. This was a cross-sectional analysis of retrospectively collected data from 72 sites providing both adult and paediatric ART as well as two providing adult ART only. All data were entered into and analysed using a WHO EWI data abstraction electronic tool. Twenty-one percent of sites providing adult and 4.2% of sites providing paediatric ART managed to meet the target for on time pill pick up. Retention in care indicator was met by 48.7% (95% CI: 36.9-60.6) of sites. ARV stock-outs occurred in 81.1% (95% CI: 70-89.3) adult sites and 63.9% (95% CI: 50-78.6) paediatric sites. ARVs were appropriately dispensed by 86.5% (95% CI: 75.6-93.3) of adult sites and 84.7% (95% CI: 74.3-92.1) of paediatric sites. Most sites had low performance in many indicators in this survey and failed to meet the recommended targets. Some policies such as the current buffer stock and storage outside Harare should be revised in order to improve site access to ARVs. The country should prioritize the provision of viral load testing services in all provinces. The electronic patient management system should be rolled out to all ART sites to improve patient tracking and monitoring by sites.

Bottlenecks and opportunities for delivering integrated pediatric HIV services in Nepal.

BackgroundIn children, integration of HIV in MNCH services has been shown to incr. ease uptake of early infant diagnosis. This article examines bottlenecks and opportunities for scaling up integrated pediatric HIV services in Nepal.MethodsThis is a descriptive study using both mixed qualitative and quantitative methods, conducted in January 2015 in 19 facilities in five regions of Nepal most affected by HIV epidemic. The qualitative methods comprised in-depth structured interviews with key informants (leadership of The National Center for AIDS and STD Control and National Public Health Laboratory, district management teams, medical officers in charge of health facilities and HIV clinics, frontline staff at antenatal care and HIV clinics and laboratory). The quantitative methods were used to abstract data of HIV-infected pregnant women seen between January and December 2014, HIV-exposed infants aged less than 12 months, and HIV infected children aged less than 15 years who were initiated HIV treatment from 2010 to 2014. Structured tools were used to collect data which were analysed using IBM SPSS.ResultsOf the 19 facilities assessed, 18(98%), 18(98%), 14(75%), and 11(58%) provided prevention of mother-to-child transmission (PMTCT), Expanded Program on Immunization (EPI), pediatric ART and nutrition rehabilitation services, respectively. However, only 1(5%) facility collected onsite dried blood spots (DBS) for PCR HIV testing and 6(32%) facilities provided counselling and referral for DBS. In 2014, of the 121 HIV-exposed infants recorded, only 21(17%) received PCR test. The median turnaround time of the PCR test results was 54 days. Of the 21 records with PCR test, 11(52.5%) were from PMTCT clinics, 7(33%) from Nutritional rehabilitation clinics, and 3(14.5%) from pediatric outpatient clinic.Conversely, 934 children were initiated ART between 2010 and 2014, of which 5% were infants and 29% aged between 1 and 5 years. 298(32%) had comorbidities of which 64% had malnutrition. A total of 534(57%) had tuberculosis (TB) status assessed of which 58(11%) had active TB. Infants had lowest retention (63%), high mortality (17.4%), and loss to follow-up (10.9%).ConclusionFew facilities collect DBS and few children receive PCR tests with limited linkage to ART. This has led to late ART initiation, comorbidities, including TB coinfections and poor outcomes. The results indicate that there are opportunities for improving HIV case finding among HIV-exposed infants in PMTCT, EPI, TB, and nutrition services if provider initiated testing and counselling at the point of service delivery is institutionalized in these settings.

Immunological Response of Hiv-Infected Children to Highly Active Antiretoviral Therapy at Gondar University Hospital, North-Western Ethiopia.

The effectiveness of highly active antiretroviral therapy (HAART) in children has not been well studied specially in developing countries where the burden of HIV is high. This study was aimed to assess the immunologic response of HIV-infected children to HAART at Pediatric ART Clinic Gondar University Hospital. Institution based cross-sectional study was conducted at the Pediatric ART Clinic Gondar University Hospital from March 01-April 30, 2014. The study included 283 HIV-infected children who were on HAART for 6 months and above. Medical records of HIV-infected children were reviewed using pre-tested questionnaire. CD4 count/percent was collected every 6 months retrospectively. For all statistical significance tests, the cut-off value was p<0.05. Poison Regression was used for further analysis. The mean age of children was 6.9 years with a standard deviation of 3.4 years. The median CD4 count/percent was 232/13%, 450/21%, 540/25% and 608/27% at the time of initiation, 6, 12 and 18 months of ART, respectively. HAART initiated at higher CD4 count, good adherence and HIV status disclosure were found to have positive effects for immunological response. The study revealed that there was good Immunological response to ART, and that the maximum response was in the 1(st) 6 months of ART. Low CD4 count at initiation, undisclosed HIV status and lack of good adherence were found to cause low immunological response to HAART.

High rates of virological failure and drug resistance in perinatally HIV-1-infected children and adolescents receiving lifelong antiretroviral therapy in routine clinics in Togo.

IntroductionAntiretroviral treatment (ART) has been scaled up over the last decade but compared to adults, children living with HIV are less likely to receive ART. Moreover, children and adolescents are more vulnerable than adults to virological failure (VF) and emergence of drug resistance. In this study we determined virological outcome in perinatally HIV-1-infected children and adolescents receiving ART in Togo.MethodsHIV viral load (VL) testing was consecutively proposed to all children and adolescents who were on ART for at least 12 months when attending HIV healthcare services for their routine follow-up visit (June to September 2014). Plasma HIV-1 VL was measured using the m2000 RealTime HIV-1 assay (Abbott Molecular, Des Plaines, IL, USA). Genotypic drug resistance was done for all samples with VL>1000 copies/ml.Results and discussionAmong 283 perinatally HIV-1-infected children and adolescents included, 167 (59%) were adolescents and 116 (41%) were children. The median duration on ART was 48 months (interquartile range: 28 to 68 months). For 228 (80.6%), the current ART combination consisted of two nucleoside reverse transcriptase inhibitors (NRTIs) (zidovudine and lamivudine) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) (nevirapine or efavirenz). Only 28 (9.9%) were on a protease inhibitor (PI)-based regimen. VL was below the detection limit (i.e. 40 copies/ml) for 102 (36%), between 40 and 1000 copies/ml for 35 (12.4%) and above 1000 copies/ml for 146 (51.6%). Genotypic drug-resistance testing was successful for 125/146 (85.6%); 110/125 (88.0%) were resistant to both NRTIs and NNRTIs, 1/125 (0.8%) to NRTIs only, 4/125 (3.2%) to NNRTIs only and three harboured viruses resistant to reverse transcriptase and PIs. Overall, 86% (108/125) of children and adolescents experiencing VF and successfully genotyped, corresponding thus to at least 38% of the study population, had either no effective ART or had only a single effective drug in their current ART regimen.ConclusionsOur study provided important information on virological outcome on lifelong ART in perinatally HIV-1-infected children and adolescents who were still on ART and continued to attend antiretroviral (ARV) clinics for follow-up visits. Actual conditions for scaling up and monitoring lifelong ART in children in resource-limited countries can have dramatic long-term outcomes and illustrate that paediatric ART receives inadequate attention.

Hematological manifestation in HIV infected children.

To determine the common hematological abnormalities in HIV infected children and any association of these abnormalities with HIV disease severity. Cross-sectional study. Regional Pediatric ART centre, Medical College and Hospital, Kolkata, West Bengal, India, from November 2011 to November 2012. Children up to 12 years with confirmed diagnosis of HIV infection were clinically examined and tested for complete hemogram and CD4 count. Bone marrow study was done in selected patient depending on hemogram report. Children were divided in different stages according to WHO clinical staging. Each of the hematological parameters was assessed for any association with progression of disease. Fisher's Exact Test was used for determining the association between WHO clinical staging and abnormal blood parameters. P-value < 0.05 was taken as significant. Sixty nine percent of the study population was anemic; 47.37% (18/38), 66.67% (8/12), 71.43% (15/21) and 93.10% (27/29) of stage 1, 2, 3 and 4 respectively were anemic in the study population (p=0.001). Leucopenia was present in 34% (34/100) children. Neutropenia and lymphopenia was present in 19% (19/100) and 22% (22/100) children. Lymphopenia was present in 7.89% (3/38), 16.67% (2/12), 19.05% (4/21) and 44.83% (13/29) of patient with stage 1, 2, 3 and 4 respectively (p=0.020). Eosinophilia was present in 17% (17/100) and thrombocytopenia in 11% (11/100) children. 2 patients with stage 4 disease were with hypoplastic bone marrow. Anemia was the most common hematological abnormality in HIV infected children. Anemia and lymphopenia had a significant association with the stage of the disease.

Predictors of early mortality in a cohort of HIV-infected children receiving high active antiretroviral treatment in public hospitals in Ethiopia

Highly active antiretroviral therapy (HAART) is the breakthrough in care and treatment of people living with HIV, leading to a reduction in mortality and an improvement in the quality of life. Without antiretroviral treatment, most HIV-infected children die before their fifth birthday. So the objective of this study is to determine the mortality and associated factors in a cohort of HIV-infected children receiving ART in Ethiopia. A multicentre facility-based retrospective cohort study was done in selected pediatric ART units in hospitals found in Addis Ababa, Ethiopia. The probability of survival was estimated using the Kaplan–Meier method, and multivariate analysis by Cox proportional hazards regression models was conducted to determine the independent predictor of survival. A total of 556 children were included in this study. Of the total children, 10.4% were died in the overall cohort. More deaths (70%) occurred in the first 6 months of ART initiation, and the remaining others were still on follow-up at different hospitals. Underweight (moderate and severe; HR: 10.10; 95% CI: 2.08, 28.00; P = 0.004; and HR: 46.69; 95% CI: 9.26, 200.45; P < 0.01, respectively), advanced disease stage (WHO clinical stages III and IV; HR: 10.13: 95% CI: 2.25, 45.58; P = 0.003), poor ART adherence (HR: 11.72; 95% CI: 1.60, 48.44; P = 0.015), and hemoglobin level less than 7 g/dl (HR: 4.08: 95% CI: 1.33, 12.56; P = 0.014) were confirmed as significant independent predictors of death after controlling for other factors. Underweight, advanced disease stage, poor adherence to ART, and anemia appear to be independent predictor of survival in HIV-infected children receiving HAART at the pediatric units of public hospitals in Ethiopia. Nutritional supplementations, early initiation of HAART, close supervision, and monitoring of patients during the first 6 months, the follow up period is recommended.

Pediatric neurosurgery-science, art, and humility: reflection of personal experience.

I have given you my humble experiences of the managements of representative pediatric brain tumors including various aspects, from clinical to basic research. There is no question in my mind that we have made great strides in diagnosing and treating pediatric brain tumors over the past four decades. Look at medulloblastoma! We are now able to cure 80 % of these children. Unfortunately, however, not necessarily all children live. Still these children with medulloblastoma need cytotoxic therapies which unavoidably cause short or long-term side effects [59]. Could we cure Koh-chan with recurrent craniopharyngioma or a child with DIPG seen 40 years ago in the soap opera? I am afraid the answer is “no.” I did not mention in this presentation about the treatment of craniopharyngioma which still remains controversial in terms of extent of resection: total resection vs. limited resection followed by RT [60]. How about DIPG? There have been absolutely no breakthroughs. Insanity, as Albert Einstein once said, “is doing the same thing again and again and expecting different results.” Progress in molecular biology which enables us to understand tumor origin, character, genetic, and epigenetic features is breathtaking. It is our obligation to identify the safest and most effective therapy based upon current scientific research.

Reducing mother-to-child transmission of HIV: findings from an early infant diagnosis program in south-south region of Nigeria

BackgroundEarly diagnosis of HIV in infants provides a critical opportunity to strengthen follow-up of HIV-exposed children and assure early access to antiretroviral (ARV) treatment for infected children. This study describes findings from an Early Infant Diagnosis (EID) program and the effectiveness of a prevention of mother-to-child transmission (PMTCT) intervention in six health facilities in Cross-River and Akwa-Ibom states, south-south Nigeria.MethodsThis was a retrospective study. Records of 702 perinatally exposed babies aged six weeks to 18 months who had a DNA PCR test between November 2007 and July 2009 were reviewed. Details of the ARV regimen received to prevent mother-to-child transmission (MTCT), breastfeeding choices, HIV test results, turn around time (TAT) for results and post test ART enrolment status of the babies were analysed.ResultsTwo-thirds of mother-baby pairs received ARVs and 560 (80%) babies had ever been breastfed. Transmission rates for mother-baby pairs who received ARVs for PMTCT was 4.8% (CI 1.3, 8.3) at zero to six weeks of age compared to 19.5% (CI 3.0, 35.5) when neither baby nor mother received an intervention. Regardless of intervention, the transmission rates for babies aged six weeks to six months who had mixed feeding was 25.6% (CI 29.5, 47.1) whereas the transmission rates for those who were exclusively breastfed was 11.8% (CI 5.4, 18.1). Vertical transmission of HIV was eight times (AOR 7.8, CI: 4.52-13.19) more likely in the sub-group of mother-baby pairs who did not receive ARVS compared with mother-baby pairs that did receive ARVs. The median TAT for test results was 47 days (IQR: 35-58). A follow-up of 125 HIV positive babies found that 31 (25%) were enrolled into a paediatric ART program, nine (7%) were known to have died before the return of their DNA PCR results, and 85 (67%) could not be traced and were presumed to be lost-to-follow-up.ConclusionReduction of MTCT of HIV is possible with effective PMTCT interventions, including improved access to ARVs for PMTCT and appropriate infant feeding practices. Loss to follow up of HIV exposed infants is a challenge and requires strategies to enhance retention.

Disclosure of diagnosis by parents and caregivers to children infected with HIV: Prevalence associated factors and perceived barriers in Addis Ababa, Ethiopia

Vertical transmission of HIV from infected mothers to children is a common phenomenon. After the introduction of highly active antiretroviral treatment (HAART), most children live longer than before. Recently, HAART has become widely available to children living in sub-Saharan African countries, and this makes disclosure of HIV status an important issue. We conducted a cross-sectional survey involving 172 parents/caregivers of HIV-infected school-age children who had follow-up at the Pediatric Infectious Disease Clinic of the Yekatit 12 Hospital, Addis Ababa. Only 16.3% of HIV-infected schoolchildren knew their diagnosis. The child's age was the main predictor of disclosure (OR: −0.25; 95% CI: −0.35, −0.09; p<0.05). The main reason for nondisclosure was fear of negative emotional consequences for the child. More than half of the parent/caregivers agreed that they need to tell the children their diagnosis, but 86% reported that they needed health care providers to help them at the event. The low rate of disclosure found in this study shows the need for awareness creation and training of health professionals, and this should be supported by appropriate guidelines to be followed by health professionals working in pediatric ART clinics. Caregivers need to be provided with the necessary knowledge and skills on how to look after children who know their HIV status.

A biregional survey and review of first‐line treatment failure and second‐line pediatric antiretroviral access and use in Asia and southern Africa

The article published in [1], contains incorrect data in Table 1 regarding the nationally recommended paediatric second-line ART regimen after NNRTI failure in India. This has been corrected. The editors and authors regret the inconvenience caused to readers by the error in the original paper.

Barriers to implementation of the HIV guidelines in the IMCI algorithm among IMCI trained health workers in Zambia

BackgroundZambia adopted integrated management of Childhood illnesses (IMCI) in 1995 and a number of adaptations have been made to the generic WHO/UNICEF IMCI guidelines to better conform to Zambia's health service needs. One significant adaptation is the incorporation of HIV guidelines into the IMCI algorithm. Since 2004, health workers that have undergone IMCI case management training have also received training in HIV assessment. During initial follow-up visits in 11 districts 90 health workers were assessed in 2007 to determine their adherence to the IMCI algorithm. The assessment showed that 97% of the health workers assessed did not review or mention the HIV guidelines even though they had received HIV training as part of IMCI. This study aimed to explore reasons for non-adherence to HIV guidelines in the IMCI algorithm and make recommendations on how this can be improved.MethodsBoth quantitative and qualitative methods were used to collect information from eligible health workers. Forty (40) health workers were randomly selected from among those who received initial follow-up visits between March 2007 and January 2008. The health workers were selected from eight districts in four provinces of Zambia. Qualitative data was collected using Focus group discussion and key informant interviewsResults83% of the respondents said they had no difficulties in following the HIV adapted IMCI guidelines. 17% said they had difficulties. Of those who admitted having difficulties (60%) had difficulties in HIV assessment. Interesting, prompting and focus group discussions revealed that most respondents actually had difficulties in HIV assessment but could not admit it readily. Some barriers that contributed to non-adherence to the guidelines included lack of time due to inadequate staffing, lack of privacy in the health facilities and HIV related stigma from both caregivers and health workers. Frequent use of guidelines and supervision appeared to re-enforce adherence to the guidelines.ConclusionThe findings in this study suggest that training in HIV adapted IMCI guidelines is not sufficient to enable health workers to actually use their knowledge in their daily practice. Barriers may exist which prevent them from adhering to the guidelines. Addressing these barriers is critical in increasing the uptake of paediatric ART in Zambia

Pediatric Art Preferences: Countering the “One-Size-Fits-All” Approach

To determine the stated art preferences of pediatric patients through an art survey and determine whether preferences vary, with different age groups associated with different stages of cognitive development. Exposure to visual art has been shown to have an impact on improved health and satisfaction outcomes. However, there is little literature on the effect of art on pediatric patients. While designing pediatric wards, a common assumption is to use fantasy and Disney-like themes; but research across all age groups on whether children prefer these themes is limited. A survey including 20 images with a variety of subject matter and styles was administered to 64 pediatric inpatients (ages 5-17) at Memorial Hermann Hospital in Houston, TX. Children were asked to rate the selection of, and their emotional response to, the images in the survey. Qualitative comments were recorded. Results were analyzed for each of the three age groups (5-6, 7-10, and 11-17 years) according to Piaget's developmental stages, as well as across all age groups. There were significant differences in art preferences across the different age groups, especially with respect to child art (art created by children). Overall, the results for 5-10-year-olds were more significant than those for 11-17-year-olds (adolescents). Nature elements were preferred across all age groups, but all nature images were not rated similarly. Images that were bright and colorful were rated better than images that were pale. The presence of a strong context that children could associate with was a defining feature of preferred images. Content drove preference more than style, though color was a key determinant. Comments on the artwork tended to be more objective/absolute for the youngest patients and more subjective/relative for the oldest. The combination of bright colors, engaging themes, and nature content is consistently highly rated by pediatric patients. However, pediatric preferences vary significantly among the three operational stages, so one should be careful before using the "one-size-fits-all" approach. Child art, typically used in pediatric wards, is better suited for younger children than for older children.

231 Lopinavir/ritonavir-based Second Line Antiretroviral Treatment in children at National Pediatric Hospital, Phnom Penh, Cambodia

Background and Objectives: Cambodia has scaling up a large national ART program using 1st line therapy (d4T or AZT+3TC+NVP or EFV). As March 31st 2008, 2689 HIV infected children were on HAART in Cambodia. 1059 children were registered (664 on HAART) in Child Health Improvement Clinic (CHIC), an HIV outpatient clinic set up by the National Pediatric Hospital (NPH), with French Red Cross technical support. We evaluated the current pediatric cases with 2nd line regimen. Methods: Data and medical records from a retrospective cohort followed at CHIC to 31st March 2008 were analyzed. Patients meeting the Cambodian National Guidelines for the Use of Pediatric ART for treatment failure were evaluated. Treatment failure was confirmed based on clinical and immunological failure and/or virological failure. Plasma viral load has been assessed by HIV RNA real time PCR using 2nd generation ANRS Kit. Genotypic resistance results were done at Institute Pasteur according to ANRS algorithm (v.sep.07). Results: 29/612 patient (4.7%), 31% female, switched to 2nd line were enrolled in this study. Median age was 10.4 years (4.3-17.1). Median duration in the 1st line was 1.9 years (0.6-6.3). Median of CD4 percentage when switching to 2nd line was 5.0% and VL was 5.1Log (4.0-6.3) with +/− clinical failure. At switch, 22 patients were tested for HIV drug resistance for RT gene. The results revealed that 95.4% (21/22) children were resistance to NVP/EFV, 77.3% to AZT/d4T, 54.5% to ABC/ddI, and 9.1% to TD. Median time in the 2nd line was 0.9 years (0.2-2.5). 18 of 29 patients (62.1%) receive standard 2nd line regimen (ABC/ddI/LPV/r), 5 (17.2%) with 3TC/TDF/LPV/r) and 2 (6.9%) with 3TC/AZT/LPV/r). Median CD4 gain on 2nd line regimen were 11.5% (1-31%) at M6 (n = 22); 15% (0-27) at M12 (n = 11); 15.5% (10-26) at M18 (n = 6); 18% (16-25) at M24 (n = 3); and 17% at M30 (n = 1). Patients who achieved undetectable VL (VL<2.4Log) at M2 were 62.5% (n = 24); 84.2% at M6 (n = 19); 80% at M12 (n = 10), 75% at M18 (n = 4) and 100% at M24 (n = 2). Conclusion: We report here the first immunological and virological results of children on 2nd line of ART in Cambodian. This data confirm a strong efficacy of LPV/r-based 2nd line regimen and provide important information for appropriate and effective HAART in children.

A Visual Dosing Aid for First-line Pediatric Antiretroviral Treatment in Resource-poor Settings

The visual dosing aid (VDA) was developed to facilitate dosing calculations in response to children's; growth and weight during antiretroviral treatment. The theoretical accuracy of the VDA was assessed using anthropometric data from 55 children receiving care in the USA and 324 children in the Democratic Republic of the Congo. The VDA dose was similar to the WHO recommended dose. A potentially significant relative dosing difference of >or=20% occurred in <3% of children for NVP, AZT and d4T, but was observed in 20% for 3TC, overdosing being more frequent. The VDA compared well with generic pediatric fixed dose combination tablets. Results did not differ between sites. The VDA enables accurate dosing of pediatric ART in distinct populations and could facilitate roll-out of pediatric ART in resource-poor settings.

Scale-up of paediatric ART in Zambia makes an impact

Scale-up of paediatric ART in Zambia makes an impact

Scale-up of paediatric ART in Zambia makes an impact

Scale-up of paediatric ART in Zambia makes an impact