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South African Medical Journal

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Antiretroviral treatment for children

Brian Eley, Mary-Ann Davies, Patti Apolles, Carol Cowburn, Heloise Buys, Marco Zampoli, Heather Finlayson, Spasina King, James Nuttall

Abstract


Objective. To describe the response of children during their first year on highly active antiretroviral therapy (HAART).
Design. Retrospective, descriptive.
Setting. Tertiary, referral hospital.
Subjects. All HIV-infected children commenced on HAART from 1 August 2002 until31 December 2004.
Outcome measures. Children were retrospectively restaged using the WHO 4-stage clinical classification and CDC immunological staging system. After commencing HAART, patients were assessed at monthly intervals for the first 6 months and thereafter mostly 3-monthly. Baseline and 6- monthly CD4 counts and viral loads were performed.
Results. Of 409 children commenced on HAART, 50.6% were < 2 years old, 62.7% had severe clinical disease and 76.6% had severe immune suppression. After 1 year, 65.8% were alive and continued HAART at the hospital, 11.2% had been transferred to another antiretroviral site, 15.4% had died, 4.6% were lost to follow-up and treatment had been discontinued in 2.9%. Kaplan-Meier survival estimate for 407 children at 1 year was 84% (95% confidence interval (CI) 80- 87%). On multivariate analysis, survival was adversely affected in children with WHO stage 4 v. stage 2 and 3 disease (adjusted hazard ratio (HR): 5.26 (95% CI 2.25- 12.32), p = 0.000), age < 12 months (adjusted HR: 2.46 (95% CI 1.48- 4.09), p = 0.001) and CD4 absolute count (per 100 cell increase)  (adjusted HR: 0.93 (95% CI 0.88- 0.98), p = 0.013). In a separate multivariate model including only children with an initial viral load (N = 367), viral load :2: 1 million copies/ml (adjusted HR: 1.84 (95% CI 1.03- 3.29)) and taking a protease inhibitor (PI)-based regimen (adjusted HR: 2.25 (95% CI 1.10- 4.61)) were additionally independently associated with poorer survival; however, young age was not a significant predictor of mortality, after adjusting for viral load (p = 0.119). After 1 year of HAART 184/264 (69.7%) of children had a viral load < 400 copies/mi.  Comparative analysis showed significant improvements in growth, immunological status and virological control.
Conclusion
. HAART can improve the health of many HIV infected children with advanced disease, including those aged less than 2 years in resource-limited settings.



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