Acceptabilite´ du test VIH propose´ aux nourrissons dans les services pe´ diatriques, en Coˆ te d’Ivoire, Significations pour la couverture du diagnostic pe´diatrique

Proble`me: Le de´pistage VIH chez les enfants a rarement e´te´ au centre des pre´occupations des chercheurs. Quand le de´pistage pe´diatrique a retenu l’attention, cela a e´te´ pour e´clairer seulement sur les performances diagnostiques en ignorant meˆme que le test pe´diatrique comme bien d’autres peut s’accepter ou se refuser. Cet article met au coeur de son analyse les raisons qui peuvent expliquer qu’on accepte ou qu’on refuse de faire de´pister son enfant.Objectif: Etudier chez les parents, les me`res, les facteurs explicatifs de l’acceptabilite´ du test VIH des  nourrissons de moins de six mois.Me´thodes: Entretien semi-directif a` passages re´pe´te´s avec les parents de nourrissons de moins de six mois dans les formations sanitaires pour la pese´e/vaccination et les consultations pe´diatriques avec proposition syste´matique d’un test VIH pour leur nourrisson.Re´sultats: Nous retenons que la re´alisation effective du test pe´diatrique du VIH chez le nourrisson repose sur trois e´le´ments. Primo, le personnel de sante´ par son discours (qui de´note de ses connaissances et  perceptions meˆme sur l’infection) oriente´ vers les me`res influence leur acceptation ou non du test. Secundo, la me`re qui par ses connaissances et perceptions meˆme sur le VIH, dont le statut particulier, l’impression de bien-eˆtre chez elle et son enfant influence toute re´alisation du test pe´diatrique VIH. Tertio, l’environnement conjugal de la me`re, particulie`rement caracte´rise´ par les rapports au sein du couple, sur la facilite´ de parler du test VIH et sa re´alisation chez les deux parents ou chez la me`re seulement sont autant de facteurs qui influencent la re´alisation effective du de´pistage du VIH chez l’enfant. Le principe pre´ventif du VIH, et le de´sir de faire tester l’enfant ne suffisent pas a` eux seuls pour aboutir a` sa re´alisation effective, selon certaines me`res confronte´es au refus du conjoint. A l’oppose´, les autres me`res refusant la re´alisation du test  pe´diatrique disent s’y opposer ; bien entendu, meˆme dans le cas ou` le conjoint l’accepterait.Discussion: Les me`res sont les principales mises en cause et craignent les re´primandes et la stigmatisation. Le pe`re, le conjoint peut eˆtre un obstacle, quand il s’oppose au test VIH du nourrisson, ou devenir le facilitateur de sa re´alisation s’il est convaincu. Le positionnement du pe`re demeure donc essentiel dans la question de l’acceptabilite´ du VIH pe´diatrique. Les me`res en ont conscience et pre´sagent des difficulte´s a` faire  de´pister ou non les enfants sans avis pre´alable du conjoint a` la fois pe`re, et chef de famille.Conclusion: La question du de´pistage pe´diatrique du VIH, au terme de notre analyse, met en face trois e´le´ments qui exigent une gestion globale pour assurer une couverture effective. Ces trois e´le´ments n’existeraient pas sans s’influencer, donc ils sont constamment en interaction et empeˆchent ou favorisent la re´alisation ou non du test pe´diatrique. Aussi, dans une intention d’aboutir a` une couverture effective du de´pistage VIH des nourrissons, faut-il tenir compte d’une gestion harmonieuse de ces trois e´le´ments: La premie`re, la me`re seule (avec ses connaissances, ses perceptions), son environnement conjugal (de  proposition du test inte´grant 1- l’e´poux et / ou pe`re de l’enfant avec ses perceptions et connaissances sur l’infection 2- la facilite´ de parler du test et sa re´alisation chez les deux ou un des parents, la me`re) et les connaissances, attitudes et pratiques du personnel de l’e´tablissement sanitaire sur l’infection du VIH.Recommandations: Nos recommandations proposent une rede´finition de l’approche du VIH/sida vers des familles expose´es au VIH et une inte´gration plus accentue´e du pe`re facilitant leur propre acceptation du test VIH et celle de leur enfant.Mots cle´s: Acceptabilite´, Test VIH, Enfants, Nourrissons Problem: HIV testing in children had rarely been a central concern for researchers. When pediatric tracking retained the attention, it was more to inform on the diagnosis tools performances rather than the fact the pediatric test can be accepted or refused. This article highlights the parent’s reasons which explain why pediatric HIV test is accepted or refused.Objective: To study among parents, the explanatory factors of the acceptability of pediatric HIV testing among infant less than six months.Methods: Semi-structured interview with repeated passages in the parents of infants less than six months attending in health care facilities for the pediatric weighing/vaccination and consultations.Results: We highlight that the parent’s acceptance of the pediatric HIV screening is based on three elements.Firstly, the health care workers by his speech (which indicates its own knowledge and perceptions on the infection) directed towards mothers’ influences their acceptance or not of the HIV test. Secondly, the mother who by her knowledge and perceptions on HIV, whose particular status, give an impression of her own wellbeing for her and her child influences any acceptance of the pediatric HIV test. Thirdly, the marital environment of the mother, particularly characterized by the ease of communication within the couple, to speak about the HIV test and its realization for the parents or the mother only are many factors which influence the effective realization of the pediatric HIV testing. The preventive principle of HIV transmission and the desire to realize the test in the  newborn are not enough alone to lead to its effective realization, according to certain mothers confronted with the father’s refusal. On the other hand, the other mothers refusing the realization of the pediatric test told to be opposed to it; of course, even if their partner would accept it.Discussion: The mothers are the principal facing the pediatric HIV question and fear the reprimands and stigma. The father, the partner could be an obstacle, when he is opposed to the infant HIV testing, or also the facilitator with his realization if he is convinced. The father position thus remains essential face to the question of pediatric HIV testing acceptability. The mothers are aware of this and predict the difficulties of achieving their infant to be tested without the preliminary opinion of their partner at the same time father, and head of the family.Conclusion: The issue of pediatric HIV testing, at the end of our analysis, highlights three elements which require a comprehensive management to improve the coverage of pediatric HIV test. These three elements would not exist without being influenced; therefore they are constantly in interaction and prevent or support the realization or not pediatric test. Also, with the aim to improve the pediatric HIV test coverage, it is necessary to take into account the harmonious management of these elements. Firstly, the mother alone (with her knowledge, and perceptions), its marital environment (with the proposal of the HIV test integrating (1) the partner and/or father with his perceptions and knowledge on HIV infection and (2) facility of speaking about the test and its realization at both or one about the parents, the mother) and of the knowledge, attitudes and practices about the infection of health care workers of the sanitary institution.Recommendations: Our recommendations proposed taking into account a redefinition of the HIV/AIDS approach towards the families exposed to HIV and a more accentuated integration of the father facilitating their own HIV test acceptation and that of his child.Keywords: acceptability, HIV testing, children, infantsArticle in French

Severe morbidity and mortality in untreated HIV-infected children in a paediatric care programme in Abidjan, Côte d'Ivoire, 2004-2009

<p>Abstract</p> <p>Background</p> <p>Clinical evolution of HIV-infected children who have not yet initiated antiretroviral treatment (ART) is poorly understood in Africa. We describe severe morbidity and mortality of untreated HIV-infected children.</p> <p>Methods</p> <p>All HIV-infected children enrolled from 2004-2009 in a prospective HIV programme in two health facilities in Abidjan, Côte d'Ivoire, were eligible from their time of inclusion. Risks of severe morbidity (the first clinical event leading to death or hospitalisation) and mortality were documented retrospectively and estimated using cumulative incidence functions. Associations with baseline characteristics were assessed by competing risk regression models between outcomes and antiretroviral initiation.</p> <p>Results</p> <p>405 children were included at a median age of 4.5 years; at baseline, 66.9% were receiving cotrimoxazole prophylaxis, and 27.7% met the 2006 WHO criteria for immunodeficiency by age. The risk of developing a severe morbid event was 14% (95%CI: 10.7 - 17.8) at 18 months; this risk was lower in children previously exposed to any prevention of mother-to-child-transmission (PMTCT) intervention (adjusted subdistribution hazard ratio [sHR]: 0.16, 95% CI: 0.04 - 0.71) versus those without known exposure. Cumulative mortality reached 5.5% (95%CI: 3.5 - 8.1) at 18 months. Mortality was associated with immunodeficiency (sHR: 6.02, 95% CI: 1.28-28.42).</p> <p>Conclusions</p> <p>Having benefited from early access to care minimizes the severe morbidity risk for children who acquire HIV. Despite the receipt of cotrimoxazole prophylaxis, the risk of severe morbidity and mortality remains high in untreated HIV-infected children. Such evidence adds arguments to promote earlier access to ART in HIV-infected children in Africa and improve care interventions in a context where treatment is still not available to all.</p

Optimal timing of antiretroviral treatment initiation in HIV-positive children and adolescents: a multiregional analysis from Southern Africa, West Africa and Europe

BACKGROUND: There is limited knowledge about the optimal timing of antiretroviral treatment initiation in older children and adolescents. METHODS: A total of 20 576 antiretroviral treatment (ART)-naïve patients, aged 1-16 years at enrolment, from 19 cohorts in Europe, Southern Africa and West Africa, were included. We compared mortality and growth outcomes for different ART initiation criteria, aligned with previous and recent World Health Organization criteria, for 5 years of follow-up, adjusting for all measured baseline and time-dependent confounders using the g-formula. RESULTS: Median (1st;3rd percentile) CD4 count at baseline was 676 cells/mm(3) (394; 1037) (children aged ≥ 1 and 10 years at enrolment we did not find any difference in mortality or growth with immediate ART initiation, with estimated differences of -0.1% (-0.2%; 0.6%) and -0.03 (-0.05; 0.00), respectively. Growth differences in children aged < 10 years persisted for treatment thresholds using higher CD4 values. Regular follow-up led to better height and mortality outcomes. CONCLUSIONS: Immediate ART is associated with lower mortality and better growth for up to 5 years in children < 10 years old. Our results on adolescents were inconclusive

CD4-specific mortality rates among HIV-infected adults with high CD4 counts and no antiretroviral treatment in West Africa

Background: CD4-specific rates of mortality in sub-Saharan African adults with high CD4 counts have rarely been estimated. This estimation is useful to the when to start antiretroviral treatment (ART) debate. Methods: We pooled data from National Agency for Research on AIDS and Viral Hepatitis (ANRS)-funded research cohorts or associated partners in West Africa. All HIV-infected adults (>= 18 years) with available follow-up time off ART were eligible. We used a joint model to estimate CD4 count evolution. We estimated CD4-specific rates of mortality, loss-to-follow-up (LTFU) and ART initiation by dividing the number of first event by the follow-up time off ART within each CD4 category. Results: Between 1996 and 2009, 2588 adults (80% women) from 5 cohorts in Cote d'Ivoire and Burkina Faso were followed off ART during 6862 person-years. In the 201-350, 351-500, 501-650, and >650 cells per cubic millimeter CD4 categories, mortality rates were: 3.0, 1.5, 0.4, 0.2 per 100 person-years; LTFU rates: 6.0, 4.6, 6.1, 6.0 per 100 person-years; and ART initiation rates: 18.1, 2.7, 0.5, 0.5 per 100 person-years, respectively. All estimates varied across cohorts; mortality rates were higher when rates of LFTU and ART initiation were lower; LTFU rates were 2-40 times higher than mortality rates. Conclusions: Among untreated West African adults with high CD4 counts, mortality and LTFU rates were substantial. Even when data are collected under research conditions, informative censoring due to ART initiation and LTFU could lead to significantly underestimate mortality figures

Pediatr Infect Dis J

BACKGROUND: There is limited information about malnutrition, growth evolution and metabolic changes among children initiated early on lopinavir-based antiretroviral therapy (ART) in Africa. METHODS: HIV-1-infected children, age <2 years were initiated on ART, as part of the MONOD ANRS 12206 project, conducted in Burkina Faso and Cote d'Ivoire. Weight-for-age, height-for-age and weight-for-height Z-scores (WAZ, HAZ, WHZ) defined malnutrition (Z-score <-2 standard deviations [SD]) using WHO growth references. Biological data were collected every 6 months. Factors associated with baseline malnutrition were evaluated using multivariate logistic regression, and with growth evolution in the first 24 months on ART using linear mixed models. RESULTS: Between 2011 and 2013, 161 children were enrolled: 64% were from Abidjan, 54% were girls. At ART initiation, median age was 13.7 months [IQR 7.7; 18.4], 52% were underweight (WAZ), 52% were stunted (HAZ), and 36% were wasted (WHZ). Overall, baseline malnutrition was more likely for children living in Burkina Faso, with low birth-weight, never breastfed, and older age (12-24 months). Growth improved on ART, mainly within the first 6 months for weight, and was greater for the most severely malnourished children at baseline, but 8% to 32% remained malnourished after 24 months. Over the 24-month period of ART, there was a significant increase of hypercholesterolemia and decrease of anemia and hypoalbuminemia. CONCLUSIONS: Prevalence of malnutrition was high before ART initiation. Even though growth improved on ART, some children remained malnourished even after 2 years of ART, highlighting the need for more active nutritional support

Optimal Timing of Antiretroviral Treatment Initiation in HIV-Positive Children and Adolescents: a Multiregional Analysis from Southern Africa, West Africa and Europe

Background: There is limited knowledge about the optimal timing of antiretroviral treatment initiation in older children and adolescents.\ud \ud Methods: A total of 20 576 antiretroviral treatment (ART)-naïve patients, aged 1-16 years at enrolment, from 19 cohorts in Europe, Southern Africa and West Africa, were included. We compared mortality and growth outcomes for different ART initiation criteria, aligned with previous and recent World Health Organization criteria, for 5 years of follow-up, adjusting for all measured baseline and time-dependent confounders using the g-formula.\ud \ud Results: Median (1st;3rd percentile) CD4 count at baseline was 676 cells/mm3 (394; 1037) (children aged ≥ 1 and < 5 years), 373 (172; 630) (≥ 5 and < 10 years) and 238 (88; 425) (≥ 10 and < 16 years). There was a general trend towards lower mortality and better growth with earlier treatment initiation. In children < 10 years old at enrolment, by 5 years of follow-up there was lower mortality and a higher mean height-for-age z-score with immediate ART initiation versus delaying until CD4 count < 350 cells/mm3 (or CD4% < 15% or weight-for-age z-score < -2) with absolute differences in mortality and height-for-age z-score of 0.3% (95% confidence interval: 0.1%; 0.6%) and -0.08 (-0.09; -0.06) (≥ 1 and < 5 years), and 0.3% (0.04%; 0.5%) and -0.07 (-0.08; -0.05) (≥ 5 and < 10 years). In those aged > 10 years at enrolment we did not find any difference in mortality or growth with immediate ART initiation, with estimated differences of -0.1% (-0.2%; 0.6%) and -0.03 (-0.05; 0.00), respectively. Growth differences in children aged < 10 years persisted for treatment thresholds using higher CD4 values. Regular follow-up led to better height and mortality outcomes.\ud \ud Conclusions: Immediate ART is associated with lower mortality and better growth for up to 5 years in children < 10 years old. Our results on adolescents were inconclusive