HIV Disclosure to Infected Children Involving Peers: A New Take on HIV Disclosure in the Democratic Republic of Congo.

Appropriately informing HIV-infected children of their diagnosis is a real challenge in sub-Saharan Africa. Until now, there is no consensus on who ought to disclose and how to disclose. This paper describes the model for HIV status disclosure in which HIV-positive children/adolescents are informed about their diagnosis in a process conducted by young peers under healthcare worker (HCW) supervision in a hospital in Kinshasa, the Democratic Republic of Congo. This new take on HIV status disclosure involving peers includes four stages that help the trained peer supporters to provide appropriate counseling, taking into account the age and level of maturity of the child/adolescent: the preliminary stage, the partial disclosure stage, the full disclosure stage, and the post-disclosure follow-up stage. Of all children/adolescents whose HIV status disclosure data were documented at Kalembelembe Pediatric Hospital (KLLPH) between 2004 and 2016, we found that disclosure by peers was highly accepted by parents, children/adolescents, and health workers. Compared to children/adolescents disclosed to by HCWs or parents, children/adolescents disclosed to by peers had (a) fewer depressive symptoms reported, (b) better drug adherence resulting in higher viral load suppression, and (c) a higher proportion of survivors on treatment. We found that involving peers in the disclosure process of HIV is an important approach to ensure adherence to treatment, resilience, and mental wellbeing of HIV-infected children/adolescents.

Caregivers' Perspective on the Psychological Burden of Living with Children Affected by Sickle Cell Disease in Kinshasa, the Democratic Republic of Congo.

There is limited information on knowledge, perceptions, and management of sickle cell disease (SCD) in Africa in general and in the Democratic Republic of the Congo (DRC) in particular. This study explored knowledge, perceptions, and burden of 26 parents/caregivers of children with SCD in three selected hospitals in Kinshasa, DRC. We conducted a focus group with in-depth interviews with parents/caregivers of children affected with SCD. Four themes were discussed, including knowledge and perceptions, diagnosis and management, society's perceptions, and the psychosocial burden and the quality of life of the family affected by SCD. The majority of participants/caregivers felt that society, in general, had negative perceptions of, attitudes toward, and knowledge about SCD. They reported that children with sickle cell are often marginalized, ignored, and excluded from society or school. They face a number of challenges related to care, management, financial difficulties, and a lack of psychological support. The results suggest the need to promote measures and strategies to improve knowledge and management of SCD in Kinshasa, DRC.

Lessons Learned from the Impact of HIV Status Disclosure to Children after First-Line Antiretroviral Treatment Failure in Kinshasa, DR Congo.

HIV status disclosure to children remains a challenge in sub-Saharan Africa. For sociocultural reasons, parents often delay disclosure with subsequent risks to treatment compliance and the child's psychological well-being. This article assesses the effects of HIV disclosure on second-line ART compliance after first-line failure. We conducted a retrospective study of 52 HIV-positive children at Kalembelembe Pediatric Hospital in Kinshasa who were unaware of their HIV status and had failed to respond to the first-line ART. Before starting second-line ART, some parents agreed to disclosure. All children were followed before and during the second-line ART. Conventional usual descriptive statistics were used. For analysis, the children were divided into two groups: disclosed to (n = 39) and not disclosed to (n = 13). Before starting the second-line ART, there was no difference in CD4 count between the two groups (p = 0.28). At the end of the first year of second-line ART, the difference was statistically significant between the two groups with regard to CD4% (p < 0.001) and deaths (p = 0.001). The children disclosed to also reported fewer depressive symptoms post-disclosure and had three times fewer clinic visits. HIV status disclosure to children is an important determinant of ART compliance and a child's psychological well-being.

"The Peer Educator Is the Game-Changer of My Life": Perceptions of Adolescents Living with HIV in DR Congo on Involving Peer Educators in the Process of HIV Disclosure.

Several approaches to the disclosure of HIV status to children and adolescents have been described. Each of these places particular emphasis on the role of parents and health care workers (HCWs) to mitigate the impact of disclosure on the adolescent without exploring the possible roles that other individuals might play in the process of disclosure. This article assesses the perceptions of adolescents living with HIV (ALHIV) about disclosure done by parents, guardians, HCWs, peer educators in the role of peer supporters, accidentally or by self-discovery, and the subsequent effects of disclosure method on their mental health. We used a qualitative study to conduct semi-structured interviews with 73 ALHIV at the Kalembelembe Paediatric Hospital, in DR Congo disclosed to by parents, guardians, HCWs, and/or peer educators, respectively, or disclosed to accidentally or by self-discovery. Microsoft Excel analysis matrix was used to organize the qualitative data. The majority of ALHIV whose disclosure involved a peer educator unanimously acknowledged the important role of the peer in accepting their HIV status, in their ART adherence, and their development of self-esteem. However, most ALHIV disclosed without involving peers declared that they had accepted their situation after a relatively long period followed by contact with the peer and integration in the self-support group. We found that the peer approach is the game-changer of the HIV status disclosure process that would allow ALHIV to accept their HIV status with minimum distress, it builds resilience, and allows them to adhere to treatment.

APOL1 Risk Genotypes Are Associated With Early Kidney Damage in Children in Sub-Saharan Africa.

INTRODUCTION: Apolipoprotein-L1 (APOL1) risk variants G1 and G2 increase the risk of chronic kidney disease (CKD), including HIV-related CKD, among African Americans. However, such data from populations living in Africa, especially children, remain limited. Our research aimed to determine the prevalence of APOL1 risk variants and to assess the association between these variants and early-stage CKD in the general pediatric population and HIV-infected children. METHODS: In a cross-sectional study, we enrolled 412 children from the general population and 401 HIV-infected children in Kinshasa, Democratic Republic of Congo (DRC). APOL1 high-risk genotype (HRG) was defined by the presence of 2 risk variants (G1/G1, G2/G2, or G1/G2), and low-risk genotype (LRG) by the presence of 0 or 1 risk variants. The main outcome was elevated albuminuria, defined as a urinary albumin/creatinine ratio ≥30 mg/g. RESULTS: APOL1 sequence analysis revealed that in the general population, 29 of 412 participants (7.0%) carried HRG, 84 of 412 (20.4%) carried the G1/G0 genotype, and 61 of 412 (14.8%) carried the G2/G0 genotype. In HIV-infected children, 23 of 401 (5.7%) carried HRG, and the same trend as in the general population was observed in regard to the prevalence of LRG. Univariate analysis showed that in the general population, 5 of 29 participants (17.2%) carrying HRG had elevated albuminuria, compared with 35 of 383 (9.0%) with LRG (odds ratio [OR] 2.1, 95% confidence interval [CI] 0.6-6.0; P = 0.13). In HIV-infected children, participants who carried APOL1 HRG had almost 22-fold increased odds of albuminuria compared to those with LRG. CONCLUSION: The APOL1 risk variants are prevalent in children living in DRC. HRG carriers have increased odds of early kidney disease, and infection with HIV dramatically increases this probability.

Simple markers for the detection of severe immunosuppression in children with HIV infection in highly resource-scarce settings: experience from the Democratic Republic of Congo.

OBJECTIVES: The decision to initiate the antiretroviral therapy in HIV-infected children living in poor countries is compromised by lack of resources. The objective of this study is to identify simple clinical and biological markers other than CD4+ count and viral load measurement that could help the decision to introduce antiretroviral treatment and to monitor patients. METHODS: A cross sectional study was conducted between January and March 2005 in Kinshasa, Democratic Republic of Congo. RESULTS: Eighty-four children infected with HIV were recruited. In this cohort, the lymphocytes (P = 0.001) and CD4 (P = 0.0001) were significantly lower in children with immunological stage 3 and viral load (P = 0.027) was significantly higher in children at the same immunological stage. Reticulocytes (r = +0.440), white blood cells count (r = +0.560), total lymphocytes (r = +0.675) and albumin (r = +0.381) showed positive significant correlations with CD4. Haemoglobin (r = - 0.372), Haematocrit (r = - 0.248), red blood cells (r = - 0.278) and CD4 (r = - 0.285) showed negative significant correlations with viral load. Neutropaenia (P = 0.02), enlarged nodes (P = 0.005) and oral candidiasis (P = 0.04) were associated with viral load >10,000 copies/ml. Oral candidiasis (P = 0.02) was associated with CD4 level < 15%. CONCLUSION: Oral candidiasis, enlarged nodes, total lymphocytes count, neutropaenia and albumin predict severe immunodepression. These clinical and biological markers may guide the clinician in making the decision to initiate antiretroviral therapy in highly resource-scarce settings.

Quantification of CD4 responses to combined antiretroviral therapy over 5 years among HIV-infected children in Kinshasa, Democratic Republic of Congo.

BACKGROUND: The long-term effects of combined antiretroviral therapy (cART) on CD4 percentage in HIV-infected children are incompletely understood, with evidence from resource-deprived areas particularly scarce even though most children with HIV live in such settings. We sought to describe this relationship. METHODS: Observational longitudinal data from cART-naive children enrolled between December 2004 and May 2010 into an HIV care and treatment program in Kinshasa, Democratic Republic of Congo were analyzed. To estimate the effect of cART on CD4 percentage while accounting for time-dependent confounders affected by prior exposure to cART, a marginal structural linear mean model was used. RESULTS: Seven hundred ninety children were active for 2090 person-years and a median of 31 months; 619 (78%) initiated cART. At baseline, 405 children (51%) were in HIV clinical stage 3 or 4; 528 (67%) had advanced or severe immunodeficiency. Compared with no cART, the estimated absolute rise in CD4 percentage was 6.8% [95% confidence interval (CI), 4.7% to 8.9%] after 6 months of cART, 8.6% (95% CI, 7.0% to 10.2%) after 12 months, and 20.5% (95% CI, 16.1% to 24.9%) after 60 months. cART-mediated CD4 percentage gains were slowest but greatest among children with baseline CD4 percentage <15. The cumulative incidence of recovery to "not significant" World Health Organization age-specific immunodeficiency was lower if cART was started when immunodeficiency was severe rather than mild or advanced. CONCLUSIONS: cART increased CD4 percentages among HIV-infected children in a resource-deprived setting, as previously noted among children in the United States. More gradual and protracted recovery in children with lower baseline CD4 percentages supports earlier initiation of pediatric cART.

Barriers to and facilitators of adherence to pediatric antiretroviral therapy in a sub-Saharan setting: insights from a qualitative study.

Despite the need for HIV-positive children to adhere effectively to antiretroviral treatment (ART), a guiding theory for pediatric ART in resource-limited settings is still missing. Understanding factors that influence pediatric ART adherence is critical to developing adequate strategies. In-depth qualitative interviews were undertaken in Kinshasa, Democratic Republic of the Congo, with 20 sets of HIV disclosed and nondisclosed children along with respective caregivers to better characterize barriers, facilitators, and adherence experiences in children taking ART. Commonly cited barriers included lack of food or nutritional support, lack of assistance or supervision for children, lack of assistance for caregivers, and being unable to remember to take medicines on a consistent basis. Facilitators included having a strong caregiver-child relationship and support system along with strategies for maintaining adherence. Similar themes arose within the child-caregiver sets, but were often characterized differently between the two. Children who were aware of their HIV status displayed fewer instances of frustration and conflict concerning taking medicines and within the child-caregiver relationship. Continued study on pediatric ART adherence should account for differing perspectives of children and caregivers, as well as between status disclosed and nondisclosed children. Areas of future intervention should focus on child-caregiver relationships, disclosure of HIV status, and available nutritional and psychosocial support for children and their caregivers.

The effect of highly active antiretroviral therapy on the survival of HIV-infected children in a resource-deprived setting: a cohort study.

BACKGROUND: The effect of highly active antiretroviral therapy (HAART) on the survival of HIV-infected children has not been well quantified. Because most pediatric HIV occurs in low- and middle-income countries, our objective was to provide a first estimate of this effect among children living in a resource-deprived setting. METHODS AND FINDINGS: Observational data from HAART-naïve children enrolled into an HIV care and treatment program in Kinshasa, Democratic Republic of the Congo, between December 2004 and May 2010 were analyzed. We used marginal structural models to estimate the effect of HAART on survival while accounting for time-dependent confounders affected by exposure. At the start of follow-up, the median age of the 790 children was 5.9 y, 528 (66.8%) had advanced or severe immunodeficiency, and 405 (51.3%) were in HIV clinical stage 3 or 4. The children were observed for a median of 31.2 mo and contributed a total of 2,089.8 person-years. Eighty children (10.1%) died, 619 (78.4%) initiated HAART, six (0.8%) transferred to a different care provider, and 76 (9.6%) were lost to follow-up. The mortality rate was 3.2 deaths per 100 person-years (95% confidence interval [CI] 2.4-4.2) during receipt of HAART and 6.0 deaths per 100 person-years (95% CI 4.1-8.6) during receipt of primary HIV care only. The mortality hazard ratio comparing HAART with no HAART from a marginal structural model was 0.25 (95% CI 0.06-0.95). CONCLUSIONS: HAART reduced the hazard of mortality in HIV-infected children in Kinshasa by 75%, an estimate that is similar in magnitude but with lower precision than the reported effect of HAART on survival among children in the United States. Please see later in the article for the Editors' Summary.

Anti-retroviral therapy reduces incident tuberculosis in HIV-infected children.

BACKGROUND: We aimed to estimate the effect of anti-retroviral therapy (ART) on incident tuberculosis (TB) in a cohort of HIV-infected children. METHODS: We analysed data from ART-naïve, TB disease-free children enrolled between December 2004 and April 2008 into an HIV care program in Kinshasa, Democratic Republic of Congo. To estimate the effect of ART on TB incidence while accounting for time-dependent confounders affected by exposure, a Cox proportional hazards marginal structural model was used. RESULTS: 364 children contributed 596.0 person-years of follow-up. At baseline, the median age was 6.9 years; 163 (44.8%) were in HIV clinical stage 3 or 4. During follow-up, 242 (66.5%) children initiated ART and 81 (22.3%) developed TB. At TB diagnosis, 41 (50.6%) were receiving ART. The TB incidence rate in those receiving ART was 10.2 per 100 person-years [95% confidence interval (CI) 7.4-13.9] compared with 20.4 per 100 person-years (95% CI 14.6-27.8) in those receiving only primary HIV care. TB incidence decreased with time on ART, from 18.9 per 100 person-years in the first 6 months to 5.3 per 100 person-years after 12 months of ART. The model-estimated TB hazard ratio for ART was 0.51 (95% CI 0.27-0.94). CONCLUSIONS: For HIV-infected children in TB-endemic areas, ART reduces the hazard of developing TB by 50%.

Mortality and associated factors after initiation of pediatric antiretroviral treatment in the Democratic Republic of the Congo.

OBJECTIVE: We aimed to describe factors associated with mortality among children receiving antiretroviral treatment (ART) at a pediatric hospital in Kinshasa, Democratic Republic of the Congo. RESULTS: Two hundred ninety-nine children, <18 years old, were followed for a median of 77 weeks (interquartile range: 61-103) post-ART initiation. Survival probability was 89.6% [95% confidence interval (CI): 85.5-92.6%] at 12 months; 24 of 31 deaths (77.4%) occurred within 2 months of ART initiation. Predictors of mortality in bivariate analysis were >/=2 opportunistic infections before ART initiation, severe immunosuppression as defined by age-specific CD4 count or percentage criteria, hemoglobin <9 g/dL, oral candidiasis, and severe malnutrition. In multivariate analysis, weight for age z-score [hazard ratio (HR): 0.39; 95% CI: 0.27-0.61; P < 0.001] and oral candidiasis (HR: 5.86; 95% CI: 2.34-14.65; P = 0.0002) were independent predictors of mortality. Suspected septic shock was the most common cause of death (n = 12/31, 38.7%). CONCLUSIONS: Children receiving ART in this resource-poor setting were at the highest risk of dying in the first 2 months of ART, particularly when they presented with malnutrition or oral candidiasis. Optimal timing of ART initiation during nutritional rehabilitation should be determined. Promotion of early care seeking, strengthened health care, and prevention services are important to further improve outcome of pediatric ART in resource-poor settings.

A visual dosing aid for first-line pediatric antiretroviral treatment in resource-poor settings.

The visual dosing aid (VDA) was developed to facilitate dosing calculations in response to children's; growth and weight during antiretroviral treatment. The theoretical accuracy of the VDA was assessed using anthropometric data from 55 children receiving care in the USA and 324 children in the Democratic Republic of the Congo. The VDA dose was similar to the WHO recommended dose. A potentially significant relative dosing difference of >or=20% occurred in <3% of children for NVP, AZT and d4T, but was observed in 20% for 3TC, overdosing being more frequent. The VDA compared well with generic pediatric fixed dose combination tablets. Results did not differ between sites. The VDA enables accurate dosing of pediatric ART in distinct populations and could facilitate roll-out of pediatric ART in resource-poor settings.

Computed CD4 percentage as a low-cost method for determining pediatric antiretroviral treatment eligibility.

BACKGROUND: The performance of the WHO recommendations for pediatric antiretroviral treatment (ART) in resource poor settings is insufficiently documented in routine care. METHODS: We compared clinical and immunological criteria in 366 children aged 0 to 12 years in Kinshasa and evaluated a simple computation to estimate CD4 percent, based on CD4 count, total white blood cell count and percentage lymphocytes. Kappa (kappa) statistic was used to evaluate eligibility criteria and linear regression to determine trends of CD4 percent, count and total lymphocyte count (TLC). RESULTS: Agreement between clinical and immunological eligibility criteria was poor (kappa = 0.26). One third of children clinically eligible for ART were ineligible using immunological criteria; one third of children immunologically eligible were ineligible using clinical criteria. Among children presenting in WHO stage I or II, 54 (32%) were eligible according to immunological criteria. Agreement with CD4 percent was poor for TLC (kappa = 0.04), fair for total CD4 count (kappa = 0.39) and substantial for CD4 percent computational estimate (kappa = 0.71). Among 5 to 12 years old children, total CD4 count was higher in younger age groups (-32 cells/mm3 per year older), CD4 percent was similar across age groups. CONCLUSION: Age-specific thresholds for CD4 percent optimally determine pediatric ART eligibility. The use of CD4 percent computational estimate may increase ART access in settings with limited access to CD4 percent assays.

Pulmonary cystic disease in HIV positive individuals in the Democratic Republic of Congo: three case reports.

Pulmonary emphysema and bronchiectasis in HIV seropositive patients has been described in the presence of injection drug use, malnutrition, repeated opportunistic infections, such as Pneumocytis jirovici pneumonia and Mycobacterium tuberculosis infection, and has been linked to the presence of HIV virus in lung tissue. Given the high burden of pulmonary infections and malnutrition among people living with HIV in resource poor settings, these individuals may be at increased risk of developing pulmonary emphysema, potentially reducing the long term benefit of antiretroviral therapy (ART) if initiated late in the course of HIV infection.In this report, we describe three HIV-infected individuals (one woman and two children) presenting with extensive pulmonary cystic disease.

Pulmonary Sporothrix schenckii infection in a HIV positive child.

Sporothrix schenckii is a ubiquitous fungus, causing mostly non life-threatening localized infections of the skin and subcutaneous tissues that can be treated with oral antifungal agents. Meningeal, pulmonary and osteoarticular dissemination occur mainly in immunosuppressed patients. Pulmonary sporotrichosis is rare and responds poorly to treatment. Cases of disseminated sporotrichosis have most frequently been reported in patients residing in South America and Asia, and have increasingly been reported in AIDS patients. The distribution and pathogenicity of S. schenckii in Sub-Saharan Africa is not well known. We report a case of invasive pulmonary sporotrichosis in an eleven year old HIV-infected boy in Kinshasa, Democratic Republic of the Congo, successfully treated with oral fluconazole.