Setting and patient characteristicsIn June 2004, Aconda, a nongovernmental organization created by researchers who had studied cohorts of HIV-infected adults and children in Abidjan, Côte d'Ivoire, between 1996 and 2003, 9,16 formed a partnership with the Institute of Public Health, Epidemiology and Development in Bordeaux, France, to study access to HIV care and treatment.The study was funded by the United States President's Emergency Plan for AIDS Relief through the Elizabeth Glaser Pediatric AIDS Foundation in Washington, DC, United States of America (USA).Details of the Aconda programme have been described elsewhere. 17Briefly, the Aconda team trained health workers in HIV care and implemented a standardized computer data management system which was controlled by a designated Une traduction en français de ce résumé figure à la fin de l'article.Al final del artículo se facilita una traducción al español. املقالة. لهذه الكامل النص نهاية يف الخالصة لهذه العربية الرتجمةObjective To investigate deaths and losses to follow-up in a programme designed to scale up antiretroviral therapy (ART) for HIVinfected children in Côte d'Ivoire.Methods Between 2004 and 2007, HIV-exposed children at 19 centres were offered free HIV serum tests (polymerase chain reaction tests in those aged < 18 months) and ART.Computerized monitoring was used to determine: (i) the number of confirmed HIV infections, (ii) losses to the programme (i.e.death or loss to follow-up) before ART, (iii) mortality and loss-to-programme rates during 12 months of ART, and (iv) determinants of mortality and losses to the programme.Findings The analysis included 3876 ART-naïve children.Of the 1766 with HIV-1 infections (17% aged < 18 months), 124 (7.0%) died, 52 (2.9%) left the programme, 354 (20%) were lost to follow-up before ART, 259 (15%) remained in care without ART, and 977 (55%) started ART (median age: 63 months).The overall mortality rate during ART was significantly higher in the first 3 months than in months 4-12: 32.8 and 6.9 per 100 child-years of follow-up, respectively.Loss-to-programme rates were roughly double mortality rates and followed the same trend with duration of ART.Independent predictors of 12-month mortality on ART were pre-ART weightfor-age z-score < -2, percentage of CD4+ T lymphocytes < 10, World Health Organization HIV/AIDS clinical stage 3 or 4, and blood haemoglobin < 8 g/dl.Conclusion The large-scale programme to scale up paediatric ART in Côte d'Ivoire was effective.However, ART was often given too late, and early mortality and losses to programme before and just after ART initiation were major problems.
Introduction: Most data on tuberculosis in human immunodeficiency virus (HIV)-infected children in Africa come from hospital-based and cross-sectional studies. Objectives: To estimate the incidence of tuberculosis in HIV-infected children participating in an observational cohort. Methods: HIV-infected children in Abidjan, Côte d'Ivoire, are followed in a prospective cohort. At enrollment, all children had a physical examination, CD4 lymphocyte counts, chest radiograph and a tuberculin test. Quarterly follow-up visits are organized. All patients with suspected tuberculosis undergo specific investigations including gastric aspiration and culture. All isolates are tested for susceptibility. Results: From October 2000 to December 2003, 129 girls and 153 boys were recruited. Of children without a current or previous diagnosis of tuberculosis, 6.5% (13 of 199) had a tuberculin test result of >5 mm, compared with 17.5% of children (10 of 57) with current or previous tuberculosis (P < 0.02). Forty-eight children (17%) had a history of treated tuberculosis, and 27 children were being treated for tuberculosis at enrollment or during the first month of follow-up. Eleven children were diagnosed with tuberculosis after the first month of follow-up, and the diagnosis of mycobacterial infection was confirmed in 7 cases. Of 5 tested isolates of Mycobacterium tuberculosis, 3 were resistant to at least 1 antitubercular drug. Cumulative incidence of tuberculosis was 2060/100,000 at 12 months, 3390/100,000 at 2 years and 5930/100,000 at 3 years. The 3-year risk was 12,400/100,000 in immunocompromised children (CD4 <15%) and 3300/100,000 in other children (P < 0.0001). Conclusion: The risk of tuberculosis among HIV-infected children in Côte d'Ivoire is strongly associated with the degree of immunodeficiency in HIV infection.
To analyze the determinants of CD4 change in children during 3 periods: before highly active antiretroviral therapy (HAART), during the first year after HAART initiation, and past 1 year after HAART initiation.One hundred seventy-seven children enrolled in a prospective cohort in Abidjan received HAART during a mean follow-up of 30 months. A linear mixed-effects model was used for the first period, a mixed-effects piecewise model for the second period, and an asymptotic mixed-effects model for long-term CD4 dynamics.Before HAART initiation, CD4 percentage decreased along time [beta = -0.59 (-0.92 to -0.26)] was positively associated with body mass index for age [beta = 0.47 (0.22 to 0.72)] and negatively associated with viral load [beta = -1.01 (-1.90 to -0.13)]. During the first year of treatment, the CD4 decrease reverted to a steep increase that was negatively associated with age at HAART initiation [beta = -0.24 (-0.4 to -0.07)] and with the mean viral load under HAART [beta = -1.51 (-2.21 to -0.81)]. The long-term CD4 percentage was also negatively associated with the mean viral load under HAART [beta = -4.97 (-6.22 to -3.72)] and age at HAART initiation [beta = -0.82 (-1.12 to -0.51)].Before HAART initiation, the CD4 cell percentage was associated with growth indicators whereas, after HAART, an early increase and a long-term plateau were negatively associated with the viral load and age at HAART initiation.
In Africa, prevention of mother-to-child transmission of HIV (PMTCT) with antiretrovirals is becoming a key component of the response to the pandemic. Toxicity issues remain however a concern and require careful monitoring. We report here three observations of mild neurological deterioration among children for whom a diagnosis of mitochondrial dysfunction was considered possible. These children were identified within a PMTCT research program (ANRS 049) conducted in Abidjan, Côte d'Ivoire, and evaluating a short regimen of maternal zidovudine monotherapy for PMTCT of HIV type 1. Maternal HIV-1 infection was diagnosed during pregnancy before enrolment in the randomised trial (two cases) or in the subsequent open cohort (one case). These three women had been allocated to the ZDV group and had no particular medical history. Pregnancy check-up was negative except the diagnosis of HIV-1 infection. The three children were diagnosed as uninfected by HIV-1. Symptoms developed by the age of six months (two cases) and 13 months (one case): growth failure, anthropometric abnormalities, impaired psycho-motor development, generalised and repeated seizures. The evolution of these three HIV-uninfected children was favourable after 12 to 18 months. The transient nature of these abnormalities is compatible with mild complications of mitochondrial dysfunction. We conclude however that the anticipated benefits of PMTCT with antiretrovirals in Africa greatly outweigh the potential risks and should not lead to reconsider their public health interest
Objective: To estimate the frequency of human immunodeficiency virus type 1 (HIV-1) displaying genotypic drug resistance in highly active antiretroviral therapy (HAART)-treated children in Abidjan. Methods: Among the 269 HIV-1-infected children enrolled in the ANRS 1278 prospective observational cohort between October 2000 and September 2003, 115 [median age, 6.35 years (range, 1.2–15)] required treatment and received HAART for at least 6 months. Treatment consisted of 2 nucleoside analogue reverse transcriptase inhibitors associated with nelfinavir (70.5%) or efavirenz (29.5%). Plasma HIV-1 RNA and CD4+ T cell counts were determined at baseline and every 6 months thereafter. Genotypic resistance tests were performed in cases of virologic failure (viral load ≥3 log10 copies/mL) after at least 6 months of HAART. Results: After a median of 10.2 months of HAART, 66% (76 of 115) of children were in virologic success. Most of these children were infected with CRF02 strains. Twenty-seven viruses displayed resistance to at least 1 antiretroviral drug (27 of 38, 71%). Thirteen, 9 and 5 children had viruses with resistance to 1, 2 or 3 of the drugs included in their regimen, respectively. Resistance to lamivudine and/or to non-nucleoside analogue reverse transcriptase inhibitors was frequent among the 38 children in virologic failure. The 90M, 46L, 88S or 54V mutations were found in 11 (38%) of the 29 children taking nelfinavir. The overall frequency of viruses showing genotypic resistance to at least 1 antiretroviral drug was 23% (27 of 115) among the treated children. Conclusion: These results are similar to what is generally observed in industrialized countries. Despite these encouraging results, efforts are needed to maximize the long-term efficiency of treatment and to minimize the risk of emergence of drug resistance in treated children.
