Mortality in Children with Human Immunodeficiency Virus Initiating Treatment: A Six-Cohort Study in Latin America

Abstract

Objectives To assess the risks of and factors associated with mortality, loss to followup, and changing regimens after perinatally HIV-infected children initiate combination antiretroviral therapy (cART) in Latin America and the Caribbean. Study design This 1997–2013 retrospective cohort study included 1174 ART-naïve perinatally-infected children who started cART age<18 years (median 4.7 years; interquartile range [IQR] 1.7–8.8) at one of six cohorts from Argentina, Brazil, Haiti, and Honduras, within the Caribbean, Central and South America Network for HIV Epidemiology (CCASAnet). Median follow-up was 5.6 years (interquartile range [IQR] 2.3 to 9.3). Study outcomes were all-cause mortality, loss to followup, and major changes/interruption/stopping of cART. We used Cox proportional hazards models stratified by site to examine the association between predictors and times to death or changing regimens. Results Only 52% started cART <5 years of age; 19% began a protease inhibitor. At cART initiation, median CD4 count was 472 cells/mm3 (IQR: 201–902); median CD4% was 16% (IQR:10–23). Probability of death was high in the first year of cART: 0.06 (95% confidence interval [CI] 0.04–0.07). Five years after cART initiation, the cumulative mortality incidence was 0.12 (CI 0.10–0.14). Cumulative incidences for loss to followup and regimen change after five years were 0.16 (CI 0.14–0.18) and 0.30 (CI 0.26–0.34), respectively. Younger children had the highest risk of mortality, whereas older children had the highest risk of being lost to followup or changing regimens. Conclusions Innovative clinical and community approaches are needed for quality improvement for HIV pediatric care in the Americas.

Outcomes After Second-Line Antiretroviral Therapy in Children Living With HIV in Latin America

“…Second-line ART was defined as the regimen after a switch of ≥2 ARVs in the initial regimen, the addition of ≥2 ARVs to the initial regimen, or a substitution of a single drug that was different from the initial drug class. 14…”

“…8,9 Moreover, the need for second-line and third-line treatment options is projected to increase as countries incorporate WHO recommendations for viral load monitoring that will result in increased identification of virologic failure. 10 Although a number of studies on switching regimens after starting first-line ART in pediatric populations have been conducted globally, 3,[10][11][12][13][14] little is known about outcomes among children and adolescents after initiating a second-line ART regimen. One recent global analysis investigated CD4 rebound, loss to follow-up, and mortality among children after starting second-line ART.…”

Timing of HIV diagnosis relative to pregnancy and postpartum HIV care continuum outcomes among Latin American women, 2000 to 2017

“…Additional outcomes of interest included cumulative incidence of LTFU at 12 months and 5 years of postpartum [14], time to LTFU and virological suppression at 12 months postpartum. Virological suppression was determined by whether the closest VL to 12 months postpartum (AE6 months) was <200 copies/mL.…”

Using Observational Data to Inform HIV Policy Change for Children and Youth

“…Observational data from clinical care cohorts can fill evidence gaps by providing detailed information on critical outcomes, including age and CD4 at ART start, retention and loss to follow-up, and mortality. 3 , 20 – 22 Such data are particularly valuable for addressing clinical questions that are unlikely to be evaluated in randomized controlled trials and for assessing the real-world impact of implementing new guidelines or interventions.…”