Parental concerns on disclosure of HIV status to children living with HIV: children's perspective.

Disclosure is an important component of comprehensive management of children living with HIV infection (CLHIV). Many parental concerns are barriers for disclosure in children and only few studies addresses children's perspective on these concerns. Our study aims to understand children's perspective on parental concerns for disclosure and assess the knowledge of HIV. A questionnaire-based cross-sectional study involving CLHIV between 10 and 18 years attending HIV clinic in southern India, was conducted. Data were collected by directly interviewing only the children after obtaining consent from parents/caregivers. Initial open-ended questions were asked to assess the disclosure status and only fully disclosed children were included. Out of 362 enrolled eligible children, the prevalence of full and partial disclosure was 36.7% and 24%, respectively. The mean age of disclosure was 10.4 years (SD ± 2.6) and non-parental family members in an informal setting were the most common source of disclosure (38.3%). Forty-six percentages of parents were unaware of their child's disclosure status. Only 2% had disclosed their status to others who were not part of their care. Among disclosed children, 33.8% became upset or sad upon knowing their status, 12% faced discrimination and 41.4% had complete knowledge about their illness. Though the prevalence of disclosure among CLHIV was high, a majority of them had incomplete knowledge about HIV infection. The parental concerns as reported in literature like the child is too young to disclose, concerns about coping, fear of stigma and discrimination and child disclosing to others were not expressed by children.

Nevirapine-related adverse events among children switched from efavirenz to nevirapine as compared to children who were started on nevirapine-based antiretroviral therapy directly.

In this retrospective study, incidence of nevirapine (NVP) toxicity in children who were switched from efavirenz (EFV) to NVP (treatment experienced [TE] group) was compared with that of children who had started NVP-based antiretroviral therapy directly (treatment naïve [TN] group). This study also identified risk factors associated with development of NVP toxicity in children. The incidence and risk of developing NVP toxicities were significantly higher in TE when compared to TN group. Median duration of onset of NVP toxicity from the initiation was 2.14 and 3.84 weeks in TE and TN children, respectively. Mean CD4 count was found to be significantly higher in children who developed toxicity (577 ± 81 cells/µL) as compared to the children who did not develop toxicity (403 ± 29 cells/µL). Similarly, children in TE group who developed NVP toxicity had higher mean CD4 cell count than children in TN with NVP toxicity. The risk factors for the development of NVP toxicity include female gender with CD4 count >250 cells/µL and TE children especially girls with CD4% >15% and boys with CD4 count >400 cells/µL. To conclude, the higher incidence of NVP toxicity among TE group warrants a cautious approach while switching the NVP- from EFV-based therapy.

Transition of Children with Perinatally Acquired HIV-Infection into Adulthood: Social Outcome and Quality of Life.

OBJECTIVES: In India, access to free anti-retroviral therapy has improved the survival of perinatally human immunodeficiency virus (HIV) infected children resulting in the transition of many such children to adulthood. This study aims to understand the social-outcomes and quality of life (QOL) among these adults. METHODS: This cross-sectional study was conducted in two tertiary HIV care centers in south India. Perinatally HIV-infected adults aged >18 y were enrolled after obtaining consent. Data were collected by questionnaire based interviews for social outcomes and WHO Quality of Life-BREF (WHOQOL-BREF) for QOL. The social-outcome indicators monitored pertained to family support, educational qualification and occupational, economic, and marital status. RESULTS: The mean age of 107 participants was 18·9 ± 1·1y. The school drop-out rate was 58%. Sixty-two percent were double orphans. Forty-three-percent of the participants were employed with mean per-capita monthly income of Rs.4105 ± 2979 ($65·2 ± 47·3). Fourteen-percent of the participants were married, or in a relationship, and a majority of them, 93%, were females. For QOL, the mean raw score was highest for social relationship (15·79). Relative to studying subjects, a higher proportion of school dropouts scored poorly in social relationship (42% vs.14·8%; Chi-square = 5·28; p = 0·02) and environmental QOL (46% vs.19·6%;Chi-square = 8·09; p = 0·004). The proportion of subjects with a poor physical health QOL was higher among those with a per-capita monthly income above the national average than those with below the national average (69% vs.33·3%; Chi-square = 5·27; p = 0·02). CONCLUSIONS: Though clinico-immunological disease was stable in these perinatally HIV-infected young adults, their social-outcomes pertaining to education, occupation, income, and family support were poor. Factors like education, parental care, and income of the subjects were associated with poor QOL.

Predictors of Mortality and Mortality Rate in a Cohort of Children Living with HIV from India.

OBJECTIVES: To study the predictors of mortality and mortality rate in a clinical cohort of Children Living with Human Immunodeficiency Virus infection (CLHIV) from India. METHODS: This retrospective cohort analysis of CLHIV aged between 2 mo and 18 y registered during January 2004 through December 2014 at Pediatric Centre of Excellence (PCOE), Indira Gandhi Institute of Child Health (IGICH), was conducted using standard data collection sheet. Demographic and clinical characteristics of all eligible children were analyzed. The primary outcome measured was mortality. The authors also analyzed the cause of death and baseline parameters associated with death to study the predictors of mortality. RESULTS: Out of 1289 CLHIV registered in the PCOE during the study period, 834 (64.7 %) CLHIV, with or without antiretroviral therapy (ART) care, were included. The total time contributed by the study participants was 2872.8 child-years. The mortality rate in these children was 4.9/100 child-years. A significantly higher mortality rate of 28.2 % was found in children < 5 y, 38.6 % in children with advanced WHO clinical staging, 35.2 % among severely immunosuppressed children and 22.3 % in severely malnourished children. Tuberculosis accounted for 28 % of deaths. Univariate Cox regression analysis showed treatment status, age <5 y, baseline WHO clinical stage 3 and 4, severe immune suppression and severe malnutrition were strongly associated with mortality. CONCLUSIONS: The mortality rate in the index study cohort was 4.9/100 child-years and tuberculosis was the major cause of death. Younger age, baseline advanced clinical and immunological staging were predictors of mortality. Even though mortality was significantly higher in Pre-ART children, treatment status was not found to be an independent predictor of mortality.

Immunological failure despite virological suppression in HIV seropositive individuals on antiretroviral therapy.

BACKGROUND: Some individuals experience a discordant response during antiretroviral therapy (ART), with a blunted CD4+ cell count response despite low HIV-1 RNA plasma levels. MATERIALS AND METHODS: CD4 counts and viral load of 251 individuals on ART referred to the center were analysed for immunological failure. The viral load tests of 28 patients revealed a discordant response, characterized by low CD4 counts despite viral suppression (<47 copies in 23, <5000 in 4 patients and <10000 in one patient). Univariate and multiple regression analysis was done to determine factors associated with immunological failure in patients with viral suppression. RESULTS: Twenty-eight patients developed immunological failure over a duration of 3.7±1.14 years despite viral suppression. In univariate analysis of discordant patients, low CD4 counts(<100cells/µl) at start of ART(P=0.0261), less than 50% gain in CD4 count (P=0.048) after one year of start of ART and duration on ART for more than 3 years (P=0.0436) were associated with immunological failure. In multiple regression, duration on ART, age and nadir CD4 count (lowest ever) on treatment were predictors of immunological failure in these patients. Overall females (n=8) demonstrated much higher CD4 counts of 136±72 than males (n=20) 79±38 cells/µl at the time of diagnosis of immunological failure. CONCLUSIONS: Discordance was observed in 13.59% of patients. Detection of failure to first line therapy based on immunologic criteria, without viral load testing, can result in unnecessary switches to 2(nd) line therapy.