Review of the missed opportunities for the prevention of vertical transmission of HIV in Brazil

OBJECTIVE: The present literature review aims to highlight gaps in the treatment of preventative mother-to-child HIV transmission and the risk factors in Brazil. METHODS: Among the 425 articles identified in SciELO and PubMed searches, 59 articles published between 1994 and 2016 were selected for reading and data extraction, and 33 articles were included in the present review. RESULTS: The rates of vertical HIV transmission described in the studies varied widely, from 1.8% to 27.8%, with a significant reduction over the years. However, recent rates were also found to be variable in different regions of Brazil, and despite the significant reduction in mother-to-child transmission, many gaps remain in prevention services. A failure to attend prenatal care is the main factor associated with the increased risk of vertical transmission of HIV, hindering early maternal diagnosis and the completion of preventative measures during the prenatal period and, often, the peripartum and postnatal periods. A small number of studies discussed the sociodemographic factors, including a low level of education for pregnant women and the inadequacies of health services, such as difficulties scheduling appointments and undertrained staff, associated with vertical transmission. As such, the current challenge is to better define the sociodemographic and infrastructural factors that increase the risk of mother-to-child transmission of HIV to provide the necessary investments to promote an earlier inclusion of these populations in prevention services. CONCLUSIONS: This review may serve as a guide for future programs to focus efforts on the prevention of vertical HIV transmission.

Cardiovascular complications of HIV / Complicações cardiovasculares do HIV

With the advent of the antiretroviral therapy (ART), people infected with HIV are experiencing a significant increase in life expectancy. However, as this population ages, the morbidity and mortality due to events not related to HIV infection and/or treatment become increasingly clear. Cardiovascular diseases are among the major causes of death, and, thus, understanding the factors that trigger this situation is necessary. This review article will assess how the intrinsic and extrinsic factors related to HIV, ART and the associated risk factors can aid the epidemiological transition of mortality in this population. Moreover, we will present the studies on the epidemiology and pathogenesis of each clinical condition related to HIV-infected individuals, in addition to introducing the major markers of cardiovascular disease in this population. Finally, we will point the main issues to be addressed by health professionals for an adequate prognosis

Transmisión vertical del virus de la inmunodeficiencia humana en mujeres usuarias del Centro Hospitalario Pereira Rossell; Uruguay, 2012-2014. Resultados de la aplicación del protocolo zidovudina - nevirapina en niños uruguayos / Vertical transmission of the HIV in women who are users of the Pereira Rossell Hospital Center, Uruguay 2012-2014. Results of the application of the Zidovudine ­ Nevirapine combined protocol in Uruguayan children / Transmissão vertical do Vírus da Imunodeficiência Humana em mulheres usuárias do Centro Hospitalário Pereira Roussel; Uruguai 2012-2014. Resultados da aplicação do protocolo Zidovudina - Nevirapina em crianças uruguaias

Introducción: el embarazo controlado y la supresión del amamantamiento son estrategias para disminuir la transmisión vertical (TMI) del virus de inmunodeficiencia humana (VIH). La profilaxis al neonato con zidovudina o zidovudina con nevirapina se utiliza según el riesgo de TMI. Objetivo: describir la TMI entre los años 2012 y 2014 en el Centro Hospitalario Pereira Rossell (CHPR), su relación con la carga viral materna y el cumplimiento de la recomendación AZT-NVP al neonato. Material y método: estudio descriptivo en el Centro de Referencia Obstétrico - Pediátrico VIH-Sida desde 1° de setiembre de 2012 al 31de diciembre 2014. Se incluyeron los recién nacidos de mujeres con carga viral detectable o indetectable al momento del parto. Se registró la administración de zidovudina-nevirapina. Se determinó la transmisión vertical. Resultados: se incluyeron 162 mujeres, 86 con carga viral detectable o desconocida y 76 indetectable. Las primeras tuvieron 88 hijos y las segundas 76. La TMI global fue de 4,9%; 9% en el primer grupo y 0% en el segundo. Se registró asociación entre TMI y CV materna (p <0,05). La administración de AZT-NVP se indicó en 46,5% de los niños. De los ocho niños infectados, la TMI fue intraútero en cinco. En los tres restantes, dos recibieron AZT y otro ninguna profilaxis. Discusión y conclusiones: la mitad de las mujeres no controló bien su embarazo. La TMI promedio fue de 4,9%. De los ocho infectados, cinco fueron intraútero; solo un diagnóstico y tratamiento precoces lo hubiesen evitado. El protocolo AZT-NVP no se utiliza en forma adecuada. Quizá su aplicación en los tres niños restantes hubiera evitado la infección.

Introduction: controlled pregnancy and interruption of breastfeeding are strategies used to reduce vertical transmission of the immunodeficiency virus (HIV). Neonates are subject to prophylactic treatment of zidovudine or combination therapy with zidovudine and nevirapine based on the mother-to-child transmission risk. Objective: to describe mother-to-child transmission from 2012 to 2014 at the Pereira Rossell Hospital Center, its relationship with the maternal viral load and the observation of the AZT-NVP prophylactic treatment recommended for neonates. Method: descriptive study, at the Obstetric Pediatrix HIV-Aids Reference Center from September 1, 2012 until December, 31, 2014. The newborns to mother with detectable or undetectable viral loads at the time of delivery. Administration of zidovudine-nevirapine was recorded. Vertical transmission was defined. Results: 162 women were included in the study, 86 of them with a detectable or unknown viral load and 76 women with a detectable load. The first group gave birth to 88 children and the second one to 76. Global mother-to-child transmission rate was 4.9%, 9% in the first group and 0% in the second one. The association between mother-to-child transmission and maternal load was recorded (P<0.05). Administration of AZT-NVP was indicated in 45.5% of children. Intrauterine mother-to child transmission was 5 for the 8 infected children. As to the other three children: 2 received AZT and another one received no prophylactic therapy. Discussion and conclusions: fifty per cent of the women's pregnancies were not dully controlled. Average mother-to-child transmission was 4.9%. Out of the 8 infected cases, 5 happened in the uterus, only an early diagnosis and treatment would have prevented it from happening. The AZT-NVP protocol is not applied in the right way. Its application on the other 3 children may have avoided the infection.

Introdução: o controle da gravidez e a supressão do aleitamento materno são estratégias para diminuir a transmissão vertical (TMI) do Vírus da Imunodeficiência Humana (VIH). No neonato, a profilaxia com zidovudina ou zidovudina com nevirapina é utilizada de acordo com o risco de TMI. Objetivo: descrever a TMI no período 2012-2014 no CHPR, sua relação com a carga viral materna e o cumprimento da recomendação AZT-NVP no neonato. Material e métodos: estudo descritivo, realizado no Centro de Referencia Obstétrico- Pediátrico VIH-Sida no período 1° de setembro de 2012 ­ 31 de dezembro de 2014. Foram incluídos os recém-nascidos de mulheres com carga viral (CV) detectável ou indetectável no momento do parto. A administração de zidovudina ­ nevirapina e a transmissão vertical foram registradas. Resultados: foram incluídas 162 mulheres, 86 com carga viral detectável ou desconhecida e 76 indetectável. As primeiras tiveram 88 filhos e as segundas 76. A TMI global foi de 4,9%, 9% no primeiro grupo e 0% no segundo. A associação entre TMI e CV materna (P<0.05) foi registrada. A administração de AZT-NVP foi indicada em 46.5% das crianças. Nas 8 crianças infectadas, a TMI foi intrauterina em 5 . Nas 3 restantes, duas receberam AZT e a restante não recebeu nenhum tipo de profilaxia. Discussão e conclusões: a metade das mulheres não controlou sua gravidez adequadamente. A TMI média foi de 4.9%. Das 8 infectadas, 5 foram intrauterinas; somente o diagnóstico e tratamento precoces poderiam ter evitado. O protocolo AZT-NVP, não foi utilizado de forma adequada. É possível que sua aplicação nas 3 crianças restantes tivesse evitado a infecção.

Características clínicas y epidemiológicas de embarazadas portadoras de VIH del Hospital Regional de Coronel Oviedo, periodo 2007 - 2017 / Clinical and epidemiological characteristics Of pregnant women with HIV Regional Hospital of Colonel Oviedo, period 2007 - 2017

Introducción: El Virus de la Inmunodeficiencia Adquirida (VIH) se presenta actualmente como uno de los problemas más serios de salud pública a nivel mundial debido a la alta tasa de casos nuevos. En Paraguay, según los últimos informes del PRONASIDA, en el 2017, el 23,92% del total de mujeres que ingresaron al programa fueron embarazadas. Objetivos: Caracterizar a las embarazadas portadoras de VIH en el Hospital Regional de Coronel Oviedo, periodo 2007 - 2017. Materiales y método: Estudio observacional descriptivo de corte transversal. Fueron incluidas todas las embarazadas portadoras de VIH que acudieron al Hospital Regional de Coronel Oviedo, 2007 - 2017 con fichas clínicas completas según los datos de interés para este trabajo. Resultados: Ingresaron al estudio 73 embarazadas portadoras de VIH. La mediana de edad fue de 23 años y la mitad de la población estuvo entre 19 a 28 años. La mayor cantidad de ingresos fueron en los años 2012 y 2014. El 93,15% de las embarazadas procedieron del departamento de Caaguazú y la mayoría fueron captadas en el Hospital Regional de Coronel Oviedo; siendo el rango del primer contacto con el servicio entre las 6 y 39 semanas de gestación. El 69,86% de las gestantes fueron diagnosticadas portadoras del virus antes del embarazo, el 61,64% y el 83,56% utilizó antirretrovirales (ARV) antes y durante del embarazo, respectivamente. El nacimiento se produjo entre las 35 y 40 semanas de gestación, el 93,15% fue por cesárea y el 95,89% de las gestantes recibieron Zidovudina (AZT) endovenoso durante el parto. Conclusión: En este servicio no se encontró ningún caso de transmisión materno-infantil del VIH, por más de que en algunas pacientes el diagnóstico y tratamiento fue a una edad gestacional muy avanzada.

Impacto do tratamento antirretroviral na ocorrência de macrocitose em pacientes com HIV/AIDS do município de Maringá, Estado do Paraná / Impact of antiretroviral therapy on occurrences of macrocytosis in patients with HIV/AIDS in Maringá, State of Paraná

INTRODUÇÃO: AIDS é uma doença causada pelo HIV que compromete o sistema imune do organismo. O advento da terapia antirretroviral (TARV) altamente eficaz promoveu melhora substancial do prognóstico da doença e da qualidade de vida dos pacientes com HIV/AIDS. Durante seu tratamento prolongado, notam-se algumas alterações hematológicas, dentre elas, anemia e macrocitose, bem como carências de micronutrientes, tais como, de vitamina B12 e ácido fólico. O objetivo do presente trabalho é relacionar a macrocitose e anemia ao uso de TARV, ou à deficiência de vitamina B12 ou de ácido fólico. MÉTODOS: Foram avaliados 110 pacientes HIV positivos, comparando-se aqueles em uso de TARV com zidovudina (AZT) (grupo 1), TARV sem AZT (grupo 2) ou sem uso de TARV (grupo 3). RESULTADOS: Os pacientes dos três grupos não apresentaram diferenças estatísticas significativas quanto aos níveis de hemoglobina (p = 0,584) e de ácido fólico (p = 0,956). Os pacientes do grupo 1 (G1) apresentaram volume corpuscular médio (VCM) aumentado quando comparado ao grupo 3 (G3) (p < 0,05), bem como do grupo 2 (G2) em relação ao G3 (p < 0,001). As dosagens de vitamina B12 do G1 e G3 foram menores do que as encontradas pelo G2 (p = 0,008). CONCLUSÕES: Conclui-se que os indivíduos em uso de TARV apresentaram macrocitose, embora não pudesse ser relacionada ao tipo de TARV ou a deficiência de vitamina B12. Entretanto, a deficiência de ácido fólico não esteve relacionada ao uso de TARV e nem à macrocitose.

INTRODUCTION: AIDS is a disease caused by HIV that compromises the organism's immune system. The advent of highly active antiretroviral therapy (HAART) has promoted substantial improvement in the prognosis for this disease and in HIV/AIDS patients' quality of life. During prolonged treatment, certain hematological disorders are observed, such as anemia and macrocytosis, as well as deficiencies of micronutrient such as vitamin B12 and folic acid. The objective of this study was to correlate the presence of macrocytosis and anemia with HAART use or vitamin B12 and folic acid deficiencies. METHODS: 110 HIV-positive patients were included, in three groups: HAART use with zidovudine (AZT) (group 1), HAART use without AZT (group 2) and no HAART (group 3). RESULTS: None of the patients in any of the three groups presented statistically significant differences relating to hemoglobin level (p = 0.584) or folic acid level (p = 0.956). Group 1 (G1) had a higher mean corpuscular volume (MCV) than G3 (p < 0.05), and group 2 (G2) had a higher volume than group 3 (G3) (p < 0.001). Vitamin B12 levels in G1 and G3 were smaller than those in G2 (p = 0.008). CONCLUSIONS: It was concluded that patients undergoing HAART treatment presented macrocytosis, even though this could not be correlated with the type of HAART or with vitamin B12 deficiency. However, folic acid deficiency was unrelated to either HAART or macrocytosis.

High incidence of zidovudine induced anaemia in HIV infected patients in eastern India.

Background & objectives: Zidovudine (ZDV) is the preferred nucleoside reverse transcriptase inhibitor in the first line antiretroviral regimen in India. It is known to be associated with life threatening toxicity like anaemia. This study was aimed at determining the prevalence of ZDV induced anaemia in HIV infected patients initiated on ZDV containing antiretroviral therapy regimen and also to find out the correlates, if any, for causing ZDV induced anaemia. Methods: This retrospective study was carried in ART Centre, Sir Sunderlal Hospital, Banaras Hindu University, Varanasi between March 2005 to December 2007. HIV infected patients registered at ART Centre were treated according to guidelines of National AIDS Control Organization (NACO). Patients (n=1256) with haemoglobin (Hb) >8 g/dl were prescribed ZDV based antiretroviral therapy regimens. Patients developing anaemia (<8 g/dl) with other causes of anaemia excluded were recorded. Correlation of baseline characteristics (age, gender, haemoglobin levels, weight, CD4 counts and WHO clinical stage) with risk of developing anaemia was also calculated. Results: Two hundred three (16.2%) patients on ZDV regimen developed anaemia (<8 g%); 7.9 per cent (n=100) of these developed severe anaemia (<6.5 g%). Females were more prone to develop anaemia (P=0.026). Age, weight, WHO clinical stage and CD4 counts had no relation to development of anaemia. Interpretation & conclusion: High incidence of ZDV induced anaemia seen in this study indicates regular monitoring of patients, particularly women on ZDV based antiretroviral regimens.

Efectos adversos y uso de antirretrovirales en el centro de atención integral VIH-Sida pediátrico del Hospital Nacional Dr. Mario Catarino Rivas / Adverse effects and use of antiretrovirals at the comprehensive pediatric HIV-AIDS center at the Dr. Mario Catarino Rivas National Hospital

En la tercera dé cada de la infecci ón por VIH, las nuevas terapias antirretrovirales han transformado la enfermedad de mortal a crónica. La realidad actual es reconocer que el prin- cipal y único enemigo del VIH es la preven- ción. Los ni ños infectados por VIH tambi én se han beneficiado de los avances en los conocimientos de la propia infecci ón, t écni cas diagnó sticas y de los tratamientos anti - rretrovirales del momento, igual que los adultos. Desde 1996, los niños infectados por el virus de la inmunodeficiencia humana reci ben tratamientos antirretrovirales denomina dos de gran actividad (TARGA). Se realiz ó un estudio Retrospectivo, anal ítico, longitudinal de dichos efectos en los pacientes atendidos en el Cen tro de Atenci ón integral (CA Í) del Hospital Nacional Dr. Mario Catarino Rivas de San Pedro Sula, en el periodo comprendido desde Enero del añ o 2000, hasta Noviembre del 2010, con una poblaci ón de 406 pacientes los cuales recibieron TARGA en nuestro hospital...(AU)

Towards the complete eradication of mother-to-child HIV/HBV coinfection at Saint Camille Medical Centre in Burkina Faso, Africa

The coinfection of HIV and hepatitis B virus (HBV) and their vertical transmission constitute a public health problem in sub-Saharan countries of Africa. The objectives of this research are: i) identify the pregnant women that are coinfected by HIV and HBV at Saint Camille Medical Centre; ii) use three antiretroviral drugs (zidovudine, nevirapine and lamivudine) to interrupt the vertical transmission of HIV and HBV from infected mothers; and iii) use the PCR technique to diagnose children who are vertically infected by these viruses in order to offer them an early medical assistance. At Saint Camille Medical Centre, 115 pregnant women, aged from 19 to 41 years, were diagnosed as HIV-positive and, among them, 14 coinfected with HBV. They had at least 32 weeks of amenorrhoea and all of them received the HAART, which contained lamivudine. Two to six months after childbirth, the babies underwent PCR diagnosis for HIV and HBV. The results revealed that, among these mothers, 64.4 percent were housewives, 36.5 percent were illiterates, and only 1.7 percent had a university degree. The rate of vertical transmission of HIV and HBV was 0.0 percent (0/115) and 21.4 percent (3/14), respectively. The 3 mothers who transmitted the HBV to their children had all HBsAg, HbeAg, and HBV DNA positive. An antiretroviral therapy that in addition to zidovudine and nevirapine includes lamivudine could, as in the present study, block or reduce the vertical transmission in HIV positive pregnant women who are coinfected with HBV.

Rapid HIV diagnostic test in undocumented pregnant women applied at an inner-city teaching hospital / Diagnóstico da infecção pelo HIV através de um teste rápido em gestantes sem resultados comprobatórios atendidas em um hospital escola do interior

A significant number of Brazilian gestational-age women are still not tested for HIV, representing a high risk of transmission to their newborns. The current study sought to identify the number of pregnant women with no previous testing or undocumented for HIV referred to the Gynecology and Obstetrics Department of a Regional Teaching Hospital and included diagnosis of HIV infection determined by a rapid test and perinatal transmission in pregnancy. Medical records of all pregnant women admitted to hospital from January 2001 to December 2005 were reviewed. Pregnant women without HIV results were submitted to a rapid HIV test. Those who tested positive were further tested by ELISA and confirmed by indirect immunofluorescence assay (IIA) or Western blot (WB). The viral load from babies born to HIV-infected mothers was assessed by bDNA. Of the 16,424 pregnant women analyzed (6.6 percent), 1,089 were undocumented for HIV. Eleven women were positive in rapid testing and 10 were confirmed by ELISA, IIA or WB, with 0.9 percent seropositivity. Mother/infant pairs received zidovudine monotherapy prophylaxis and infant viral load was lower than 50 copies/mL. A higher number of pregnant women previously tested for HIV during antenatal care was verified, compared to that obtained nationwide.

No Brasil um número significativo de mulheres em idade gestacional ainda não foi testado para HIV, representando risco acentuado de transmissão vertical. Nosso objetivo foi determinar o número de gestantes que não foram previamente testadas ou não portavam documentos comprobatórios para HIV, ou seja, o diagnóstico da infecção para HIV através de um teste rápido e a transmissão vertical em gestantes admitidas no Departamento de Ginecologia e Obstetrícia de um Hospital Universitário Regional. Foram revisados os prontuários das gestantes admitidas entre janeiro de 2001 e dezembro de 2005. Gestantes sem resultados para HIV foram submetidas a um teste rápido. Testes positivos foram submetidos ao teste de ELISA e confirmados por imunofluorescência indireta (IIA) ou Western blot (WB). A carga viral dos recém-nascidos de mães infectadas foi determinada por bDNA. Dentre as 16.424 gestantes analisadas, 6,6 por cento (1.089) não apresentaram resultados comprobatórios. Onze gestantes tiveram resultados positivos no teste rápido e 10 foram confirmadas por ELISA, IIA ou WB com 0,9 por cento de positividade. Mães e recém-nascidos receberam profilaxia com zidovudina e todos os recém-nascidos tiveram carga viral inferior a 50 copias/mL. Foi encontrado um número maior de gestantes previamente testadas para HIV quando comparado à média obtida no país.

Profilaxia da transmissão vertical do vírus da imunodifeciência humana tipo 1 / Prophylaxis of vertical transmission human immunodeficiency virus type 1

O conhecimento progressivo dos fatores ou situações que influenciam a transmissão vertical (TV) do vírus da imunodeficiência humana tipo 1 (HIV-1) possibilitou a adoção de estratégias profiláticas com redução notável de suas taxas ao longo dos anos. Dos primeiros relatos indicando 35 por cento de TV desse vírus, observam-se taxas menores que 1 por cento na atualidade. Dentre as intervenções pré-natais de maior impacto sobre a transmissão perinatal do HIV-1 sobressai a utilização de antirretrovirais (ARV), o controle das infecções gerais e genitais, evitar condutas invasivas sobre o feto assim como sexo sem preservativos e afastar-se do uso de drogas lícitas e ilícitas. Atualmente, os esquemas de ARV consideram a Highly Active Anti-Retroviral Therapy (HAART), independete de sua finalidade terapêutica (materna) ou profilática (TV do HIV-1). O esquema HAART mais utilizado contempla a associação de inibidores da transcriptase reversa (zidovudina e lamivudina) com inibidores da protease (lopinavir e ritonavir). Completando o ciclo das estratégias obstétricas de maior impacto na redução da TV do HIV-1 está a cesárea eletiva, cuja efetividade está ligada à observação dos critérios de sua indicação (carga viral > 1.000 cópias/ml, gestação >38 semanas, membranas íntegras e fora de trabalho de parto). Sempre que possível deve-se evitar corioamniorrexe prolongada, manobras invasivas sobre o feto, parto instrumentalizado e episiotomia. Das intervenções pós-natais consideradas importantes para a redução da TV do HIV-1 são apontadas a recepção pediátrica de boa qualidade, utilização da zidovudina neonatal e a amamentação artificial.

The progressive knowledge about the factors or situations that influence the vertical transmission (VT) of human immunodeficiency type 1 (HIV-1) has led to the implementation of strategies which have promoted a remarkable decline along the years. From the first results showing 35 percent, it is possible to observe less than 1 percent nowadays. Among the prenatal interventions with higher impact on the HIV-1 VT the most evident are the use of antiretrovirals (ARV), the control of general and genital infections, and to avoid fetal invasion. Additionally, we recognize the importance of protected sex with condom and to avoid licit and illicit drugs. The modern schemes of ARV drugs during pregnancy consider the Highly Active Antiretroviral Therapy (HAART) as a rule, independently if indication is therapeutic (for mothers) or prophylactic (to avoid VT of HIV-1). The most used HAART schema among pregnant women considers the association of reverse transcriptase inhibitors (zidovudine and lamivudine) with protease inhibitors (lopinavir and ritonavir). Completing the cycle of obstetrical strategies for greater impact on reduction of VT of HIV-1, we point that the elective cesarean section has its positive role linked to the criteria of its indication (viral load higher than 1,000 copies/ml, pregnancy with more than 38 weeks, integrity of membranes, and before start the uterine contractions). If possible, we need to avoid prolonged rupture of membranes, invasive fetal management, forceps and episiotomy. Among the postnatal interventions considered important to reduce VT of HIV-1 we point that the good quality of neonatal reception, use of neonatal zidovudine, and bottle-feeding are the best.

Enterocolitis necrosante en un niño prematuro hijo de padres VIH+ / Necrotizing enterocolitis observed in a premature newborn with HIV+parents

En Cuba, entre el 1ero. de enero de 1986 y el 30 de abril de 2007 nacieron 280 niños hijos de madres VIH+. De ellos solo 22 (7,8 por ciento) nacieron con edad gestacional menor de 37 semanas y solo uno (4,5 por ciento) presentó una enterocolitis necrosante. En el presente artículo se describe un episodio de esta enfermedad en un niño prematuro hijo de padres VIH+, supuestamente asociado al uso profiláctico de zidovudina en las madres seropositivas por la posibilidad de producir toxicidad mitocondrial en el feto. Con el tratamiento quirúrgico empleado, la evolución del niño fue favorable. El caso presentado constituye una evidencia que el personal médico debe tener en cuenta para el cuidado y diagnóstico de estos pacientes.

In Cuba, from January 1, 1986 to April 30, 2007 were born 280 children from HIV+ mothers. Only 22 (7, 8 percent) had a gestational age under 37 weeks and only one (4, 5 percent) presented with a necrotizing enterocolitis. In present paper we describe an episode of this disease in a premature baby son of HIV+ parents, supposedly associated with prophylactic use of Zidovudine in seropositive mothers by possibility to produce mitochondria toxicity in fetus. This case is an evidence that family physician must to assess for care and diagnosis of these patients.

Adherence to antiretroviral drug therapy in children with HIV/AIDS in Jamaica / Adhesión a la terapia con medicamento antiretroviral en niños con VIH/SIDA en Jamaica

OBJECTIVE: We aimed to describe the adherence patterns to antiretroviral therapy (ART) in a cohort of HIV-infected children. METHODS: Between the periods May to October 2005, 63 HIV-infected children and their caregivers recruited consecutively at four Paediatric Infectious Disease Clinics in Greater Kingston and St Catherine, Jamaica, were interviewed. Adherence was defined as no missed doses in the last four days. Biomedical markers and factors associated with adherence were explored. RESULTS: Global adherence level was 85.7% (54/63) and was significantly higher for children in residential care (approaching 100%) compared to 76.3% for children in family care (p = 0.008). Children had median age 7.9 years (range 0.8 - 19.4 years) and 57% were male. Median duration on ART was 18.3 months (range 0.1 - 123.8 months). Median CD4 count and per cent available for 95.2% (60/63) and 92.1% (58/63) children were 440 cells per µL (IQR 268-897 cells/µL) and 24.9% (IQR 15.6-42.7 %), respectively. Median viral load was 9.60 x 103 copies/ml (IQR 0.05 x 103 - 52.50 x 103) with 16% (10/63) having viral loads # 50 copies/ml. Children in residential care (n = 26), receiving directly observed therapy had higher CD4 counts (p = 0.006) and CD4 per cent (p # 0.001). Factors associated with non-adherence were primarily caregiver related, especially long work hours (p = 0.002) and nausea as a side effect of ART (p = 0.007). Non-adherence was positively correlated with missing clinic appointments (r = 0.342, p = 0.009) and increasing age of child (r = 0.310, p = 0.013). CONCLUSION: In resource-limited settings, psychosocial factors contribute significantly to non-adherence and should complement biomedical markers in predicting adherence to antiretroviral therapy in children.

OBJETIVO: Este trabajo tiene por objeto describir los patrones de adhesión a la terapia antiretroviral (TAR) en una cohorte de niños infectados por el VIH. MÉTODOS: Entre los períodos de mayo a octubre de 2005, se entrevistaron 63 niños infectados con el VIH y las personas a cargo de su cuidado, reclutados consecutivamente en cuatro clínicas pediátricas de enfermedades infecciosas en Greater Kingston y Saint Catherine, Jamaica. La adhesión fue definida en términos de las dosis no perdidas en los últimos cuatro días. Se exploraron los marcadores y factores biomédicos asociados con la adhesión. RESULTADOS: El nivel de adhesión global fue de 85.7% (54/63) y fue significativamente más alto para niños en cuidados residenciales (cerca de 100%) en comparación con el 76.3% de los niños en cuidado familiar (p = 0.008). La edad promedio de los niños fue de 7.9 años (rango 0.8 - 19.4 años) y el 57% eran varones. La duración promedio del TAR fue de 18.3 meses (rango 0.1 - 123.8 meses). El conteo medio de CD4 y el porciento disponible para el 95.2% (60/63) y el 92.1% (58/63) de los niños fueron 440 células por µL (IQR 268-897 células/µL) y 24.9% (IQR 15.6 - 42.7 %), respectivamente. La carga viral media fue 9.60 x 103 copias/ml (IQR 0.05 x 103 - 52.50 x 103) con 16% (10/63) con cargas virales # 50 copias/ml. Los niños en cuidado residencial (n = 26), que recibían terapia directamente observada, tuvieron conteos más altos CD4 (p = 0.006) y porciento de CD4 (p # 0.001). Los factores asociados con la no adhesión estuvieron fundamentalmente relacionados con el encargado del cuidado, especialmente largas horas de trabajo (p = 0.002) y náuses como un efecto colateral de TAR (p = 0.007). La no adhesión fue correlacionada positivamente con los turnos médicos perdidos (r = 0.342, p = 0.009) y el aumento de la edad del niño (r = 0.310, p = 0.013). CONCLUSIÓN: En escenarios donde los recursos son limitados, los factores psicosociales contribuyen significativamente a la no adhesión y deben complementar los marcadores biológicos a la hora de predecir la adhesión a la terapia antiretroviral en niños.

Safety of antiretroviral drug therapy in Jamaican children with HIV/AIDS / Seguridad de la terapia con medicamento antiretroviral en niños jamaicanos con VIH/SIDA

BACKGROUND: HIV has been a leading cause of death in Jamaican children aged # five years. Antiretroviral drugs (ARVs) are increasingly available in Jamaica through the Global Fund. Adverse effects of ARVs are a major cause for non-adherence to medications. Knowledge of the use and side effects of these drugs are crucial in the management of HIV-infected children as we scale-up the use of antiretroviral therapy, islandwide. We evaluated the adverse events and safety of antiretroviral therapy in children attending four Infectious Disease Clinics in Kingston, Jamaica, a resource limited setting. METHODS: Data for children prospectively enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme during September 2002 to April 2005 were analyzed. RESULTS: Among 121 HIV-infected children, 77 (64%) were on ARVs, 90% had CDC class C disease, 60% were males and perinatal transmission predominated. AZT/3TC based regime was utilized in 93%, trimethoprim/sulphamethoxazole prophylaxis was used in 100% and five were completing anti-tuberculous drugs. Anaemia occurred in all patients, with increased severity in those on ARVs. Macrocytosis occurred in 83% and thrombocytopenia in 8% of those on ARVs. Elevation of bilirubin, aspartate transaminase (AST) and alanine transaminase (ALT) levels and reversed albumin to globulin ratio prior to commencing ARVs, with significantly lower prevalence following use of ARVs emphasized the severity of HIV disease at time of ARV initiation. Clinical adverse reactions were uncommon and included nail discoloration (8%), vomiting (7%), nausea (3%), peripheral lipodystrophy (4%) and abnormal dreams (1%). Ten children required change of ARV medication because of severe adverse effects: three for severe anaemia with repeat blood transfusions, three for severe nevirapine-associated rash and four for indinavir-associated haematuria. CONCLUSIONS: ARVs are being successfully initiated in HIV-infected Jamaican children using the public health model. The excellent safety profile, good tolerance and few reported significant adverse effects augur well as antiretroviral therapy is scaled-up islandwide.

ANTECEDENTES: EL VIH ha sido la principal causa de muerte en los niños jamaicanos de # cinco años de edad. Las drogas antiretrovirales (ARVs) se hallan cada vez más a disposición en Jamaica a través del Fondo Global. Los efectos adversos de los ARVs constituyen una causa fundamental para la no adherencia a los medicamentos. El conocimiento del uso y los efectos colaterales de estos medicamentos son cruciales para el tratamiento de los niños infectados por VIH en la medida en que escalamos el uso de la terapia antiretroviral a lo largo de toda la isla. Evaluamos los eventos adversos y la seguridad de la terapia antiretroviral en niños que asisten a cuatro clínicas de enfermedades infecciosas en Kingston, Jamaica, las cuales constituyen un escenario limitado en recursos. MÉTODOS: Se analizaron los datos de niños prospectivamente alistados en el Programa VIH/SIDA Prenatal y Pediátrico de Kingston, Jamaica, durante septiembre de 2002 hasta abril de 2005. RESULTADOS: Entre los 121 niños infectados con VIH, 77 (64%) estaban bajo medicación con ARVs, 90% tenían enfermedades del subgrupo C según la clasificación de CDC, 60% eran varones y predominó la transmisión perinatal. El régimen basado en AZT/3TC fue utilizado en 93%, trimeto-prima/sulfametoxazol se usó en el 100%, y cinco estaban completando medicamentos antituberculosos. La anemia estaba presente en todos los pacientes, con mayor severidad en aquellos bajo ARVs. Se observó macrocitosis en el 83% y trombocitopenia en un 8% de los que se hallaban bajo ARVs. La elevación de los niveles de bilirrubina, aspartato transaminasa (AST) y alanina transaminasa (ALT) y la relación albúmina/globulina invertida antes de comenzar con los ARVs, con una prevalencia significativamente menor tras el uso de los ARVs, enfatizaron la severidad de la enfermedad del VIH al momento de la iniciación del ARV. Las reacciones clínicas adversas fueron poco común e incluyeron decoloración de las uñas (8%), vómitos (7%), náuseas (3%), lipodistrofia periférica (4%) y sueños anormales (1%). Diez de los niños necesitaron cambio de medicación ARV debido a los severos efectos adversos: tres a causa de una anemia severa con repetidas transfusiones de sangre, tres debido a una severa erupción asociada con la nevirapina, y cuatro a causa de hematuria asociada con indinavir. CONCLUSIONES: Los medicamentos ARVs han comenzado a ser administrados exitosamente en niños jamaicanos infectados por el VIH, usando el modelo de salud pública. El excelente perfil de seguridad, la buena tolerancia y el pequeño número de efectos adversos significativos reportados, auguran un buen futuro a la escalada de la terapia antiretroviral en toda la isla.