Integration of HIV Care into Community Management of Acute Childhood Malnutrition Permits Good Outcomes: Lusaka, Zambia

Background

While HIV has had a major impact on health care in southern Africa, there are few data on its impact on acute malnutrition in children in the community. We report an analysis of outcomes in a large programme of community management of acute malnutrition in the south of Lusaka.

Programme Activities and Analysis

Over 3 years, 68,707 assessments for undernutrition were conducted house-to-house, and children with severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) were enrolled into either Outpatient Therapeutic Programme (OTP) or Supplementary Feeding Programme (SFP) respectively. Case records were analysed using tabulation and unconditional logistic regression.

Findings

1,859 children (889 boys, 970 girls; median age 16 months) with MAM (n = 664) or SAM (n = 1,195) were identified. Of 1,796 children whose parents consented to testing, 185 (10.3%) were HIV positive. Altogether 1,163 (62.6%) were discharged as recovered from acute malnutrition. Case fatality while in the programme was 4.2% in children with SAM and 0.5% in those with MAM, and higher in children with HIV infection. In multivariate analysis, HIV, MUAC <11.5cm and the first year of the program all increased mortality. Children with HIV infection who were able to initiate antiretroviral therapy had lower mortality.

Interpretation

Our programme suggests that a comprehensive community malnutrition programme, incorporating HIV care, can achieve low mortality even in a population heavily affected by HIV.

Below:  Flow of children with MAM through the program

Full article at:   http://goo.gl/N84AKd

By:  

Beatrice Amadi, Mercy Imikendu, Milika Sakala, Rosemary Banda 
Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia

Beatrice Amadi, Paul Kelly 

Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia

Paul Kelly 

Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, 4 Newark Street, London, United Kingdom

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Factors Associated with the Failure of First & Second-Line Antiretroviral Therapies in Cambodian HIV-1 Infected Children

BACKGROUND:

Little is known about the efficacy of first and and second-line antiretroviral therapies (ART) for HIV-1 infected children in resource limited Southeast Asian settings. Previous studies have shown that orphans are at a higher risk for virological failure (VF) in Cambodia. Consequently most of them required transfer to second-line ART. We assessed the factors associated with VF among HIV-1 infected children who were either under first-line (mostly 3TC + D4T + NVP) or under second-line (mostly ABC + DDI + LPV) therapies at a referral hospital in Cambodia.

METHODS:

A case-control study was conducted from February to July 2013 at the National Pediatric Hospital among HIV-1 infected children (aged 1-15 years) under second-line ART (cases) or first-line (matched controls at a ratio of 1:3) regimens. Children were included if a HIV-1 RNA plasma viral load (VL) result was available for the preceding 12 months. A standardized questionnaire explored family sociodemographics, HIV history, and adherence to ART. Associations between VF (HIV-1 RNA levels ≥1000 copies/ml) and the children's characteristics were assessed using bivariate and multivariate analyses.

RESULTS:

A total of 232 children, 175 (75.4 %) under first-line and 57 (24.6 %) under second-line ART, for a median of 72.0 (IQR: 68.0-76.0) months, were enrolled. Of them, 94 (40.5 %) were double orphans and 51 (22.0 %) single orphans, and 77 (33.2 %) were living in orphanages. A total of 222 children (95.6 %) were deemed adherent to ART. Overall, 18 (7.7 %; 95 % CI 4.6-11.9) showed a VF, 14 (8.6 %; 95 % CI 4.8-14.0) under first-line and 4 (7.0 %; 95 % CI 1.9-17.0) under second-line ART (p = 0.5). Their median CD4 percentage was 8 % (IQR 2.9-12.9) at ART initiation. Children under second-line ART were older; more often double orphans, and had lower CD4 cell counts at the last control. In the multivariate analysis, having the last CD4 percentage below 15 % was the only factor associated with VF for ART regimen separately or when combined (OR 40.4; 95 % CI 11-134).

CONCLUSIONS:

The pattern of risk factors for VF in children is changing in Cambodia. Improved adherence evaluation and intensified monitoring of children with low CD4 counts is needed to decrease the risk of VF.

Below:  Flow chart of first and second-line ART children enrolled in National Pediatric Hospital, Cambodia

Full article at:   http://goo.gl/fiJ5b1

By:  Hubert Barennes, Kang Virak, François Rouet, Yves Buisson, Michel Strobel, and Ung Vibol

Agence Nationale de Recherche sur le VIH et les Hépatites, Preah Monyvong Blvd, Phnom Penh, Cambodia

Institut de la Francophonie pour la Médecine Tropicale, Vientiane, Lao People’s Democratic Republic

ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Univ. Bordeaux, 33000 Bordeaux, France

Epidemiology Unit, Pasteur Institute, Phnom Penh, Cambodia

Virological Unit, Pasteur Institute, Phnom Penh, Cambodia

University of Health Science, Phnom Penh, Cambodia

Hubert Barennes, Phone: + 85512983572, Email: rf.oohay@buhsennerab.

BMC Res Notes. 2016 Feb 5;9(1):69.

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Tensions in Communication between Children on Antiretroviral Therapy and Their Caregivers: A Qualitative Study in Jinja District, Uganda

Introduction

HIV treatment and disclosure guidelines emphasize the importance of communicating diagnosis and treatment to infected children in ways that are appropriate to children’s developmental stage and age. Minimal attention, however, has been given to communication challenges confronted by HIV-infected children and their caregivers. This study examined the tensions between children and their caregivers arising from differing perspectives regarding when and what to communicate about antiretroviral therapy (ART).

Methods

This qualitative study was conducted between November 2011 and December 2012 and involved 29 HIV-infected children aged 8–17 years on ART and their caregivers. Data were collected through observations and in-depth interviews, which took place in homes, treatment centres and post-test clubs. Children and caregivers were sampled from among the 394 HIV-infected children and (their) 393 caregivers who participated in the cross-sectional survey that preceded the qualitative study. ATLAS.ti. Version 7 was used in the management of the qualitative data and in the coding of the emerging themes. The data were then analyzed using content thematic analysis.

Results

While the children felt that they were mature enough to know what they were suffering and what the medications were for, the caregivers wanted to delay discussions relating to the children’s HIV diagnosis and medication until they felt that the children were mature enough to deal with the information and keep it a secret and this caused a lot of tension. The children employed different tactics including refusing to take the medicines, to find out what they were suffering from and what the medications were for. Children also had their own ideas about when, where and with whom to discuss their HIV condition, ideas that did not necessarily coincide with those of their caregivers, resulting in tensions.

Conclusions

Guidelines should take into consideration differing perceptions of maturity when recommending ages at which caregivers should communicate with their children about diagnosis and ART. Health care providers should also encourage caregivers to recognize and respect children’s efforts to learn about and manage their condition. Children’s questions and expressions of feelings should be treated as openings for communication on these issues.

Summary of the topics in the in-depth interview guide.

TOPICS	SUB-TOPICS
Experiences considered most important in the life of the child	Schooling/lack of schooling experiences; a typical week of schooling; vacation/holiday-what they do, who they visit; involvement in social events e.g. sports, drama, post-test clubs, relations with peers; whom they confide in when they have good or bad news.
Socio-demographic information	Age, birth/parents, education status, residence i.e. who the child lives with/family relations, relationship to caregiver, employment of caregiver, living conditions, number of siblings.
Health & medicine experiences	Why and how often they go to the treatment centres; who escorts them; what takes place when they go; what medicines they are given and how often they take them; how long they have been taking the medicines; where they keep the medicines; who helps them to take the medicine; who they talk to about the medicine at home, school, neighbourhood; what they talk about; who else at home takes similar medicines; what they understand by the need to be on lifelong/daily medication
Learning about status/experiences of disclosure	Reasons they had been given for taking daily medicines; who told them; their experiences and reactions when they learnt reasons for taking daily medicines; how they came to know the illness/health condition for which they took daily medicines; who told them; what exactly they were told; how they were told; age at which they were told; their experiences/reactions when they were told about their illness; what they understand by having illness.
Communication about illness and treatment in different social spaces	People who knew about their illness/health and medicines at home, school, in the neighborhood, and how they came to know; people they had told about their health and medicines; reasons for telling such people; people’s reactions when they were told; who they normally communicated with about their illness and treatment and where; who they think deserved to know about their illness and why; what they liked/disliked to hear about their health and medicines; questions/challenges of being on daily medicines; whom they talk to about these challenges; how they could be supported to live on daily medicines.

Full article at:   http://goo.gl/0ZWizF

By:  Phoebe Kajubi,1,* Susan Reynolds Whyte,#2 David Kyaddondo,#1 and Anne Ruhweza Katahoire#1

David Joseph Diemert, Editor

¹Child Health and Development Centre, College of Health Sciences, Makerere University, Kampala, Uganda

²Department of Anthropology, University of Copenhagen, Copenhagen, Denmark

The George Washington University School of Medicine and Health Sciences, UNITED STATES

^#Contributed equally.

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: PK SRW DK ARK. Performed the experiments: PK. Analyzed the data: PK. Contributed reagents/materials/analysis tools: PK SRW DK ARK. Wrote the paper: PK SRW DK ARK. Participated in analysis and interpretation of data: SRW DK ARK. Drafted the manuscript: PK. Reviewed the manuscript: SRW DK ARK. Read and approved the final manuscript: PK SRW DK ARK.

* E-mail: moc.oohay@ibujakebeohp

Published online 2016 Jan 19. doi:  10.1371/journal.pone.0147119

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Evaluation of Immune Response to Measles Component of MMR Vaccine in Children with HIV Infection Receiving Antiretroviral Therapy

Children with HIV (CLHIV), respond poorly to primary immunization with measles vaccine and those responding tend to lose protective titre of antibodies by 2-3 years of age. Revaccinating CLHIV after immune reconstitution with anti-retroviral therapy (ART) may result in good sero-conversion,thereby confering them protection from measles.

To study prevalence of -measles antibodies in CLHIV receiving ART before and after inmunization with MMR vaccine.

CLHIV in the age 5-18 years,receiving ART for >6 months and with CD 4 count >15% were included in this prospective study. Their serum was assayed for IgG measles antibodies by qualitative immune-enzymatic determination using ELISA. The subjects were then immunized with a single dose of MMR vaccine. A repeat venous sample was assayed for measles antibiodies 8-12 weeks after immunization.

Sixty six subjects (46 males,20 females, mean age 10.4±2.8 years )were enrolled. The mean duration of ART was 3.4±1.5 years and median CD4 count 716.5µ/L. At enrollment, 16 (24.2%) subjects tested positive, 8 (12.1%)equivocal and 42 (63.6%) negative for -measles antibodies. After 8-12 weeks of immunization, 62 (93.3%)tested positive, 1(1.5%) equivocal and 3 (4.5%) negative. There was no difference among the sero-positive and sero-negative subjects post immunization with respect to age, sex, duration of ART, nutritional status, CD4 count or WHO clinical stage. No serious adverse reaction was observed to vaccination.

MMR vaccine leads to an excellent seroconversion to measles component of vaccine in immune- reconstituted CLHIV.

Via: http://goo.gl/xK4cPK  Purchase full article at: http://goo.gl/qnyxWu

By: Seth A1, Deepa S, Dutta R, Chandra J.

• 11Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India 2Department of Microbiology, Lady Hardinge Medical College, New Delhi, India. 

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