Includes bibliographical references. / Short-term treatment outcomes of children starting ART in the ICU, general medical wards and outpatient HIV clinics at Red Cross War Memorial Children’s Hospital (RCWMCH): A Retrospective Cohort Study. Background: Antiretroviral therapy (ART) has proven to decrease morbidity and mortality in HIV-infected children and improve immunologic, virologic and clinical outcomes. As clinical management policies evolved, an emphasis on early infant testing was adopted resulting in an increasing number of children being diagnosed and commenced on therapy before the onset of severe disease progression. However, a fair proportion still remain untested and subsequently present to hospital with advanced immunosuppression and severe disease. Since the advent of the 2013 national Standard Treatment Guidelines which encourage expedited initiation of ART within 7 days of HIV diagnosis in all children under the age of 12 months and in those with advanced immunosuppression, it is likely that many HIV-infected children are being initiated on ART during hospitalisation in South Africa. No local published data on these outcomes exist. We assessed the short-term outcomes of children initiated on ART in the intensive care unit (ICU), general medical wards (GMWs) and outpatient HIV clinics (OHCs) at RCWMCH. Methods: Structured Literature Review A Pubmed search looking at outcomes of treatment naïve HIV-infected children and adolescents up to 19 years of age living in South Africa commenced on 1st line ART regimens in accordance to the national guidelines presiding at the time, over a 10 year period was performed. This served to identify gaps in knowledge around paediatric ART in a South African context warranting further research. Retrospective Cohort Study We conducted a retrospective cohort study of HIV-infected children <13 years of age, commenced on first line ART between January 2008 and December 2011 at RCWMCH. Outcome measures included death, virologic suppression and changes in CD4 count and percentage. Kaplan-Meier estimates, multivariate Cox proportional hazard ratios and logistic regression were used to estimate outcomes 6 months after ART initiation. Results: Structured Literature Review This review identified several knowledge gaps. One of these gaps, the treatment outcomes of children started on ART at different service levels within tertiary health care settings was addressed in our retrospective cohort study and described in section C of this dissertation Retrospective Cohort Study Seven hundred and forty-nine children were included: 106 were commenced on ART in the ICU, 509 in the GMWs and 127 in the OHCs. Four hundred and ninety-two (65.7%) children were <12 months old. Children in the ICU and GMW cohorts were significantly younger than the OHC cohort (median ages: 3 and 5 months respectively vs. 22 months) and had lower WAZ scores (-2.48 and -2.33 respectively vs -1.14). Three hundred and eighty-five (51.4%) children qualified for rapid ART initiation within 7 days of HIV diagnosis or hospitalisation, based on CD4 criteria in the 2013 national Standard Treatment Guidelines. Overall mortality was 6.4% (CI: 4.9 - 8.4). Mortality was significantly higher in the ICU cohort i.e. 14 (13.2%) deaths compared to 28 (5.5%) and 5 (3.9%) deaths in the GMWs and OHCs cohorts, logrank p=0.004. Predictors of mortality included being moderately underweight HR 2.4 (CI: 1.1 – 5.2; p=0.02), severely underweight HR 3.2 (CI: 1.6 – 6.5; p=0.001), absence of caregiver counselling sessions HR 2.9 (CI: 1.4 – 6.0; p=0.005) and ART initiation in ICU HR 2.6 (CI: 1.4 – 4.9; p=0.003). Conclusion: The findings of our retrospective cohort study serve as a basis for understanding the implications of ART initiation in children during hospitalisation.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:uct/oai:localhost:11427/13245 |
| Date | January 2014 |
| Creators | Pillay, Vashini |
| Contributors | Eley, Brian, Davies, Mary-Ann |
| Publisher | University of Cape Town, Faculty of Health Sciences, Department of Public Health and Family Medicine |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Master Thesis, Masters, MPH |
| Format | application/pdf |
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