Short-term outcomes of downreferral in provision of paediatric antiretroviral therapy at Red Cross War Memorial Childrens Hospital, Cape Town

Background: The large scale-up of paediatric HIV care necessitated down-referral of many children receiving antiretroviral therapy (ART) from Red Cross War Memorial Children's Hospital (RCWMCH). No published data exists on the outcomes of these children. Objectives: To assess clinical, immunological and virological outcomes of children receiving ART in the first 12 months after down-referral to primary health care (PHC) clinics, and identify determinants of successful down-referral. Methods: We conducted a retrospective cohort study of children <15 years of age who commenced ART at RCWMCH and were subsequently down-referred to one of two PHC clinics between January 2006 and December 2012. Baseline characteristics of patients and caregivers as well as CD4 counts, viral loads and weights were collected at 6 and 12 months post-down-referral. Outcomes included retention in care and viral suppression. Results: One hundred and sixteen children down-referred to Heideveld and Gugulethu were included. After down-referral 13.8% of the cohort never arrived at the designated clinic and 10% took longer than 8 weeks, therefore probably experiencing treatment interruption. At 12 months post down-referral only 68.2% remained in care at the designated clinics. No factors were associated with retention in care. For those children who remained in care at the PHC clinics, the clinical and immunological gains achieved prior to down-referral were sustained through 12 months of follow up, and 54.7% of the retained cohort had documented viral suppression at 12 months. Conclusion: Down-referral of children on ART is a vulnerable process with risk of loss to follow-up and treatment interruption

Self-harm in young people with perinatal HIV and HIV negative young people in England: cross sectional analysis.

BACKGROUND: Self-harm in adolescents is of growing concern internationally but limited evidence exists on the prevalence of self-harm in those living with HIV, who may be at higher risk of poor mental health outcomes. Therefore our aim was to determine the prevalence and predictors of self-harm among young people with perinatally-acquired HIV (PHIV) and HIV negative (with sibling or mother living with HIV) young people living in England. METHODS: 303 PHIV and 100 HIV negative young people (aged 12-23 years) participating in the Adolescents and Adults Living with Perinatal HIV cohort study completed an anonymous self-harm questionnaire, as well as a number of standardised mental-health assessments. Logistic regression investigated predictors of self-harm. RESULTS: The median age was 16.7 years in both groups, and 40.9% of the PHIV and 31.0% of the HIV negative groups were male. In total 13.9% (56/403) reported having ever self-harmed, with no difference by HIV status (p = 0.089). Multivariable predictors of self-harm were female sex (adjusted odds ratio (AOR) 5.3, (95% confidence interval 1.9, 14.1), p = 0.001), lower self-esteem (AOR 0.9 (0.8, 0.9) per 1 point increase, p < 0.001) and having ever used alcohol (AOR 3.8 (1.8, 7.8), p < 0.001). Self-esteem z-scores for both PHIV and HIV negative participants were 1.9 standard deviations below the mean for population norms. CONCLUSIONS: Self-harm is common among PHIV and HIV negative adolescents in England. Reassuringly however, they do not appear to be at an increased risk compared to the general adolescent population (15-19% lifetime prevalence). The low level of self-esteem (compared to available normative data) in both groups is worrying and warrants further attention

Longitudinal changes in clinical symptoms and signs in children with confirmed, unconfirmed, and unlikely pulmonary tuberculosis

Background: The paucibacillary nature of paediatric pulmonary tuberculosis (PTB) makes microbiological diagnosis difficult and limits the usefulness of microbiology for assessing treatment efficacy. Clinical response to treatment has thus been used by clinicians to monitor disease activity, as well as by researchers in clinical case definitions of intrathoracic TB to differentiate those with unconfirmed PTB from those with other lower respiratory tract infections (LRTIs). There is, however, limited data on the expected pattern and timing of resolution of symptoms and signs, and whether this does indeed differ between those with PTB and those without. Objectives: To longitudinally investigate clinical response to TB treatment in children treated for PTB, to compare this to the clinical course of children with other LRTIs, and to identify factors associated with persistence of symptoms and signs. Methods: This study is a secondary analysis of data collected prospectively in a TB diagnostic study from 1 February 2009 to 31 December 2018. We enrolled children ≤15 years with features suggestive of PTB. Study participants were categorized into 3 groups according to NIH consensus definitions; confirmed PTB, unconfirmed PTB and unlikely PTB. Children were followed at 1 and 3 months after enrolment. Those with confirmed or unconfirmed TB were also followed at 6 months. At enrolment and follow-up symptoms of PTB were recorded using a standardized questionnaire and physical examination was done including anthropometry and respiratory parameters. Data were analysed using STATA version 16.1. The effect of potential predictors of persistence of symptoms and signs was explored with univariable and multivariable logistic regression modelling. Results: Two thousand and nineteen children were included in this analysis, 427 (21%) with confirmed PTB, 810 (40%) with unconfirmed PTB, and 782 (39%) with unlikely PTB. Symptoms resolved rapidly in the vast majority of participants. At 1 month, 9.2% (129/1402) of all participants who had a cough and 11.1% (111/999) of those with loss of appetite at baseline reported no improvement in these symptoms. At 3 months this declined to 2.0% (24/1222) and 2.6% (23/886) respectively, with no differences between the groups. Clinical signs persisted in a greater proportion of participants. At 3 months, tachypnoea persisted in 56.7% (410/723) of participants. Abnormal auscultatory findings (including wheeze, crackles, reduced breath sounds or abnormal breath sounds) similarly persisted in almost a third of participants, with greater proportion in the confirmed group (37.1%) than unconfirmed (23.0%) and unlikely (26.2%) groups (p=0.002). Children living with HIV and those with abnormal baseline chest radiographs had greater odds of persistence of signs or symptoms (including cough, loss of appetite, abnormal auscultatory findings, or no weight improvement if underweight at baseline). No features of clinical response differentiated those with PTB from those without. Conclusion: Symptoms resolved rapidly in the majority of children investigated for PTB whilst clinical signs took longer to resolve. The timing and pattern of resolution of symptoms and signs cannot differentiate those with PTB from those without – and is thus not a suitable parameter for confirming disease classification in paediatric TB research