Temporal trends in co-trimoxazole use among children on antiretroviral therapy and the impact of co-trimoxazole on mortality rates in children without severe immunodeficiency

Background: Co-trimoxazole is recommended for all children with human immunodeficiency virus. In this analysis, we evaluate trends in pediatric co-trimoxazole use and survival on co-trimoxazole in children using antiretroviral therapy (ART). Methods: We used data collected between January 1, 2006, and March 31, 2016, from the International Epidemiology Databases to Evaluate AIDS. Logistic regression was used to evaluate factors associated with using co-trimoxazole at ART initiation. Competing risk regression was used to assess factors associated with death. Results: A total of 54113 children were included in this study. The prevalence of co-trimoxazole use at ART initiation increased from 66.5% in 2006 to a peak of 85.6% in 2010 and then declined to 48.5% in 2015-2016. A similar trend was observed among children who started ART with severe immunodeficiency. After adjusting for year of ART initiation, younger age (odds ratio [OR], 1.18 for <1 vs 1 to <5 years of age [95% confidence interval (CI), 1.09-1.28]), lower height-for-age z score (OR, 1.15 for less than -3 vs greater than -2 [95% CI, 1.08-1.22]), anemia (OR, 1.08 [95% CI, 1.02-1.15]), severe immunodeficiency (OR, 1.25 [95% CI, 1.18-1.32]), and receiving care in East Africa (OR, 8.97 vs Southern Africa [95% CI, 8.17-9.85]) were associated with a high prevalence of co-trimoxazole use. Survival did not differ according to co-trimoxazole use in children without severe immunodeficiency (hazard ratio, 1.01 for nonusers versus users [95% CI, 0.77-1.34]). Conclusions: Recent declines in co-trimoxazole use may not be linked to the current shift toward early ART initiation. Randomized trial data might be needed to establish the survival benefit of co-trimoxazole in children without severe immunodeficiency

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

Profil épidémiologique de l’otite externe à Abidjan

Introduction : L’otite moyenne externe est une affection fréquente chez le nourrisson mais qui pose toujours des problèmes thérapeutiques dans notre contexte de vie. Objectif : Déterminer les caractéristiques épidémiologiques de l’otite moyenne externe dans à Abidjan afin d’améliorer sa prise en charge. Méthodologie : Une étude transversale à recrutement exhaustif, multicentrique, a été réalisée de janvier à septembre 2003 portant sur des nourrissons présentant une otite externe. Résultats : Cette étude a concerné les enfants des deux sexes, âgés de 0 à 2 ans présentant une otite externe. Soixante dix enfants ont été recrutés. On note une nette prédominance masculine (sex ratio de 2,18) avec un âge variant de 1mois à 24 mois. L’âge moyen était de 11,6 mois. La tranche d’âge majoritairement touchée (58,6%) était celle des enfants de moins d’un an. Plusieurs facteurs favorisants ont été identifiés. L’humidité du conduit et les lésions de grattage ont été les facteurs favorisants les plus fréquents, retrouvés respectivement dans 31 cas (soit 44,9%), et 19 cas (soit 27,6%). Dix (10) nourrissons présentaient des antécédents d’otite externe (14.6%), l’existence d’un terrain allergique a été retrouvé 2 fois (2,8%), la présence d’un corps étranger dans les mêmes proportions. Chez 7,4 % des enfants, les mères utilisaient pour les soins auriculaires, un traitement traditionnel réalisé à base d’huile de palme ou de coco et de décoctions. Quatre formes cliniques de l’otite externe ont été individualisées : une otite externe diffuse 38 cas (55,7%), 17 otites eczématisées (22,8%), des otomycoses (13 cas soit 18,6%), 2 furoncles du pavillon soit 2,9%. Conclusion : Affection fréquente du nourrisson de moins d’un an, l’otite externe présente des caractéristiques propres dans notre contexte liées aux conditions climatiques de nos pays et aux pratiques culturelles et traditionnelles sur le conduit auditif. Mots clés : Otite moyenne externe, enfant, épidémiologie.Introduction: The external otitis media is a frequent affection in nourrisson but who always poses therapeutic problems in our context of life. Objective: To determine the epidemiologic characteristics of the external otitis media in in Abidjan in order to improving its assumption of responsibility. Methodology: A cross-sectional study with exhaustive recruitment, multicentric, was carried out from January to bearing September 2003 on nourrissons presenting an external otitis. Results: This study concerned the children of the two sexes, old from 0 to 2 years presenting an external otitis. Sixty ten children were recruited. One notes a clear male prevalence (sex ratio of 2, 18) with a varying age of 1mois in 24 months. The average age was 11.6 months. The age bracket mainly touched (58.6%) was that of the children of less than one year. Several supporting factors were identified. The moisture of the conduit and the lesions of scraping were the supporting factors most frequent, found respectively in 31 cases (either 44.9%) and 19 case (or 27.6%). Ten (10) nourrissons presented antecedents of external otitis (14.6%), the existence of an allergic ground was found 2 times (2.8%), the presence of a foreign body in the same proportions. At 7.4 % of the children, the mothers used for the auricular care, a traditional treatment carried out based on decoction and coconut or palm oil. Four clinical forms of the external otitis were individualized: an external otitis diffuses 38 cases (55.7%), 17 become eczematous otitises (22.8%), of otomycoses (13 case either 18.6%), 2 furoncles of the house or 2.9%. Conclusion: Frequent affection of nourrisson of less than one year, the external otitis shows particular characteristics in our context related on the climatic conditions of our countries and the cultural and traditional practices on the auditory canal.Key words: External otitis media, child, epidemiolog

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

Global temporal changes in the proportion of children with advanced disease at the start of combination antiretroviral therapy in an era of changing criteria for treatment initiation

Introduction: The CD4 cell count and percent at initiation of combination antiretroviral therapy (cART) are measures of advanced HIV disease and thus are important indicators of programme performance for children living with HIV. In particular, World Health Organization (WHO) 2017 guidelines on advanced HIV disease noted that &gt;80% of children aged &lt;5&nbsp;years started cART with WHO Stage 3 or 4 disease or severe immune suppression. We compared temporal trends in CD4 measures at cART start in children from low-, middle- and high-income countries, and examined the effect of WHO treatment initiation guidelines on reducing the proportion of children initiating cART with advanced disease. Methods: We included children aged &lt;16&nbsp;years from the International Epidemiology Databases to Evaluate acquired immunodeficiency syndrome (AIDS) (IeDEA) Collaboration (Caribbean, Central and South America, Asia-Pacific, and West, Central, East and Southern Africa), the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE), the North American Pediatric HIV/AIDS Cohort Study (PHACS) and International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) 219C study. Severe immunodeficiency was defined using WHO guidelines. We used generalized weighted additive mixed effect models to analyse temporal trends in CD4 measurements and piecewise regression to examine the impact of 2006 and 2010 WHO cART initiation guidelines. Results: We included 52,153 children from fourteen low-, eight lower middle-, five upper middle- and five high-income countries. From 2004 to 2013, the estimated percentage of children starting cART with severe immunodeficiency declined from 70% to 42% (low-income), 67% to 64% (lower middle-income) and 61% to 43% (upper middle-income countries). In high-income countries, severe immunodeficiency at cART initiation declined from 45% (1996) to 14% (2012). There were annual decreases in the percentage of children with severe immunodeficiency at cART initiation after the WHO guidelines revisions in 2006 (low-, lower middle- and upper middle-income countries) and 2010 (all countries). Conclusions: By 2013, less than half of children initiating cART had severe immunodeficiency worldwide. WHO treatment initiation guidelines have contributed to reducing the proportion of children and adolescents starting cART with advanced disease. However, considerable global inequity remains, in 2013, &gt;40% of children in low- and middle-income countries started cART with severe immunodeficiency compared to &lt;20% in high-income countries

Characteristics of HIV-2 and HIV-1/HIV-2 Dually Seropositive Adults in West Africa Presenting for Care and Antiretroviral Therapy: The IeDEA-West Africa HIV-2 Cohort Study.

HIV-2 is endemic in West Africa. There is a lack of evidence-based guidelines on the diagnosis, management and antiretroviral therapy (ART) for HIV-2 or HIV-1/HIV-2 dual infections. Because of these issues, we designed a West African collaborative cohort for HIV-2 infection within the framework of the International epidemiological Databases to Evaluate AIDS (IeDEA).We collected data on all HIV-2 and HIV-1/HIV-2 dually seropositive patients (both ARV-naive and starting ART) and followed-up in clinical centres in the IeDEA-WA network including a total of 13 clinics in five countries: Benin, Burkina-Faso Côte d'Ivoire, Mali, and Senegal, in the West Africa region.Data was merged for 1,754 patients (56% female), including 1,021 HIV-2 infected patients (551 on ART) and 733 dually seropositive for both HIV-1 and HIV 2 (463 on ART). At ART initiation, the median age of HIV-2 patients was 45.3 years, IQR: (38.3-51.7) and 42.4 years, IQR (37.0-47.3) for dually seropositive patients (p = 0.048). Overall, 16.7% of HIV-2 patients on ART had an advanced clinical stage (WHO IV or CDC-C). The median CD4 count at the ART initiation is 166 cells/mm(3), IQR (83-247) among HIV-2 infected patients and 146 cells/mm(3), IQR (55-249) among dually seropositive patients. Overall, in ART-treated patients, the CD4 count increased 126 cells/mm(3) after 24 months on ART for HIV-2 patients and 169 cells/mm(3) for dually seropositive patients. Of 551 HIV-2 patients on ART, 5.8% died and 10.2% were lost to follow-up during the median time on ART of 2.4 years, IQR (0.7-4.3).This large multi-country study of HIV-2 and HIV-1/HIV-2 dual infection in West Africa suggests that routine clinical care is less than optimal and that management and treatment of HIV-2 could be further informed by ongoing studies and randomized clinical trials in this population