Outcomes and effectiveness of antiretroviral therapy for HIV-infected children in South African treatment cohorts

Includes abstract.Includes bibliographical references.Since 2004, increasing numbers of children in sub-Saharan Africa have commenced antiretroviral therapy (ART). This thesis reviews the outcomes of published studies of paediatric ART cohorts in Africa, describes outcomes for children receiving ART in South Africa and examines determinants of mortality and generalizability across the Southern African region. Temporal trends in characteristics at ART initiation are also examined. The measurement of treatment success in resource-limited settings is reviewed, by examining virological failure, and assessing the diagnostic accuracy of immunological criteria for identifying virological failure.The results chapter is presented in the form of published or submitted papers based on data from the International epidemiologic Databases to Evaluate AIDS-Southern Africa (IeDEASA) collaboration. The first paper reviews paediatric ART studies from Africa published before 2008. Together with the literature review in chapter 1, it provides the background to this thesis. The second paper reports on mortality (8%) and retention in care (81%) by 3 years after ART start for > 6,000 children who initiated ART in South Africa. The generalizable prognostic models in the third paper suggest that mortality during the first year on ART ranges from 45%, with the majority of children being in the group with the best prognosis. The fourth paper reports that 1 in 5 children meet criteria for confirmed virological failure by 3 years on ART. The risk is greater with triple ART containing nevirapine or unboosted ritonavir (in comparison with lopinavir/ritonavir or efavirenz). The fifth and sixth papers demonstrate that immunological criteria have low sensitivity and positive predictive value for virological failure. Targeted viral load measurement reduces the number of false positive virological failure diagnoses. The final paper shows that increasing numbers of children have initiated ART with a decline in disease severity at therapy start from 2005-2010. However, even in 2010 a substantial number of children started ART with advanced disease. The thesis concludes that access to ART for children has increased, with good outcomes. HIV cohort research is important in evaluating the safety and effectiveness of different models of care, treatment and monitoring strategies

Provider-initiated HIV testing and counselling for children

Mary-Ann Davies and Emma Kalk reflect on recent research by Rashida Ferrand and colleagues into barriers to provider-initiated HIV testing for older children in Zimbabwe. Please see later in the article for the Editors' Summar

Clinical mentorship of nurse initiated antiretroviral therapy in Khayelitsha, South Africa: a quality of care assessment.

To combat the AIDS epidemic and increase HIV treatment access, the South African government implemented a nurse-based, doctor-supported model of care that decentralizes administration of antiretroviral treatment (ART) for HIV positive patients through nurse initiated and managed ART. Médecins Sans Frontières (MSF) implemented a mentorship programme to ensure successful task-shifting, subsequently assessing the quality of clinical care provided by nurses

Twelve-year mortality in adults initiating antiretroviral therapy in South Africa

Introduction: South Africa has the largest number of individuals living with HIV and the largest antiretroviral therapy (ART) programme worldwide. In September 2016, ART eligibility was extended to all 7.1 million HIV-positive South Africans. To ensure that further expansion of services does not compromise quality of care, long-term outcomes must be monitored. Few studies have reported long-term mortality in resource-constrained settings, where mortality ascertainment is challenging. Combining site records with data linked to the national vital registration system, sites in the International Epidemiology Databases to Evaluate AIDS Southern Africa collaboration can identify >95% of deaths in patients with civil identification numbers (IDs). This study used linked data to explore long-term mortality and viral suppression among adults starting ART in South Africa

Adherence to antiretroviral therapy in young children in Cape Town, South Africa, measured by medication return and caregiver self-report : a prospective cohort study

Includes bibliographical references.Excellent adherence to antiretroviral therapy (ART) is necessary if HIV-infected children are to experience the dramatically improved outcomes that this treatment affords. However, there is very limited data on adherence to antiretroviral therapy in Africa, with few studies that examine the predictive value of low technology measures of adherence in terms of viral and immune outcomes. In addition there are no long terms studies of adherence in young children in Africa

Identifying Religious and/or Spiritual Perspectives of Adolescents and Young Adults Receiving Blood and Marrow Transplants: A Prospective Qualitative Study

AbstractThe potential benefits (or detriments) of religious beliefs in adolescent and young adults (AYA) are poorly understood. Moreover, the literature gives little guidance to health care teams or to chaplains about assessing and addressing the spiritual needs of AYA receiving hematopoietic stem cell transplants (HSCT). We used an institutional review board–approved, prospective, longitudinal study to explore the use of religion and/or spirituality (R/S) in AYA HSCT recipients and to assess changes in belief during the transplantation experience. We used the qualitative methodology, grounded theory, to gather and analyze data. Twelve AYA recipients were interviewed within 100 days of receiving HSCT and 6 participants were interviewed 1 year after HSCT; the other 6 participants died. Results from the first set of interviews identified 5 major themes: using R/S to address questions of “why me?” and “what will happen to me;” believing God has a reason; using faith practices; and benefitting from spiritual support people. The second set of interviews resulted in 4 major themes: believing God chose me; affirming that my life has a purpose; receiving spiritual encouragement; and experiencing strengthened faith. We learned that AYA patients were utilizing R/S far more than we suspected and that rather than losing faith in the process of HSCT, they reported using R/S to cope with illness and HSCT and to understand their lives as having special purpose. Our data, supported by findings of adult R/S studies, suggest that professionally prepared chaplains should be proactive in asking AYA patients about their understanding and use of faith, and the data can actively help members of the treatment team understand how AYA are using R/S to make meaning, address fear, and inform medical decisions

Improving estimates of children living with HIV from the Spectrum AIDS Impact Model

Objective: Estimated numbers of children living with HIV determine programmatic and treatment needs. We explain the changes made to the UNAIDS estimates between 2015 and 2016, and describe the challenges around these estimates. Methods: Estimates of children newly infected, living with HIV, and dying of AIDS are developed by country teams using Spectrum software. Spectrum files are available for 160 countries, which represent 98% of the global population. In 2016, the methods were updated to reflect the latest evidence on mother-to-child HIV transmission and improved assumptions on the age children initiate antiretroviral therapy. We report updated results using the 2016 model and validate these estimates against mother-to-child transmission rates and HIV prevalence from population-based surveys for the survey year. Results: The revised 2016 model estimates 27% fewer children living with HIV in 2014 than the 2015 model, primarily due to changes in the probability of mother-to-child transmission among women with incident HIV during pregnancy. The revised estimates were consistent with population-based surveys of HIV transmission and HIV prevalence among children aged 5–9 years, but were lower than surveys among children aged 10–14 years. Conclusions: The revised 2016 model is an improvement on previous models. Paediatric HIV models will continue to evolve as further improvements are made to the assumptions. Commodities forecasting and programme planning rely on these estimates, and increasing accuracy will be critical to enable effective scale-up and optimal use of resources. Efforts are needed to improve empirical measures of HIV prevalence, incidence, and mortality among children

Covid-19 among adults living with HIV: Correlates of mortality among public sector healthcare users in Western Cape, South Africa

Introduction: While a large proportion of people with HIV (PWH) have experienced SARS-CoV-2 infections, there is uncertainty about the role of HIV disease severity on COVID-19 outcomes, especially in lower-income settings. We studied the association of mortality with characteristics of HIV severity and management, and vaccination, among adult PWH. Methods: We analysed observational cohort data on all PWH aged ≥15 years experiencing a diagnosed SARS-CoV-2 infection (until March 2022), who accessed public sector healthcare in the Western Cape province of South Africa. Logistic regression was used to study the association of mortality with evidence of antiretroviral therapy (ART) collection, time since first HIV evidence, CD4 cell count, viral load (among those with evidence of ART collection) and COVID-19 vaccination, adjusting for demographic characteristics, comorbidities, admission pressure, location and time period. Results: Mortality occurred in 5.7% (95% CI: 5.3,6.0) of 17,831 first-diagnosed infections. Higher mortality was associated with lower recent CD4, no evidence of ART collection, high or unknown recent viral load and recent first HIV evidence, differentially by age. Vaccination was protective. The burden of comorbidities was high, and tuberculosis (especially more recent episodes of tuberculosis), chronic kidney disease, diabetes and hypertension were associated with higher mortality, more strongly in younger adults

Knowledge, attitude, and practice regarding COVID-19 pandemic among medical students of Ernakulam, India

Background: COVID – 19 infection is a serious pandemic the world is now facing. This study aimed to assess the knowledge, attitude, and practice regarding COVID-19 infection among medical students at a private medical college in central Kerala.  Methods: A cross-sectional web-based study was conducted during April-May 2020 in a private medical college in Ernakulam District using the Universal sampling technique. The study tool was a semi-structured validated questionnaire containing sociodemographic details and questions on knowledge, attitude, and practice (KAP) regarding COVID-19 infection. Data were analyzed using SPSS version 20 software. Results: A total of 288 students were included in the study, with a mean age of 21±1.4. The male-to-female ratio was 2.75:1. Medical students showed adequate knowledge (81.6%), attitude (91.3%), and practice (84.7%) towards the COVID-19 pandemic, respectively. The main symptoms of COVID-19 infection were known to at least 83% of the participants. The majority (85.4%) were aware that there is no specific treatment for COVID-19 infection and 90% were aware of the main modes of the disease transmission. The majority (99%) of the medical students believed that COVID-19 infection could be prevented through social distancing, wearing masks, and the practice of self-hygiene. About 75.6% believed that government measures for prevention are adequate. Steam inhalation, saline gargling, and consumption of vitamin C-rich foodstuffs were the main specific measures adopted. Older age and female gender were found to be associated with better knowledge. Conclusion: Adequate KAP levels among medical students in this study are attributable to the current lockdown and the strict government measures to contain the infection