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Predictors of Adverse Outcomes in HIV-1–infected Children Receiving Combination Antiretroviral Treatment: Results From a DREAM Cohort in Sub-Saharan Africa

Marazzi, Maria Cristina MD*†; De Luca, Simona MD†‡; Palombi, Leonardo MD†‡; Scarcella, Paola MD*†; Ciccacci, Fausto MD†‡; Ceffa, Susanna PhD; Nielsen-Saines, Karin MD, MPH§; De Luca, Andrea MD¶‖; Mancinelli, Sandro MD†‡; Gennaro, Elisabetta MD†‡; Zimba, Ines MD**; Liotta, Giuseppe MD†‡; Buonomo, Ersilia MD†‡

The Pediatric Infectious Disease Journal: March 2014 - Volume 33 - Issue 3 - p 295–300
doi: 10.1097/INF.0b013e3182a0994b
HIV Reports

Background: HIV-infected children have less access to combination antiretroviral therapy as compared with adults in resource-limited settings. Growth faltering, loss to follow-up (LTFU) and high mortality are frequently seen.

Methods: A retrospective cohort study was performed with parameters extracted from the Drug Resource Enhancement against AIDS and Malnutrition database for HIV-infected, antiretroviral naïve children under 15 years presenting for care at 17 Drug Resource Enhancement against AIDS and Malnutrition centers in Mozambique, Malawi and Guinea between January 2005 to December 2008. Predictors of time-to-death, time-to-LTFU and persistence of malnutrition by Cox’s regression and Kaplan–Meier were determined.

Results: 2215 children presented to care with 1343 (61%) being ≤5 years. At baseline, stunting and malnutrition occurred in 40% and 25%, respectively; 75% of 2149 children had CD4 cell percentages less than 20; median HIV RNA, log10 cp/mL, was 4.97 in 1927 patients. Over time 238 children died (10.7%; 2.7% person-years [PY]) 63 were LTFU (2.8%; 0.7% PY). By multivariate analysis, mortality was associated with virus load (hazards ratio: 1.19; confidence interval: 1.01–1.402, P = 0.038) and reduced weight-for-age Z scores (hazards ratio: 0.590; confidence interval: 0.53–0.66, P < 0.001). LTFU was associated with low weight-for-height Z scores (hazards ratio: 0.71; confidence interval: 0.51–0.97, P = 0.031). At 12 months after combination antiretroviral therapy, anthropometric parameters significantly improved in 1226 children (P < 0.001); virus load declined to <400 copies/mL in over 60%.

Conclusions: Despite advanced HIV disease, children initiating combination antiretroviral therapy had mortality rates of 2.7% p/PY with overall attrition rates of 11.7% p/100 PY, with significant reversal of negative anthropometric markers, and improvement of immunological and virological parameters in children with 12 months of follow-up.

Supplemental Digital Content is available in the text.

From the *Department of Preventive Medicine, LUMSA University (Libera Università Maria SS. Assunta); DREAM Program; Department of Biomedicine and Prevention, Tor Vergata University, via Montpellier, Rome, Italy; §Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA; Azienda Ospedaliedra Universitaria Senese, Siena; Università Cattolica Sacro Cuore, Rome, Italy; and **DREAM Program Mozambique, Maputo, Mozambique.

Accepted for publication May 29, 2013.

The DREAM Program of the Sant’Egidio Community, Rome, Italy, is sponsored by multiple organizations, including the World Bank Treatment Acceleration Program, several Italian private banks, several governmental cooperations including the German Agency for Technical Cooperation, the Agence Française de Développement, Catalan Agency for Development Cooperation and the Belgium Development Cooperation among others. The present article was not funded by a specific award. The authors have no other funding or conflicts of interest to disclose.

Address for correspondence: Karin Nielsen-Saines, MD, MPH, Department of Pediatrics, David Geffen School of Medicine at UCLA, MDCC 22–442, 10833 LeConte Ave, Los Angeles, CA 90095. E-mail:

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© 2014 by Lippincott Williams & Wilkins, Inc.