 |
|
Clinical Outcomes and CD4 Cell Response in Children Receiving Antiretroviral Therapy at Primary Health Care Facilities in Zambia
Carolyn Bolton-Moore, MBBCh;
Mwangelwa Mubiana-Mbewe, MBChB;
Ronald A. Cantrell, MPH;
Namwinga Chintu, MBChB;
Elizabeth M. Stringer, MD, MSc;
Benjamin H. Chi, MD;
Moses Sinkala, MBChB, MPH;
Chipepo Kankasa, MBBS;
Craig M. Wilson, MD;
Catherine M. Wilfert, MD;
Albert Mwango, MBChB;
Jens Levy, PhD;
Elaine J. Abrams, MD;
Marc Bulterys, MD, PhD;
Jeffrey S. A. Stringer, MD
JAMA. 2007;298:1888-1899.
Context The Zambian Ministry of Health provides pediatric antiretroviral therapy (ART) at primary care clinics in Lusaka, where, despite scale-up of perinatal prevention efforts, many children are already infected with the human immunodeficiency virus (HIV).
Objective To report early clinical and immunologic outcomes of children enrolled in the pediatric treatment program.
Design, Setting, and Patients Open cohort assessment using routinely collected clinical and outcome data from an electronic medical record system in use at 18 government primary health facilities in Lusaka, Zambia. Care was provided primarily by nurses and clinical officers ("physician extenders" akin to physician assistants in the United States). Patients were children (<16 years of age) presenting for HIV care between May 1, 2004, and June 29, 2007.
Intervention Three-drug ART (zidovudine or stavudine plus lamivudine plus nevirapine or efavirenz) for children who met national treatment criteria.
Main Outcome Measures Survival, weight gain, CD4 cell count, and hemoglobin response.
Results After enrollment of 4975 children into HIV care, 2938 (59.1%) started ART. Of those initiating ART, the median age was 81 months (interquartile range, 36-125), 1531 (52.1%) were female, and 2087 (72.4%) with World Health Organization stage information were in stage III or IV. At the time of analysis, 158 children (5.4%) had withdrawn from care and 382 (13.0%) were at least 30 days late for follow-up. Of the remaining 2398 children receiving ART, 198 (8.3%) died over 3018 child-years of follow-up (mortality rate, 6.6 deaths per 100 child-years; 95% confidence interval [CI], 5.7-7.5); of these deaths, 112 (56.6%) occurred within 90 days of therapy initiation (early mortality rate, 17.4/100 child-years; post–90-day mortality rate, 2.9/100 child-years). Mortality was associated with CD4 cell depletion, lower weight-for-age, younger age, and anemia in multivariate analysis. The mean CD4 cell percentage at ART initiation among the 1561 children who had at least 1 repeat measurement was 12.9% (95% CI, 12.5%-13.3%) and increased to 23.7% (95% CI, 23.1%-24.3%) at 6 months, 27.0% (95% CI, 26.3%-27.6%) at 12 months, 28.0% (95% CI, 27.2%-28.8%) at 18 months, and 28.4% (95% CI, 27.4%-29.4%) at 24 months.
Conclusions Care provided by clinicians such as nurses and clinical officers can result in good outcomes for HIV-infected children in primary health care settings in sub-Saharan Africa. Mortality during the first 90 days of therapy is high, pointing to a need for earlier intervention.
Author Affiliations: Centre for Infectious Disease Research in Zambia, Lusaka (Drs Bolton-Moore, Mubiana-Mbewe, Chintu, E. Stringer, Chi, Kankasa, Levy, and J. Stringer and Mr Cantrell); Schools of Medicine and Public Health, University of Alabama at Birmingham (Drs. E. Stringer, Chi, Sinkala, Wilson, and J. Stringer and Mr Cantrell); University Teaching Hospital, Lusaka (Dr Kankasa); Zambian Ministry of Health, Lusaka (Drs Sinkala and Mwango); Elizabeth Glaser Pediatric AIDS Foundation, Santa Monica, California (Dr Wilfert); Columbia University College of Physicians and Surgeons, New York, New York (Dr Abrams); and US Centers for Disease Control and Prevention, Global AIDS Program, Lusaka (Dr Bulterys).
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati
What's this?
RELATED ARTICLE
Bridging the Coverage Gap in Global Health
Robert B. Eiss and Roger I. Glass
JAMA. 2007;298(16):1940-1942.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Safety, Tolerability and Effectiveness of Generic HAART in HIV-Infected Children in South India
Kumarasamy et al.
J Trop Pediatr 2009;55:155-159.
ABSTRACT
| FULL TEXT
Adherence to first-line antiretroviral therapy affects non-virologic outcomes among patients on treatment for more than 12 months in Lusaka, Zambia
Chi et al.
Int J Epidemiol 2009;38:746-756.
ABSTRACT
| FULL TEXT
Anti-retroviral therapy reduces incident tuberculosis in HIV-infected children
Edmonds et al.
Int J Epidemiol 2009;0:dyp208v1-dyp208.
ABSTRACT
| FULL TEXT
Early Childhood Infection by Human Herpesvirus 8 in Zambia and the Role of Human Immunodeficiency Virus Type 1 Coinfection in a Highly Endemic Area
Minhas et al.
Am J Epidemiol 2008;168:311-320.
ABSTRACT
| FULL TEXT
Effects of Early, Abrupt Weaning on HIV-free Survival of Children in Zambia
Kuhn et al.
NEJM 2008;359:130-141.
ABSTRACT
| FULL TEXT
Predicted impact of the HIV-1 epidemic on measles in developing countries: results from a dynamic age-structured model
Scott et al.
Int J Epidemiol 2008;37:356-367.
ABSTRACT
| FULL TEXT
New Weapons Needed to Fight HIV: A Call for Papers
Zuccotti and Smith
JAMA 2007;298:2545-2545.
FULL TEXT
Bridging the Coverage Gap in Global Health
Eiss and Glass
JAMA 2007;298:1940-1942.
FULL TEXT
|
