Last data update: Jun 24, 2024. (Total: 47078 publications since 2009)
Records 1-28 (of 28 Records) |
Query Trace: Abrams EJ [original query] |
---|
Guidelines for tuberculosis screening and preventive treatment among pregnant and breastfeeding women living with HIV in PEPFAR-supported countries
Hirsch-Moverman Y , Hsu A , Abrams EJ , Killam WP , Moore B , Howard AA . PLoS One 2024 19 (4) e0296993 BACKGROUND: Tuberculosis (TB) preventive treatment (TPT) is recommended by the World Health Organization (WHO) for persons living with HIV, including pregnant and breastfeeding women. Given the President's Emergency Plan for AIDS Relief (PEPFAR)'s investment in TPT services for persons living with HIV as a strategy to prevent TB as well as uncertainty in guidelines and policy regarding use of TPT during pregnancy and the postpartum period, we conducted a review of current relevant national guidelines among PEPFAR-supported countries. METHODS: Our review included 44/49 PEPFAR-supported countries to determine if TB screening and TPT are recommended specifically for pregnant and breastfeeding women living with HIV (WLHIV). National guidelines reviewed and abstracted included TB, HIV, prevention of vertical HIV transmission, TPT, and any other relevant guidelines. We abstracted information regarding TB screening, including screening tools and frequency; and TPT, including timing, regimen, frequency, and laboratory monitoring. RESULTS: Of 44 PEPFAR-supported countries for which guidelines were reviewed, 66% were high TB incidence countries; 41% were classified by WHO as high TB burden countries, and 43% as high HIV-associated TB burden countries. We found that 64% (n = 28) of countries included TB screening recommendations for pregnant WLHIV in their national guidelines, and most (n = 35, 80%) countries recommend TPT for pregnant WLHIV. Fewer countries included recommendations for breastfeeding as compared to pregnant WLHIV, with only 32% (n = 14) mentioning TB screening and 45% (n = 20) specifically recommending TPT for this population; most of these recommend isoniazid-based TPT regimens for pregnant and breastfeeding WLHIV. However, several countries also recommend isoniazid combined with rifampicin (3RH) or rifapentine (3HP). CONCLUSIONS: Despite progress in the number of PEPFAR-supported countries that specifically include TB screening and TPT recommendations for pregnant and breastfeeding WLHIV in their national guidelines, many PEPFAR-supported countries still do not include specific screening and TPT recommendations for pregnant and breastfeeding WLHIV. |
Pre-exposure prophylaxis uptake concerns in the Democratic Republic of the Congo: Key population and healthcare workers perspectives
Shen Y , Franks J , Reidy W , Olsen H , Wang C , Mushimbele N , Mazala RT , Tchissambou T , Malele F , Kilundu A , Bingham T , Djomand G , Mukinda E , Ewetola R , Abrams EJ , Teasdale CA . PLoS One 2023 18 (11) e0280977 Key populations (KP) in the Democratic Republic of the Congo (DRC), including female sex workers (SW), are disproportionally affected by HIV. Quantitative feedback surveys were conducted at seven health facilities in DRC with 70 KP clients enrolled in pre-exposure prophylaxis (PrEP) services to measure benefits and concerns. The surveys also assessed satisfaction with PrEP services and experiences of stigma at the health facilities. Thirty healthcare workers (HCW) were surveyed to measure attitudes, beliefs, and acceptability of providing services to KP. KP client survey participants were primarily female SW. KP clients reported that the primary concern about taking PrEP was fear of side effects (67%) although few KP reported having experienced side effect (14%). HCW concurred with clients that experienced and anticipated side effects were a primary PrEP uptake concern, along with costs of clinic visits. |
Pre-exposure Prophylaxis Uptake Concerns in the Democratic Republic of the Congo: Key Population and Healthcare Workers Perspectives (preprint)
Shen Y , Franks J , Reidy W , Olsen H , Wang C , Mushimbele N , Mazala RT , Tchissambou T , Malele F , Kilundu A , Bingham T , Djomand G , Mukinda E , Ewetola R , Abrams EJ , Teasdale CA . medRxiv 2023 17 Key populations (KP) in the Democratic Republic of the Congo (DRC), including female sex workers (FSW), are disproportionally affected by HIV. Quantitative feedback surveys were conducted at seven health facilities in DRC with 70 KP clients enrolled in services to measure pre-exposure prophylaxis (PrEP) benefits and concerns. The surveys also assessed satisfaction with PrEP services and experiences of stigma at the health facilities. Thirty healthcare workers (HCW) were surveyed to measure attitudes, beliefs, and acceptability of providing services to KP. KP client survey participants were primarily female SW. KP clients reported that the primary concern about taking PrEP was fear of side effects. HCW concurred with clients that experienced and anticipated side effects were a primary PrEP uptake concern, along with costs of clinic visits. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
HIV retesting for pregnant and breastfeeding women across maternal child health services in Nampula, Mozambique
Teasdale CA , Choy M , Tsiouris F , De Gusmao EP , Banqueiro ECP , Couto A , Tibana K , Flowers N , Urso M , Vitale M , Abrams EJ . PLoS One 2023 18 (3) e0283558 BACKGROUND: Repeat HIV testing during pregnancy and breastfeeding identifies women with incident infections, those living with HIV who have been lost to care, and infants at risk for HIV infection. We report data from repeat testing for women in maternal and child health (MCH) services at 10 health facilities in Mozambique. METHODS: Routinely collected data from health facility registers are reported from April-November 2019. From antenatal care (ANC), we report numbers and proportions of women eligible for retesting; returned for care when retesting eligible; retested; and HIV-positive (HIV+) at retesting. From child welfare clinics (CWC), we report mothers retested; tested HIV-positive; HIV+ mothers linked to ART services; HIV-exposed infants (HEI) tested for HIV with polymerase chain reaction (PCR) tests; HEI testing PCR positive; PCR-positive infants linked to care. RESULTS: In ANC, 28,233 pregnant women tested HIV-negative at first ANC visit, 40.7% had a follow-up visit when retesting eligible, among whom 84.8% were retested and 0.3%(N = 26) tested HIV+. In CWC, 26,503 women were tested; 0.8%(N = 212) tested HIV+ and 74.1%(N = 157) of HIV+ women were linked to care. Among 157 HEI identified in CWC, 68.4%(N = 145) received PCR testing and 19.3%(N = 28) tested positive. CONCLUSION: In ANC, less than half of pregnant women eligible for retesting returned for follow-up visits, and test positivity was low among women retested in ANC and CWC. In CWC, linkage to infant testing was poor and almost 20% of HEI were PCR-positive. Implementing retesting for pregnant and breastfeeding women is challenging due to high numbers of women and low testing yield. |
Tuberculosis prevalence, incidence and prevention in a South African cohort of children living with HIV
Anyalechi GE , Bain R , Kindra G , Mogashoa M , Sogaula N , Mutiti A , Arpadi S , Rivadeneira E , Abrams EJ , Teasdale CA . J Trop Pediatr 2022 68 (6) BACKGROUND: We describe tuberculosis (TB) disease among antiretroviral treatment (ART) eligible children living with HIV (CLHIV) in South Africa to highlight TB prevention opportunities. METHODS: In our secondary analysis among 0- to 12-year-old ART-eligible CLHIV in five Eastern Cape Province health facilities from 2012 to 2015, prevalent TB occurred 90 days before or after enrollment; incident TB occurred >90 days after enrollment. Characteristics associated with TB were assessed using logistic and Cox proportional hazards regression with generalized estimating equations. RESULTS: Of 397 enrolled children, 114 (28.7%) had prevalent TB. Higher-income proxy [adjusted odds ratio (aOR) 1.8 [95% confidence interval (CI) 1.3-2.6] for the highest, 1.6 (95% CI 1.6-1.7) for intermediate]; CD4+ cell count <350 cells/µl [aOR 1.6 (95% CI 1.1-2.2)]; and malnutrition [aOR 1.6 (95% CI 1.1-2.6)] were associated with prevalent TB. Incident TB was 5.2 per 100 person-years and was associated with delayed ART initiation [hazard ratio (HR) 4.7 (95% CI 2.3-9.4)], malnutrition [HR 1.8 (95% CI 1.1-2.7)] and absence of cotrimoxazole [HR 2.3 (95% CI 1.0-4.9)]. Among 362 children with data, 8.6% received TB preventive treatment. CONCLUSIONS: Among these CLHIV, prevalent and incident TB were common. Early ART, cotrimoxazole and addressing malnutrition may prevent TB in these children. | BACKGROUND: We describe tuberculosis (TB) in children living with HIV (CLHIV) eligible for HIV treatment in South Africa to highlight opportunities to prevent TB. METHODS: We analyzed additional data from our original study of CLHIV who were 0–12 years old and due to start HIV treatment in five health facilities in Eastern Cape Province from 2012 to 2015 and assessed characteristics associated with existing and new TB. RESULTS: Of 397 enrolled children, 114 (28.7%) had existing TB. Children with a higher measure of household income had higher odds of existing TB. CD4+ cell count <350 cells/µl and malnutrition were also associated with existing TB. There were 5.2 new cases of TB for every 100 child-years. New TB was 4.7 times more likely for children with delayed HIV treatment start, 1.8 times more likely for children with malnutrition and 2.3 times more likely for children who did not get cotrimoxazole. Among 362 children with data, 8.6% received treatment to prevent TB. CONCLUSIONS: Among these CLHIV, existing and new TB were common. Early HIV treatment, cotrimoxazole and addressing malnutrition may prevent TB in these children. | eng |
Enhanced integration of TB services in reproductive maternal newborn and child health (RMNCH) settings in Eswatini
Hartsough K , Teasdale CA , Shongwe S , Geller A , Gusmao EPde , Dlamini P , Mafukidze A , Pasipamire M , Ao T , Ryan C , Modi S , Abrams EJ , Howard AA . PLoS Glob Public Health 2022 2 (4) e0000217 Tuberculosis (TB) primarily affects women during their reproductive years and contributes to maternal mortality and poor pregnancy outcomes. For pregnant women living with HIV (WLHIV), TB is the leading cause of non-obstetric maternal mortality, and pregnant WLHIV with TB are at increased risk of transmitting both TB and HIV to their infants. TB diagnosis among pregnant women, particularly WLHIV, remains challenging, and TB preventive treatment (TPT) coverage among pregnant WLHIV is limited. This project aimed to strengthen integrated TB and reproductive, maternal, neonatal and child health (RMNCH) services in Eswatini to improve screening and treatment for TB disease, TPT uptake and completion among women receiving RMNCH services. The project was conducted from April-December 2017 at four health facilities in Eswatini and introduced enhanced monitoring tools and on-site technical support in RMNCH services. We present data on TB case finding among women, and TPT coverage and completion among eligible WLHIV. A questionnaire (S1 Appendix) measured healthcare provider perspectives on the project after three months of project implementation, including feasibility of scaling-up integrated TB and RMNCH services. A total of 5,724 women (HIV-negative or WLHIV) were screened for active TB disease while attending RMNCH services; 53 (0.9%) were identified with presumptive TB, of whom 37 (70%) were evaluated for TB disease and 6 (0.1% of those screened) were diagnosed with TB. Among 1,950 WLHIV who screened negative for TB, 848 (43%) initiated TPT and 462 (54%) completed. Forty-three healthcare providers completed the questionnaire, and overall were highly supportive of integrated TB and RMNCH services. Integration of TB/HIV services in RMNCH settings was feasible and ensured high TB screening coverage among women of reproductive age, however, symptom screening identified few TB cases, and further studies should explore various screening algorithms and diagnostics that optimize case finding in this population. Interventions should focus on working with healthcare providers and patients to improve TPT initiation and completion rates. |
Group antenatal care for improving retention of adolescent and young pregnant women living with HIV in Kenya
Teasdale CA , Odondi J , Kidiga C , Choy M , Fayorsey R , Ngeno B , Ochanda B , Langat A , Ngugi C , Callahan T , Modi S , Hawken M , Odera D , Abrams EJ . BMC Pregnancy Childbirth 2022 22 (1) 208 BACKGROUND: Pregnant and breastfeeding adolescents and young women living with HIV (AYWLH) have lower retention in prevention of mother-to-child transmission (PMTCT) services compared to older women. METHODS: We evaluated a differentiated service model for pregnant and postnatal AYWLH at seven health facilities in western Kenya aimed at improving retention in antiretroviral treatment (ART) services. All pregnant AYWLH < 25 years presenting for antenatal care (ANC) were invited to participate in group ANC visits including self-care and peer-led support sessions conducted by health facility nurses per national guidelines. ART register data were used to assess loss to follow-up (LTFU) among newly-enrolled pregnant adolescent (< 20 years) and young women (20-24 years) living with HIV starting ART in the pre-period (January-December 2016) and post-period (during implementation; December 2017-January 2019). Poisson regression models compared LTFU incidence rate ratios (IRR) in the first six months after PMTCT enrollment and risk ratios compared uptake of six week testing for HIV-exposed infants (HEI) between the pre- and post-periods. RESULTS: In the pre-period, 223 (63.2%) of 353 pregnant AYWLH newly enrolled in ANC had ART data, while 320 (71.1%) of 450 in the post-period had ART data (p = 0.02). A higher proportion of women in the post-period (62.8%) had known HIV-positive status at first ANC visit compared to 49.3% in the pre-period (p < 0.001). Among pregnant AYWLH < 20 years, the incidence rate of LTFU in the first six months after enrollment in ANC services declined from 2.36 per 100 person months (95%CI 1.06-5.25) in the pre-period to 1.41 per 100 person months (95%CI 0.53-3.77) in the post-period. In both univariable and multivariable analysis, AYWLH < 20 years in the post-period were almost 40% less likely to be LTFU compared to the pre-period, although this finding did not meet the threshold for statistical significance (adjusted incidence rate ratio 0.62, 95%CI 0.38-1.01, p = 0.057). Testing for HEI was 10% higher overall in the post-period (adjusted risk ratio 1.10, 95%CI 1.01-1.21, p = 0.04). CONCLUSIONS: Interventions are urgently needed to improve outcomes among pregnant and postnatal AYWLH. We observed a trend towards increased retention among pregnant adolescents during our intervention and a statistically significant increase in uptake of six week HEI testing. |
Uninterrupted HIV treatment for women: Policies and practices for care transitions during pregnancy and breastfeeding in Cte d'Ivoire, Lesotho and Malawi
Phillips TK , Olsen H , Teasdale CA , Geller A , Ts'oeu M , Buono N , Kayira D , Ngeno B , Modi S , Abrams EJ . PLoS One 2021 16 (12) e0260530 Transitions between services for continued antiretroviral treatment (ART) during and after pregnancy are a commonly overlooked aspect of the HIV care cascade, but ineffective transitions can lead to poor health outcomes for women and their children. In this qualitative study, we conducted interviews with 15 key stakeholders from Ministries of Health along with PEPFAR-supported and other in-country non-governmental organizations actively engaged in national programming for adult HIV care and prevention of mother-to-child-transmission of HIV (PMTCT) services in Côte d'Ivoire, Lesotho and Malawi. We aimed to understand perspectives regarding transitions into and out of PMTCT services for continued ART. Thematic analysis revealed that, although transitions of care are necessary and a potential point of loss from ART care in all three countries, there is a lack of clear guidance on transition approach and no formal way of monitoring transition between services. Several opportunities were identified to monitor and strengthen transitions of care for continued ART along the PMTCT cascade. |
Improving retention in antenatal and postnatal care: a systematic review of evidence to inform strategies for adolescents and young women living with HIV
Brittain K , Teasdale CA , Ngeno B , Odondi J , Ochanda B , Brown K , Langat A , Modi S , Abrams EJ . J Int AIDS Soc 2021 24 (8) e25770 INTRODUCTION: Young pregnant and postpartum women living with HIV (WLHIV) are at high risk of poor outcomes in prevention of mother-to-child transmission services. The aim of this systematic review was to collate evidence on strategies to improve retention in antenatal and/or postpartum care in this population. We also conducted a secondary review of strategies to increase attendance at antenatal care (ANC) and/or facility delivery among pregnant adolescents, regardless of HIV status, to identify approaches that could be adapted for adolescents and young WLHIV. METHODS: Selected databases were searched on 1 December 2020, for studies published between January 2006 and November 2020, with screening and data abstraction by two independent reviewers. We identified papers that reported age-disaggregated results for adolescents and young WLHIV aged <25 years at the full-text review stage. For the secondary search, we included studies among female adolescents aged 10 to 19 years. RESULTS AND DISCUSSION: Of 37 papers examining approaches to increase retention among pregnant and postpartum WLHIV, only two reported age-disaggregated results: one showed that integrated care during the postpartum period increased retention in HIV care among women aged 18 to 24 years; and another showed that a lay counsellor-led combination intervention did not reduce attrition among women aged 16 to 24 years; one further study noted that age did not modify the effectiveness of a combination intervention. Mobile health technologies, enhanced support, active follow-up and tracing and integrated services were commonly examined as standalone interventions or as part of combination approaches, with mixed evidence for each strategy. Of 10 papers identified in the secondary search, adolescent-focused services and continuity of care with the same provider appeared to be effective in improving attendance at ANC and/or facility delivery, while home visits and group ANC had mixed results. CONCLUSIONS: This review highlights the lack of evidence regarding effective strategies to improve retention in antenatal and/or postpartum care among adolescents and young WLHIV specifically, as well as a distinct lack of age-disaggregated results in studies examining retention interventions for pregnant WLHIV of all ages. Identifying and prioritizing approaches to improve retention of adolescents and young WLHIV are critical for improving maternal and child health. |
Growth and Metabolic Changes After Antiretroviral Initiation in South African Children
Masi-Leone M , Arpadi S , Teasdale C , Yuengling KA , Mutiti A , Mogashoa M , Rivadeneira ED , Abrams EJ , Jao J . Pediatr Infect Dis J 2021 40 (11) 1004-1010 BACKGROUND: Poor growth and metabolic disturbances remain concerns for children living with HIV (CLHIV). We describe the impact of viral load (VL) on growth and lipid outcomes in South African CLHIV <12 years initiating World Health Organization recommended first-line antiretroviral therapy (ART) from 2012 to 2015. METHODS: Z scores for length-for-age (LAZ), weight-for-age (WAZ) and body mass index-for-age were calculated. Lipids (total cholesterol, low-density lipoprotein and high-density lipoprotein) were measured. Hemoglobin A1C ≥5.8 was defined as at risk for type 2 diabetes. Mixed effects models were used to assess the association of VL at ART initiation with Z scores and lipids over time. RESULTS: Of 241 CLHIV, 151 (63%) were <3 years initiating LPV/r-based ART and 90 (37%) were ≥3 years initiating EFV-based ART. Among CLHIV <3 years, higher VL at ART initiation was associated with lower mean LAZ (ß: -0.30, P=0.03), WAZ (ß: -0.32, P=0.01) and low-density lipoprotein (ß: -6.45, P=0.03) over time. Among CLHIV ≥3, a log 10 increase in pretreatment VL was associated with lower mean LAZ (ß: -0.29, P=0.07) trending towards significance and lower WAZ (ß: -0.32, P=0.05) as well as with more rapid increases in LAZ (ß: 0.14 per year, P=0.01) and WAZ (ß: 0.19 per year, P=0.04). Thirty percent of CLHIV were at risk for type 2 diabetes at ART initiation. CONCLUSIONS: CLHIV initiating ART <3 years exhibited positive gains in growth and lipids, though high viremia at ART initiation was associated with persistently low growth and lipids, underscoring the need for early diagnosis and rapid treatment initiation. Future studies assessing the long-term cardiometabolic impact of these findings are warranted. |
Human Immunodeficiency Virus Infection in Adolescents and Mode of Transmission in Southern Africa: A Multinational Analysis of Population-Based Survey Data
Low A , Teasdale C , Brown K , Barradas DT , Mugurungi O , Sachathep K , Nuwagaba-Biribonwoha H , Birhanu S , Banda A , Frederix K , Payne D , Radin E , Wiesner L , Ginindza C , Philip N , Musuka G , Sithole S , Patel H , Maile L , Abrams EJ , Arpadi S . Clin Infect Dis 2021 73 (4) 594-604 BACKGROUND: Adolescents aged 10-19 years living with human immunodeficiency virus (HIV) (ALHIV), both perinatally infected adolescents (APHIV) and behaviorally infected adolescents (ABHIV), are a growing population with distinct care needs. We characterized the epidemiology of HIV in adolescents included in Population-based HIV Impact Assessments (2015-2017) in Zimbabwe, Malawi, Zambia, Eswatini, and Lesotho. METHODS: Adolescents were tested for HIV using national rapid testing algorithms. Viral load (VL) suppression (VLS) was defined as VL <1000 copies/mL, and undetectable VL (UVL) as VL <50 copies/mL. Recent infection (within 6 months) was measured using a limiting antigen avidity assay, excluding adolescents with VLS or with detectable antiretrovirals (ARVs) in blood. To determine the most likely mode of infection, we used a risk algorithm incorporating recency, maternal HIV and vital status, history of sexual activity, and age at diagnosis. RESULTS: HIV prevalence ranged from 1.6% in Zambia to 4.8% in Eswatini. Of 707 ALHIV, 60.9% (95% confidence interval, 55.3%-66.6%) had HIV previously diagnosed, and 47.1% (41.9%-52.3%) had VLS. Our algorithm estimated that 72.6% of ALHIV (485 of 707) were APHIV, with HIV diagnosed previously in 69.5% of APHIV and 39.4% of ABHIV, and with 65.3% of APHIV and 33.5% of ABHIV receiving ARV treatment. Only 67.2% of APHIV and 60.5% of ABHIV receiving ARVs had UVL. CONCLUSIONS: These findings suggest that two-thirds of ALHIV were perinatally infected, with many unaware of their status. The low prevalence of VLS and UVL in those receiving treatment raises concerns around treatment effectiveness. Expansion of opportunities for HIV diagnoses and the optimization of treatment are imperative. |
Patient feedback surveys among pregnant women in Eswatini to improve antenatal care retention
Teasdale CA , Geller A , Shongwe S , Mafukidze A , Choy M , Magaula B , Yuengling K , King K , De Gusmao EP , Ryan C , Ao T , Callahan T , Modi S , Abrams EJ . PLoS One 2021 16 (3) e0248685 BACKGROUND: Uptake and retention in antenatal care (ANC) is critical for preventing adverse pregnancy outcomes for both mothers and infants. METHODS: We implemented a rapid quality improvement project to improve ANC retention at seven health facilities in Eswatini (October-December 2017). All pregnant women attending ANC visits were eligible to participate in anonymous tablet-based audio assisted computer self-interview (ACASI) surveys. The 24-question survey asked about women's interactions with health facility staff (HFS) (nurses, mentor mothers, receptionists and lab workers) with a three-level symbolic response options (agree/happy, neutral, disagree/sad). Women were asked to self-report HIV status. Survey results were shared with HFS at monthly quality improvement sessions. Chi-square tests were used to assess differences in responses between months one and three, and between HIV-positive and negative women. Routine medical record data were used to compare retention among pregnant women newly enrolled in ANC two periods, January-February 2017 ('pre-period') and January-February 2018 ('post-period') at two of the participating health facilities. Proportions of women retained at 3 and 6 months were compared using Cochran-Mantel-Haenszel and Wilcoxon tests. RESULTS: A total of 1,483 surveys were completed by pregnant women attending ANC, of whom 508 (34.3%) self-reported to be HIV-positive. The only significant change in responses from month one to three was whether nurses listened with agreement increasing from 88.3% to 94.8% (p<0.01). Overall, WLHIV had significantly higher proportions of reported satisfaction with HFS interactions compared to HIV-negative women. A total of 680 pregnant women were included in the retention analysis; 454 (66.8%) HIV-negative and 226 (33.2%) WLHIV. In the pre- and post-periods, 59.4% and 64.6%, respectively, attended at least four ANC visits (p = 0.16). The proportion of women retained at six months increased from 60.9% in the pre-period to 72.7% in the post-period (p = 0.03). For HIV-negative women, pre- and post-period six-month retention significantly increased from 56.6% to 71.6% (p = 0.02); however, the increase in WLHIV retained at six months from 70.7% (pre-period) to 75.0% (post-period) was not statistically significant (p = 0.64). CONCLUSION: The type of rapid quality improvement intervention we implemented may be useful in improving patient-provider relationships although whether it can improve retention remains unclear. |
Approaches to transitioning women into and out of prevention of mother-to-child transmission of HIV services for continued ART: a systematic review
Phillips TK , Teasdale CA , Geller A , Ng'eno B , Mogoba P , Modi S , Abrams EJ . J Int AIDS Soc 2021 24 (1) e25633 INTRODUCTION: Women living with HIV are required to transition into the prevention of mother-to-child transmission of HIV (PMTCT) services when they become pregnant and back to ART services after delivery. Transition can be a vulnerable time when many women are lost from HIV care yet there is little guidance on the optimal transition approaches to ensure continuity of care. We reviewed the available evidence on existing approaches to transitioning women into and out of PMTCT, outcomes following transition and factors influencing successful transition. METHODS: We searched PubMed and SCOPUS, as well as abstracts from international HIV-focused meetings, from January 2006 to July 2020. Studies were included that examined three points of transition: pregnant women already on ART into PMTCT (transition 1), pregnant women living with HIV not yet on ART into treatment services (transition 2) and postpartum women from PMTCT into general ART services after delivery (transition 3). Results were grouped and reported as descriptions of transition approach, comparison of outcomes following transition and factors influencing successful transition. RESULTS & DISCUSSION: Out of 1809 abstracts located, 36 studies (39 papers) were included in this review. Three studies included transition 1, 26 transition 2 and 17 transition 3. Approaches to transition were described in 26 studies and could be grouped into the provision of information at the point of transition (n = 8), strengthened communication or linkage of data between services (n = 4), use of transition navigators (n = 12), and combination approaches (n = 4). Few studies were designed to directly assess transition and only nine compared outcomes between transition approaches, with substantial heterogeneity in study design, setting and outcomes. Four themes were identified in 25 studies reporting on factors influencing successful transition: fear, knowledge and preparedness, clinic characteristics and the transition requirements and process. CONCLUSIONS: This review highlights that, despite the need for women to transition into and out of PMTCT services for continued ART in many settings, there is very limited evidence on optimal transition approaches. Ongoing operational research is required to identify sustainable and acceptable transition approaches and service delivery models that support continuity of HIV care during and after pregnancy. |
Drug resistance mutations among South African children living with HIV on WHO-recommended ART regimens.
Hackett S , Teasdale CA , Pals S , Muttiti A , Mogashoa M , Chang J , Zeh C , Ramos A , Rivadeneira ED , DeVos J , Sleeman K , Abrams EJ . Clin Infect Dis 2020 73 (7) e2217-e2225 ![]() BACKGROUND: Children living with HIV (CLHIV) receiving antiretroviral treatment (ART) in resource limited settings are susceptible to high rates of acquired HIV drug resistance (HIVDR), but few studies include children initiating age-appropriate WHO-recommended first-line regimens. We report data from a cohort of ART-naïve South African children who initiated first-line ART. METHODS: ART-eligible CLHIV aged 0-12 years were enrolled from 2012 to 2014 at five public South African facilities and followed for up to 24 months. Enrolled CLHIV received standard of care WHO-recommended first-line ART. At the final study visit, a dried blood spot sample was obtained for viral load and genotypic resistance testing. RESULTS: Among 72 successfully genotyped CLHIV, 49 (68.1%) received ABC/3TC/LPV/r, and 23 (31.9%) received ABC/3TC/EFV. All but 2 children on ABC/3TC/LPV/r were <3 years and all CLHIV on ABC/3TC/EFV were ≥3 years. Overall, 80.6% (58/72) had at least one drug resistance mutation (DRM). DRMs to NNRTIs and NRTIs were found among 65% and 51% of all CLHIV, respectively, with no statistical difference by ART regimen. More CLHIV on ABC/3TC/EFV, 47.8% (11/23), were found to have 0 or only 1 effective antiretroviral drug remaining in their current regimen compared to 8.2% (4/49) on ABC/3TC/LPV/r. CONCLUSIONS: High levels of NNRTI and NRTI DRMs among CLHIV receiving ABC/3TC/LPV/r suggests a lasting impact of failed PMTCT interventions on DRMs. However, drug susceptibility analysis, reveals that CLHIV with detectable viremia on ABC/3TC/LPV/r are more likely to have maintained at least two effective agents on their current HIV regimen than those on ABC/3TC/EFV. |
Birth testing for infant HIV diagnosis in Eswatini: Implementation experience and uptake among women living with HIV in Manzini Region
Teasdale CA , Tsiouris F , Mafukidze A , Shongwe S , Choy M , Nhlengetfwa H , Simelane S , Mthethwa S , Ao T , Ryan C , Dale H , Rivadeneira E , Abrams EJ . Pediatr Infect Dis J 2020 39 (9) e235-e241 INTRODUCTION: HIV testing at birth of HIV-exposed infants (HEIs) may improve the identification of infants infected with HIV in utero and accelerate antiretroviral treatment (ART) initiation. METHODS: ICAP at Columbia University supported implementation of a national pilot of HIV testing at birth (0-7 days) in Eswatini at 2 maternity facilities. Dried blood spot (DBS) samples from neonates of women living with HIV (WLHIV) were collected and processed at the National Molecular Reference Laboratory using polymerase chain reaction (PCR). Mothers received birth test results at community health clinics. We report data on HIV birth testing uptake and outcomes for HIV-positive infants from the initial intensive phase (October 2017-March 2018) and routine support phase (April-December 2018). RESULTS: During the initial intensive pilot phase, 1669 WLHIV delivered 1697 live-born HEI at 2 health facilities and 1480 (90.3%) HEI received birth testing. During the routine support phase, 2546 WLHIV delivered and 2277 (93.5%) HEI received birth testing. Overall October 2017-December 2018, 22 (0.6%) infants of 3757 receiving birth testing had a positive PCR test, 15 (68.2%) of whom were successfully traced and linked for confirmatory testing (2 infants were reported by caregivers to have negative follow-up HIV tests). Median time from birth test to receipt of results by the caregiver was 13 days (range: 8-23). Twelve (60.0%) of 20 infants confirmed to be HIV-positive started ART at median age of 17.5 days (12-43). One mother of an HIV-positive infant who was successfully traced refused ART following linkage to care and another child died after ART initiation. Three infants (15.0%) had died by the time their mothers were reached and 4 (15.0%) infants were never located. CONCLUSION: This pilot of universal birth testing in Eswatini demonstrates the feasibility of using a standard of care approach in a low resource and high burden setting. We document high uptake of testing for newborns among HIV-positive mothers and very few infants were found to be infected through birth testing. |
Delays in fast track ART initiation and reasons for not starting treatment among eligible children in Eastern Cape, South Africa
Teasdale CA , Yuengling KA , Mutiti A , Arpadi S , Nxele M , Pepeta L , Mogashoa M , Rivadeneira ED , Abrams EJ . AIDS 2019 33 (13) 2099-2101 We report data from an observational cohort of South African children living with HIV <12 years of age eligible for fast track ART (rapid) initiation. We found that less than half those eligible for rapid ART initiation based on immunologic and disease status started treatment within one week. |
Delays in fast track ART initiation and reasons for not starting treatment among eligible children in Eastern Cape, South Africa
Teasdale CA , Yuengling KA , Mutiti A , Arpadi S , Nxele M , Pepeta L , Mogashoa M , Rivadeneira ED , Abrams EJ . AIDS 2019 33 (13) 2099-2101 We report data from an observational cohort of South African children living with HIV <12 years of age eligible for fast track ART (rapid) initiation. We found that less than half those eligible for rapid ART initiation based on immunologic and disease status started treatment within one week. |
Eliminating perinatal HIV in the United States: mission possible
Gnanashanmugam D , Rakhmanina N , Crawford K , Nesheim S , Ruel T , Birkhead GS , Chakraborty R , Lawrence R , Jean-Philippe P , Jayashankar L , Hoover A , Statton A , D'Souza P , Fitzgibbon J , Hazra R , Warren B , Smith S , Abrams EJ . AIDS 2018 33 (3) 377-385 In 2015, only 53 infants born in the United States acquired HIV, the lowest recorded number of perinatal HIV infections. Recognizing this significant achievement, we must acknowledge that the United States has not yet reached the goal of eliminating perinatal HIV transmission. This manuscript describes different approaches to perinatal HIV preventive services among five states and the District of Columbia as case studies. Continuous focus on improving identification, surveillance and prevention of HIV infection in pregnant women and their infants is necessary to reach the goal of eliminating perinatal HIV transmission in the United States. |
HIV viral suppression and longevity among a cohort of children initiating antiretroviral therapy in Eastern Cape, South Africa
Teasdale CA , Sogaula N , Yuengling KA , Wang C , Mutiti A , Arpadi S , Nxele M , Pepeta L , Mogashoa M , Rivadeneira ED , Abrams EJ . J Int AIDS Soc 2018 21 (8) e25168 INTRODUCTION: There are limited data on viral suppression (VS) in children with HIV receiving antiretroviral therapy (ART) in routine care in low-resource settings. We examined VS in a cohort of children initiating ART in routine HIV care in Eastern Cape Province, South Africa. METHODS: The Pediatric Enhanced Surveillance Study enrolled HIV-infected ART eligibility children zero to twelve years at five health facilities from 2012 to 2014. All children received routine HIV care and treatment services and attended quarterly study visits for up to 24 months. Time to VS among those starting treatment was measured from ART start date to first viral load (VL) result <1000 and VL <50 copies/mL using competing risk estimators (death as competing risk). Multivariable sub-distributional hazards models examined characteristics associated with VS and VL rebound following suppression among those with a VL >30 days after the VS date. RESULTS: Of 397 children enrolled, 349 (87.9%) started ART: 118 (33.8%) children age <12 months, 122 (35.0%) one to five years and 109 (31.2%) six to twelve years. At study enrolment, median weight-for-age z-score (WAZ) was -1.7 (interquartile range (IQR):-3.1 to -0.4) and median log VL was 5.6 (IQR: 5.0 to 6.2). Cumulative incidence of VS <1000 copies/mL at six, twelve and twenty-four months was 57.6% (95% CI 52.1 to 62.7), 78.7% (95% CI 73.7 to 82.9) and 84.0% (95% CI 78.9 to 87.9); for VS <50 copies/mL: 40.3% (95% CI 35.0 to 45.5), 63.9% (95% CI 58.2 to 69.0) and 72.9% (95% CI 66.9 to 78.0). At 12 months only 46.6% (95% CI 36.6 to 56.0) of children <12 months had achieved VS <50 copies/mL compared to 76.9% (95% CI 67.9 to 83.7) of children six to twelve years (p < 0.001). In multivariable models, children with VL >1 million copies/mL at ART initiation were half as likely to achieve VS <50 copies/mL (adjusted sub-distributional hazards 0.50; 95% CI 0.36 to 0.71). Among children achieving VS <50 copies/mL, 37 (19.7%) had VL 50 to 1000 copies/mL and 31 (16.5%) had a VL >1000 copies/mL. Children <12 months had twofold increased risk of VL rebound to VL >1000 copies/mL (adjusted relative risk 2.03, 95% CI: 1.10 to 3.74) compared with six to twelve year olds. CONCLUSIONS: We found suboptimal VS among South African children initiating treatment and high proportions experiencing VL rebound, particularly among younger children. Greater efforts are needed to ensure that all children achieve optimal outcomes. |
Pediatric HIV treatment gaps in 7 east and southern African countries: Examination of modeled, survey, and routine program data
Saito S , Chung H , Mahy M , Radin AK , Jonnalagadda S , Hakim A , Awor AC , Mwila A , Gonese E , Wadonda-Kabondo N , Rwehumbiza P , Ao T , Kim EJ , Frederix K , Nuwagaba-Birbomboha H , Musuka G , Mugurungi O , Mushii J , Mnisi Z , Munthali G , Jahn A , Kirungi WL , Sivile S , Abrams EJ . J Acquir Immune Defic Syndr 2018 78 Suppl 2 S134-s141 BACKGROUND: Remarkable success in the prevention and treatment of pediatric HIV infection has been achieved in the past decade. Large differences remain between the estimated number of children living with HIV (CLHIV) and those identified through national HIV programs. We evaluated the number of CLHIV and those on treatment in Lesotho, Malawi, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. METHODS: We assessed the total number of CLHIV, CLHIV on antiretroviral treatment (ART), and national and regional ART coverage gaps using 3 data sources: (1) Joint United Nations Programme on HIV/AIDS model-based estimates and national program data used as input values in the models, (2) population-based HIV impact surveys (PHIA), and (3) program data from the President's Emergency Plan for AIDS Relief (PEPFAR)-supported clinics. RESULTS: Across the 7 countries, HIV prevalence among children aged 0-14 years ranged from 0.4% (Uncertainty Bounds (UB) 0.2%-0.6%) to 2.8% (UB: 2.2%-3.4%) according to the PHIA surveys, resulting in estimates of 520,000 (UB: 460,000-580,000) CLHIV in 2016-2017 in the 7 countries. This compared with Spectrum estimates of pediatric HIV prevalence ranging from 0.5% (UB: 0.5%-0.6%) to 3.5% (UB: 3.0%-4.0%) representing 480,000 (UB: 390,000-550,000) CLHIV. CLHIV not on treatment according to the PEPFAR, PHIA, and Spectrum for the countries stood at 48% (UB: 25%-60%), 49% (UB: 37%-50%), and 38% (UB: 24%-47%), respectively. Of 78 regions examined across 7 countries, 33% of regions (PHIA data) or 41% of regions (PEPFAR data) had met the ART coverage target of 81%. CONCLUSIONS: There are substantial gaps in the coverage of HIV treatment in CLHIV in the 7 countries studied according to all sources. There is continued need to identify, engage, and treat infants and children. Important inconsistencies in estimates across the 3 sources warrant in-depth investigation. |
Pregnant and breastfeeding women: A priority population for HIV viral load monitoring
Myer L , Essajee S , Broyles LN , Watts DH , Lesosky M , El-Sadr WM , Abrams EJ . PLoS Med 2017 14 (8) e1002375 Landon Myer and colleagues discuss viral load monitoring for pregnant HIV-positive women and those breastfeeding; ART treatments can suppress viral load and are key to preventing transmission to the child. |
Task-sharing with nurses to enhance access to HIV treatment in Cote d'Ivoire
McNairy ML , Bashi JB , Chung H , Wemin L , Lorng MA , Brou H , Nioble C , Lokossue A , Abo K , Achi D , Ouattara K , Sess D , Sanogo PA , Ekra A , Ettiegne-Traore V , Diabate CJ , Abrams EJ , El-Sadr WM . Trop Med Int Health 2017 22 (4) 431-441 OBJECTIVE: We report the first national programme in Cote d'Ivoire to evaluate the feasibility of nurse-led HIV care as a model of task-sharing with nurses to increase coverage and decentralisation of HIV services. METHODS: Twenty-six public HIV facilities implemented either a nurse-with-onsite-physician or a nurse-with-visiting-physician model of HIV task-sharing. Routinely collected patient data were reviewed to analyse patient characteristics of those enrolling in care and initiating antiretroviral therapy (ART). Retention, loss to programme and death were compared across facility-level characteristics. RESULTS: A total of 1224 patients enrolled in HIV care, with 666 initiating ART, from January 2012 to May 2013 (median follow-up 13 months). The majority (94%) were adults ≥15 years. Fourteen facilities provided ART initiation for the first time during the pilot period; 20 facilities were primary level. Nurse-led care with a visiting physician was provided in 14 of the primary-level facilities. Nurse-led ART care with an onsite physician was provided in all secondary-level facilities and six of the primary-level facilities. During the pilot, 567 (85%) of patients were retained, 28 (4.2%) died, 47 (7.1%) were lost to follow-up, and 24 (3.6%) transferred. Five deaths (10.9%) were recorded among children as compared to 23 deaths (3.7%) among adults (P = 0.037). There were no differences in retention by model of nurse-led ART care. CONCLUSION: Task-sharing of HIV care and ART initiation with nurses in Cote d'Ivoire is feasible. This pilot illustrates two models of nurse-led HIV care and has informed national policy on nurse-led HIV care in Cote d'Ivoire. |
Outcomes among HIV-infected children initiating HIV care and antiretroviral treatment in Ethiopia
Melaku Z , Lulseged S , Wang C , Lamb M , Gutema Y , Teasdale C , Ahmed S , Gadisa T , Habtamu Z , Bedri A , Fayorsey R , Abrams EJ . Trop Med Int Health 2017 22 (4) 474-484 Globally, the scale-up of antiretroviral treatment represents one of the greatest successes in the history of global health. By the end of 2014 an estimated 15 million individuals, including more than 800,000 children younger than 15 years, initiated antiretroviral therapy (ART). While pediatric treatment still lags behind adult successes, many countries, particularly in Southern Africa, have reported high rates of ART initiation, diminishing mortality and markedly improved health outcomes among children with HIV. |
Outcomes among children enrolled in HIV care in Mozambique 2009-2013
Teasdale CA , Yang J , Thome B , Yersin I , Sebastian T , Brusamento S , Lahuerta M , Jobarteh KM , Abrams EJ . Pediatr Infect Dis J 2016 35 (10) 1117-25 BACKGROUND: Scale-up of HIV care and antiretroviral therapy (ART) services for children has expanded access, but significant gaps and challenges remain. We examined lost to follow-up (LTF) and mortality in a large cohort of children enrolled in HIV care in Mozambique. METHODS: Routinely collected medical data on children 0-14 years enrolled in care 2009-2013 at ICAP-supported health facilities in 5 provinces of Mozambique were used. Children not receiving ART (pre-ART) were considered LTF if they did not a have a visit within 12 months of the end of data collection; for those receiving ART, LTF was no visit within 6 months. Competing risk and Kaplan-Meier estimators were used, respectively, to estimate pre-ART and on ART LTF and mortality. RESULTS: A total of 13,695 children enrolled in HIV care at 64 health facilities (48.6%, <2 years), and 7733 (56.5%) initiated ART during follow-up. Cumulative incidence of pre-ART LTF was 32.9% [95% confidence interval (CI): 32.1-33.7] and 34.4% (95% CI: 33.6-35.2) by 12 and 24 months, respectively, and was highest in children <5 years (12-month LTF in children 2-4 years, 34.2%, 95% CI: 32.6-35.9). Pre-ART mortality at 12 months was 3.3% (95% CI: 3.0-3.6) and was highest in children <2 years (4.1%, 95% CI: 3.6-4.6). On ART, LTF was 28.6% (95% CI: 27.6-29.7) and 37.6 (95% CI: 36.4-38.8) at 12 and 24 months, and 12 months mortality after ART was 8.0% (95% CI: 7.3-8.7). CONCLUSIONS: High rates of LTF were observed in this large cohort of HIV-infected children accessing care in Mozambique both before and after ART initiation highlighting the urgent need for interventions to improve retention in routine care settings. |
Characteristics and outcomes of adult Ethiopian patients enrolled in HIV care and treatment: a multi-clinic observational study
Melaku Z , Lamb MR , Wang C , Lulseged S , Gadisa T , Ahmed S , Habtamu Z , Alemu H , Assefa T , Abrams EJ . BMC Public Health 2015 15 (1) 462 BACKGROUND: We describe trends in characteristics and outcomes among adults initiating HIV care and treatment in Ethiopia from 2006-2011. METHODS: We conducted a retrospective longitudinal analysis of HIV-positive adults (≥15 years) enrolling at 56 Ethiopian health facilities from 2006-2011. We investigated trends over time in the proportion enrolling through provider-initiated counseling and testing (PITC), baseline CD4+ cell counts and WHO stage. Additionally, we assessed outcomes (recorded death, loss to follow-up (LTF), transfer, and total attrition (recorded death plus LTF)) before and after ART initiation. Kaplan-Meier techniques estimated cumulative incidence of these outcomes through 36 months after ART initiation. Factors associated with LTF and death after ART initiation were estimated using Hazard Ratios accounting for within-clinic correlation. RESULTS: 93,418 adults enrolled into HIV care; 53,300 (57%) initiated ART. The proportion enrolled through PITC increased from 27.6% (2006-2007) to 44.8% (2010-2011) (p < .0001). Concurrently, median enrollment CD4+ cell count increased from 158 to 208 cells/mm3 (p < .0001), and patients initiating ART with advanced WHO stage decreased from 56.6% (stage III) and 15.0% (IV) in 2006-2007 to 47.6% (stage III) and 8.5% (IV) in 2010-2011. Median CD4+ cell count at ART initiation remained stable over time. 24% of patients were LTF before ART initiation. Among those initiating ART, attrition was 30% after 36 months, with most occurring within the first 6 months. Recorded death after ART initiation was 6.4% and 9.2% at 6 and 36 months, respectively, and decreased over time. Younger age, male gender, never being married, no formal education, low CD4+ cell count, and advanced WHO stage were associated with increased LTF. Recorded death was lower among younger adults, females, married individuals, those with higher CD4+ cell counts and lower WHO stage at ART initiation. CONCLUSIONS: Over time, enrollment in HIV care through outpatient PITC increased and patients enrolled into HIV care at earlier disease stages across all HIV testing points. However, median CD4+ cell count at ART initiation remained steady. Pre- and post-ART attrition (particularly in the first 6 months) have remained major challenges in ensuring prompt ART initiation and retention on ART. |
Decentralization of pediatric HIV care and treatment in five sub-Saharan African countries
Fayorsey RN , Saito S , Carter RJ , Gusmao E , Frederix K , Koech-Keter E , Tene G , Panya M , Abrams EJ . J Acquir Immune Defic Syndr 2013 62 (5) e124-30 BACKGROUND: In resource-limited settings, decentralization of HIV care and treatment is a cornerstone of universal care and rapid scale-up. We compared trends in pediatric enrollment and outcomes at primary (PHF) versus secondary/tertiary health facilities (SHFs). METHODS: Using aggregate program data reported quarterly from 274 public facilities in Kenya, Lesotho, Mozambique, Rwanda and Tanzania from January 2008- March 2010 we examined trends in number of children < 15 years of age initiating antiretroviral treatment (ART) by facility type. We compared clinic-level lost to follow-up (LTFU) and mortality per 100 person years (PYs) on ART during the period by facility type. RESULTS: During the two year period, 17,155 children enrolled in HIV care and 8,475 initiated ART in 182 (66%) PHFs and 92(34%) SHFs. PHFs increased from 56 to 182, while SHFs increased from72 to 92 sites. SHFs accounted for 71% of children initiating ART; however, the proportion of children initiating ART each quarter at PHFs increased from 17% (129) to 44% (463) in conjunction with an increase in PHFs during observation period. The average LTFU and mortality rates for children on ART were 9.8/100PYsand 5.2/100PYs, respectively at PHFs and 20.2/100PYs and 6.0/100PYs at SHFs. Adjusted models show PHFs associated with lower LTFU (Adjusted Rate Ratio, ARR=0.55; p=0.022) and lower mortality (ARR=0.66; p=0.028). CONCLUSION: The expansion of pediatric services to PHFs has resulted in increased numbers of children on ART. Early findings suggest lower rates of LTFU and mortality at PHFs. Successful scale-up will require further expansion of pediatric services within PHFs. |
PEPFAR scale-up of pediatric HIV services: innovations, achievements, and challenges
Abrams EJ , Simonds RJ , Modi S , Rivadeneira E , Vaz P , Kankasa C , Tindyebwa D , Phelps BR , Bowsky S , Teasdale CA , Koumans E , Ruff AJ . J Acquir Immune Defic Syndr 2012 60 Suppl 3 S105-12 HIV/AIDS has had a profound impact on children around the world since the start of the epidemic. There are currently 3.4 million children under the age of 15 years living with HIV globally, and more than 450,000 children currently receiving lifesaving antiretroviral treatment. This article describes efforts supported by the President's Emergency Plan for AIDS Relief (PEPFAR) to expand access to treatment for children living with HIV in high-burden countries. The article also highlights a series of case studies that illustrate the impact that the PEPFAR initiative has had on the pediatric HIV epidemic. Through its support of host governments and partner organizations, the PEPFAR initiative has expanded HIV testing and treatment for pregnant women to reduce vertical transmission of HIV, increased access to early infant diagnosis for HIV-exposed infants, improved training and resources for clinicians who provide pediatric care and antiretroviral treatment, and, through public-private partnerships with pharmaceutical manufacturers, helped increase the number of medications available for the treatment of HIV-infected children in resource-limited settings. |
Mortality trends in the US Perinatal AIDS Collaborative Transmission Study (1986-2004)
Kapogiannis BG , Soe MM , Nesheim SR , Abrams EJ , Carter RJ , Farley J , Palumbo P , Koenig LJ , Bulterys M . Clin Infect Dis 2011 53 (10) 1024-34 BACKGROUND: Highly active antiretroviral therapy (HAART) has improved human immunodeficiency virus (HIV)-associated morbidity and mortality. The bimodal mortality distribution in HIV-infected children makes it important to evaluate temporal effects of HAART among a birth cohort with long-term, prospective follow-up. METHODS: Perinatal AIDS Collaborative Transmission Study (PACTS)/PACTS-HIV Follow-up of Perinatally Exposed Children (HOPE) study was a Centers for Disease Control and Prevention-sponsored multicenter, prospective birth cohort study of HIV-exposed uninfected and infected infants from 1985 until 2004. Mortality was evaluated for the no/monotherapy, mono-/dual-therapy, and HAART eras, that is, 1 January 1986 through 31 December 1990, from 1 January 1991 through 31 December 1996, and 1 January 1997 through 31 December 2004. RESULTS: Among 364 HIV-infected children, 56% were female and 69% black non-Hispanic. Of 98 deaths, 79 (81%) and 61 (62%) occurred in children ≤3 and ≤2 years old, respectively. The median age at death increased significantly across the eras (P < .0001). The average annual mortality rates were 18 (95% confidence interval [CI], 11.6-26.8), 6.9 (95% CI, 5.4-8.8), and 0.8 (95% CI, 0.4-1.5) events per 100 person-years for the no/monotherapy, mono-/dual-therapy and HAART eras, respectively. The corresponding 6-year survival rates for children born in these eras were 57%, 76%, and 91%, respectively (P < .0001). Among children who received HAART in the first 6 months of age, the probability of 6-year survival was 94%. Ten-year survival rates for HAART and non-HAART recipients were 94% and 45% (P < .05). HAART-associated reductions in mortality remained significant after adjustment for confounders (hazard ratio, 0.3; 95% CI, .08-.76). Opportunistic infections (OIs) caused 31.8%, 16.9%, and 9.1% of deaths across the respective eras (P = .051). CONCLUSIONS: A significant decrease in annual mortality and a prolongation in survival were seen in this US perinatal cohort of HIV-infected children. Temporal decreases in OI-associated mortality resulted in relative proportional increases of non-OI-associated deaths. (See the Editorial Commentary by Nachman, on pages 1035-6.) |
- Page last reviewed:Feb 1, 2024
- Page last updated:Jun 24, 2024
- Content source:
- Powered by CDC PHGKB Infrastructure