Collins, J

European Pregnancy and Paediatric HIV Cohort (EPPICC)

Galli, L

Goetghebeur, T

Goodall, R

Judd, A

Kohns, M

Noguera-Julian, A

Rodrigues, L

Scherpbier, H

English

UCL Discovery

BackgroundMethodsARE HIV+ MIGRANT CHILDREN IN EUROPE AT INCREASED RISK OF POOR OUTCOMES ON ART? Malte Kohns1, Ruth Goodall2, Luisa Galli3, Ali Judd2,  Tessa Goetghebuer4,  Antoni Noguera-Julian5, Laura Rodrigues1, Henriëtte J. Scherpbier 6, Intira Jeannie Collins2for the European Pregnancy and Paediatric HIV Cohort (EPPICC)•11.  . London School of Hygiene & Tropical Medicine, UK; 2. University College London, UK; 3 University of Florence, Italy;  4. Hospital St Pierre, Brussels, Belgium; 5. Hospital Sant Joan de Déu Barcelona, Spain; 6. Emma Children's Hospital/Academic Medical Center, Amsterdam, Netherlands.                                                              •.• Adult studies in Europe have reported higher burden of HIV among migrants as compared to native populations, and differences in key characteristics including more women, younger age and more advanced disease at HIV diagnosis among migrants [1-3].  • Large adult studies on outcomes on ART by migrant status across western Europe reported increased mortality and poorer immunological and virological response in some migrant populations (e.g. women from key regions) as compared to native patients [2,4]. • Few comparable studies have been conducted in children and have been limited to national cohorts[5-6]. Figure 2:  …• Of 2,284 children from 11 European countries, 55% were migrants (of whom 85% were from Africa), the proportion of migrants varied by country, from 5% in Poland to 97% in Sweden.• At ART start, migrant children were older, more likely to be severely immunocompromised and TB co-infected, but fewer had AIDS diagnosis as compared to domestic-born children (Table 1). • Median follow-up after ART start was 5.4 [2.3,8.7] and 7.6 [3.1,11.1] years among migrants and domestic-born children, respectively (p<0.001). AIDS and death • Of 1,901 children AIDS-free at ART start, 103 (5.4%) had ≥1 AIDS event and 14 (0.7%) died (a child can experience both events). Rate of AIDS/death was 1.02 {95% CI 0.85, 1.23} per 100 person-years.  • Cumulative probability of AIDS/death at 5 years after ART start was 6.0% {95% CI 4.6,7.7} in migrant vs. 5.0% {95% CI 3.7,6.7} in domestic-born children (p=0.17) (Figure 2). • After adjustment, the hazard of AIDS/death was not significantly higher among migrant children (adjusted hazard ratio (aHR) 1.45 {95% CI 0.90,2.33}, p=0.129) (Table 2). Conclusions EPPICC cohorts: Hospital St Pierre Cohort, Brussels, Belgium (T Goetghebuer); Italian Register for HIV infection in children, Italy (L Galli, M de Martino);  ATHENA Cohort, Netherlands (H. Scherpbier, C.Smit); Paediatric Cohort, Poland (M Marczynska); Centro Hospitalar do Porto, Portugal (L Marques); Hospital de Santa Maria/CHLN, Portugal (F Prata) ; “Victor Babes” Hospital Cohort, Romania (L Ene); The Republican Hospital of Infectious Diseases, St Petersburg, Russia (E Voronin, L Okhonskaia); CoRISPE-cat, Catalonia, Spain (A Noguera Julian); CoRISPE-1, rest of Spain cohort, Spain (M González); KarolinskaUniversity Hospital, Stockholm, Sweden (L Naver); Swiss Mother and Child HIV Cohort Study, Switzerland (C Rudin); Thailand Program for HIV Prevention and Treatment (PHPT) Study Group, Thailand (G Jourdain); National Study of HIV in Pregnancy and Childhood, UK and Ireland (C Thorne); Collaborative HIV Paediatric Study, UK and Ireland (A Judd, Di Gibb); Enquête PérinataleFrançais, France (J Waszawski); Paediatric HIV Cohort Study, Odessa, Ukraine (R Malyuta). Funding: EuroCoordreceived funding from the European Union Seventh Framework Programme (FP7/2007-2013) under EuroCoord grant agreement no 260694. This work was supported by the PENTA Foundation and Medical Research Council programme grant MC_UU_12023/26 awarded to the MRC Clinical Trials Unit at UCL.Acknowledgements Pediatric HIV observational cohorts across 16 European countries contributed to an individual patient data meta-analysis carried out in December 2014.Inclusion criteria: Children aged under 18-years at initiation of combination ART,  followed in cohorts where ≥5% of the paediatric population are migrants (defined as born abroad from the country of the cohort) were included. Outcome: First AIDS event or death among children AIDS-free at ART initiation.  Follow-up was from ART start to death, last visit in paediatric care or 21st birthday.  In sensitivity analysis, we assessed new/recurrent AIDS or death in all children, including those with AIDS diagnosis at ART start. Statistical analysis: Hazard of first AIDS event or death was assessed by migrant status, using multivariable Cox models, adjusting for key confounders including sex, mode of transmission, age, WHO severe immunosuppression for age [7] and calendar year at ART start, initial regimen and region.  Missing baseline values were imputed. Figure 1:  …Sensitivity analysis• When including children with AIDS at ART initiation (n=2284), 141 (6.2%) had ≥1 AIDS event and 36 (1.6%) died after ART start.  • Cumulative probabilities of AIDS/death at 5 years were 7.1% migrant vs. 7.3% domestic-born children (p=0.75).  In the adjusted analysis there were no significant effect of migrant status (aHR 1.29 {95% CI 0.88,1.88}, p=0.199).Results continuedResults  Table 1. Characteristics at ART initiation by migrant statusDomestic-born (%)(n=1028)Born abroad (%) (n=1256)PSex female 563 (55) 625 (50) 0.017Perinatal infection yes 1003 (98) 1107 (88) <0.001Age, years median [IQR] 1.8 [0.3, 7.2] 8.1 [4.0, 11.7] <0.001<3 years 597 (58) 238 (20)<0.0013-10 years 265 (26) 557 (44)>10 years 166 (16) 461 (37)WHO immuno-suppression (n=835, 889)Severe 353 (42) 429 (48)0.013TB coinfection yes 7 (0.7) 28 (2) 0.003AIDS diagnosis yes 192 (19) 182 (15) 0.012Initial ART regimen bPI 346 (34) 378 (30)0.002NNRTI 595 (58) 811 (65)3NRTI/Other 87 (8) 67 (5)Calendar year <2004 372 (36) 358 (29)<0.0012004-2007 352 (34) 435 (35)>2007 304 (30) 463 (37)Note: IQR interquartile range; TB tuberculosis; bPI boosted protease inhibitor; NRTI nucleoside transcript inhibitor; NNRTI non-NRTI#853Email: jeannie.collins@ucl.ac.ukObjectiveTo assess the effect of migrant status on risk of AIDS and death after ART initiation in children followed in observational cohorts in the EPPICC network (Figure 1). Probability of AIDS or deathFigure 2.  Cumulative probability of AIDS or death among children AIDS free at ART initiation, by migrant statusTable 2. Effect of migrant status on hazard of  first AIDS event or death after ART initiation (95% CI)Migrant status event/N Unadjusted HR Adjusted HR* PᶧMain analysis(exclude children with AIDS at ART start)Domestic 43/835 1 10.129Migrant 68/1066 1.30 (0.89-1.91) 1.45 (0.90-2.34)Sensitivity analysis (Including those with AIDS at ART start)Domestic 75/1028 1 10.199Migrant 93/1256 1.05 (0.77-1.42) 1.29 (0.88-1.88)*adjusted for sex, year of birth, mode of transmission, initial ART regimen, region (UK/Ireland vs rest of Europe), calendar year, age, low WAZ, detectable HIV RNA and low CD4% at initiation of ART; missing baseline values were imputed. ᶧ P-value for adjusted model. • Migrant children in Europe were older and more likely to be severely immunocompromised at ART start. After adjusting for characteristics at ART start there was no significant increase risk of AIDS/death when compared to domestic-born children. • This may be partly due to the rarity of events and/or selection bias of long-term survivors among migrant children, or it may indicate equality in care in these settings.• Limitations: There were no data on socio-economic or orphan status. We did not assess retention in care or long term immune/virological outcomes by migrant status. [1] Hernando V, Alvárez-del Arco D; Alejos B et a l. HIV Infection in Migrant Populations in the European Union and European Economic Area in 2007–2012: An Epidemic on the Move. JAIDS. 70(2):204–211, OCT 2015.  [2] Migrants Working Group on behalf of COHERE in Europe. Mortality in migrants l iving with HIV in western Europe (1997-2013): a  col laborative cohort s tudy.  Lancet HIV 2015; 2(12): e540-9. [3] Delpech V, Brown A, Croxford S, et a l. Quality of HIV care in the United Kingdom: Key indicators for the fi rs t 12 months from HIV diagnosis. HIV Medicine 2013; 14(SUPPL.3): 19-24.   [4]  Migrant Health Working Group for COHERE in Europe in EuroCoord. Immunological and vi rological response to antiretroviral therapy in migrant and native men and women in Western Europe; i s benefit equal for all? HIV Medicine 2018; 19 (1); 42-48.    [5] Cohen S, Van Bi lsen W, Smit C, et a l. Country of bi rth does not influence long-term cl inical, vi rologic, and immunological outcome of HIV-infected children living in the Netherlands: A cohort s tudy comparing children born in the Netherlands with children born in Sub-Saharan Africa. JAIDS 2015; 68(2): 178-85. [6] Turkova, A, Chappell E, Judd A, et a l . Prevalence, incidence, and associated risk factors of tuberculosis in children with HIV living in the UK and Ireland (CHIPS): A cohort s tudy. Lancet HIV 2015; 2(12): e530-e9. [7] World Health Organisation (2007) WHO case definitions of HIV for surveillance and revised cl inical staging and immunological classification of HIV-related disease in adults and children. Ava ilable from: http://www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf.ReferencesExcluded from analysis**   Included in analysis*Countries not included in the EPPICC data merger* Countries included in analysis: Belgium, France, Italy, Netherlands, Poland, Portugal, Spain, Sweden, Switzerland, UK & Ireland**Excluded due to <5% of children born abroad (Greece, Romania, Russia, Ukraine) or missing data on country of birth (Germany) Figure 1. Map of the EPPICC network in Europe and the countries of cohorts included in this analysis. 

Are HIV+ migrant children in Europe at increased risk of poor outcomes on ART?

https://discovery.ucl.ac.uk/10062955/1/EPPICC%20Migrants%20CROI%202018%20poster%20%281430_Collins_853%29.pdf

Are HIV+ migrant children in Europe at increased risk of poor outcomes on ART?

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