Antiretroviral therapy (ART) access with successful outcomes for children is expanding in resource-limited countries. The aim of this study was to determine treatment responses of children in a routine setting where first-line therapy with lopinavir/ritonavir is routinely included for young children.
Outpatient records of children who initiated ART between April 2004 and March 2008 at a government clinic in Soweto were reviewed. Children <3 years initiated ART with lopinavir/ritonavir and those ≥3 years initiated with efavirenz-containing regimens.
ART was initiated at a median age of 4.3 years, 28.6% also received tuberculosis treatment. During 3155 child-years of follow-up (median follow-up 17 months), 132 children (6%) died giving a mortality rate of 4.2 (95% confidence interval: 3.5, 5.0) deaths per 100 child-years. By 12 and 24 months, 84% and 96% of children achieved virologic suppression. The proportion of children with viral rebound increased from 5.4% to 16.3% at 24 and 36 months from start of ART. Younger children (receiving lopinavir/ritonavir-based first-line therapy) with higher viral loads suppressed more slowly and were more likely to die. Children who were started on treatment for tuberculosis at the time of viral suppression were more likely to have virologic rebound.
Despite good treatment outcomes overall, children with advanced disease at ART initiation had poorer outcomes, particularly those <3 years of age, most of whom were treated with lopinavir/ritonavir-containing therapy. The increasing risk of viral rebound over time for the whole cohort is concerning, given currently limited available treatment options for children.
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From the *Department of Paediatrics, Harriet Shezi Children's Clinic, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; †Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; ‡Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University, New York, NY; §Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; and ¶Wits Institute for Sexual Reproductive Health, HIV & Related Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Accepted for publication May 12, 2011.
Supported by grants 5U2RTW007370 and 5U2RTW007373 (to T.M. Fogarty Fellow). The Harriet Shezi Children's Clinic received funding from the United States PEPFAR programme UNICEF, the Elizabeth Glaser Pediatric AIDS Foundation and, Rockefeller Brother's Fund, South African business sector, private donations, individuals, schools and churches; and Supported by grant DHHS/NIH/FIC 5 D43 TW01039–08 and had received support from the UNC Center for Global Initiative (to M.Y. NIH Fogarty Fellow).
The authors have no other funding or conflicts of interest to disclose.
Address for correspondence: Tammy Meyers, MD, Department of Paediatrics, Harriet Shezi Children's Clinic, Chris Hani Baragwanath Hospital, PO Bertsham, 2013, Soweto, Johannesburg, South Africa. E-mail: firstname.lastname@example.org.
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