In resource-limited setting, it is possible to use HAART to treat African children. This treatment appears as effective as in developed countries.

Entry into the programmeThe Aconda programme adopted a comprehensive family-based approach. Health-care workers were trained to offer HIV testing to every pregnant woman attending antenatal clinics and to encourage HIV-infected mothers to bring their children and partners with them for testing and counselling. Each pregnant woman with an HIV infection was immediately referred for an adult consultation. She then received PMTCT therapy, either a short regimen or ART depending on her clinical and immunological status, and underwent assessment at both antenatal and adult clinics. 18Children aged ≤ 15 years entered the Aconda programme in one of two ways: (i) after referral for HIV testing at the age of ≥ 6 weeks because their mother had been diagnosed with HIV infection and had received PMTCT therapy, or (ii) after HIV testing at a paediatric clinic following presentation with AIDS-related symptoms, even if they had not been previously classified as exposed to or infected by HIV and even if their parents had not participated in the Aconda programme. Standardized paediatric follow-upThe Aconda paediatric HIV care package included systematic paediatric HIV testing which varied according to the child's age. In those aged ≥ 18 months, the standard serum testing algorithm comprised a series of two rapid HIV assays: the Determine ® HIV-1/2 assay (Inverness Medical, Bedford, United Kingdom of Great Britain and Northern Ireland) followed by the Genie II ® HIV-1/HIV-2 assay (Bio-Rad laboratories, MarneLa-Coquette, France). 19 Children aged < 18 months were diagnosed virologically using a TaqMan HIV-1, ribonucleic acid (RNA), real-time polymerase chain reaction test (Hoffmann-La Roche, Basel, Switzerland) with a threshold of 300 copies/ml. 20 Children were regarded as having HIV-1 infections if, at any age, they tested positive for HIV-1 RNA in plasma at least once or if, at age ≥ 18 months, they were positive for HIV-1 on serum testing. Children who tested negative but who were still breastfeeding were defined as HIV-undetermined and were retested 2 months after the cessation of breastfeeding or at 18 months. A negative diagnosis was regarded as definite if it was made at least 2 months after the cessation of breastfeeding and children with this diagnosis were excluded from the programme.All children with a confirmed HIV infection were seen monthly and had unrestricted free access to antiretroviral drugs and comprehensive care. 21 In all children, whether on ART or not, the CD4+ T lymphocyte (CD4 cell) count and CD4 cell percentage were measured every 6 months. Plasma viral load testing was not performed routinely after the diagnosis of HIV infection, even in children on ART. Pulmonary radiographs were available for children whose history and symptoms suggested tuberculosis.Children initiated ART if they were either at World Health Organization (WHO) HIV/AIDS clinical stage 3 or 4 or at clinical stage 1 or 2 with impaired immunity (i.e. a CD4 cell percentage ≥ 25 at age < 12 months, ≥ 20 at 12-35 months or ≥ 15 at ≥ 36 month...

BackgroundLittle is known about the long-term safety of infant feeding interventions aimed at reducing breast milk HIV transmission in Africa.Methods and FindingsIn 2001–2005, HIV-infected pregnant women having received in Abidjan, Côte d'Ivoire, a peripartum antiretroviral prophylaxis were presented antenatally with infant feeding interventions: either artificial feeding, or exclusive breast-feeding and then early cessation from 4 mo of age. Nutritional counseling and clinical management were provided for 2 y. Breast-milk substitutes were provided for free. The primary outcome was the occurrence of adverse health outcomes in children, defined as validated morbid events (diarrhea, acute respiratory infections, or malnutrition) or severe events (hospitalization or death). Hazards ratios to compare formula-fed versus short-term breast-fed (reference) children were adjusted for confounders (baseline covariates and pediatric HIV status as a time-dependant covariate). The 18-mo mortality rates were also compared to those observed in the Ditrame historical trial, which was conducted at the same sites in 1995–1998, and in which long-term breast-feeding was practiced in the absence of any specific infant feeding intervention. Of the 557 live-born children, 262 (47%) were breast-fed for a median of 4 mo, whereas 295 were formula-fed. Over the 2-y follow-up period, 37% of the formula-fed and 34% of the short-term breast-fed children remained free from any adverse health outcome (adjusted hazard ratio [HR]: 1.10; 95% confidence interval [CI], 0.87–1.38; p = 0.43). The 2-y probability of presenting with a severe event was the same among formula-fed (14%) and short-term breast-fed children (15%) (adjusted HR, 1.19; 95% CI, 0.75–1.91; p = 0.44). An overall 18-mo probability of survival of 96% was observed among both HIV-uninfected short-term and formula-fed children, which was similar to the 95% probability observed in the long-term breast-fed ones of the Ditrame trial.ConclusionsThe 2-y rates of adverse health outcomes were similar among short-term breast-fed and formula-fed children. Mortality rates did not differ significantly between these two groups and, after adjustment for pediatric HIV status, were similar to those observed among long-term breast-fed children. Given appropriate nutritional counseling and care, access to clean water, and a supply of breast-milk substitutes, these alternatives to prolonged breast-feeding can be safe interventions to prevent mother-to-child transmission of HIV in urban African settings.

This study demonstrates the durability of both clinical and biological response to HAART in African children.

Remifentanil appears to be a reasonable alternative to fentanyl during elective supratentorial craniotomy.