Scaling up antiretroviral therapy for HIV-infected children in Côte d'Ivoire: determinants of survival and loss to programme.

OBJECTIVE: To investigate deaths and losses to follow-up in a programme designed to scale up antiretroviral therapy (ART) for HIV-infected children in Côte d'Ivoire. METHODS: Between 2004 and 2007, HIV-exposed children at 19 centres were offered free HIV serum tests (polymerase chain reaction tests in those aged < 18 months) and ART. Computerized monitoring was used to determine: (i) the number of confirmed HIV infections, (ii) losses to the programme (i.e. death or loss to follow-up) before ART, (iii) mortality and loss-to-programme rates during 12 months of ART, and (iv) determinants of mortality and losses to the programme. FINDINGS: The analysis included 3876 ART-naïve children. Of the 1766 with HIV-1 infections (17% aged < 18 months), 124 (7.0%) died, 52 (2.9%) left the programme, 354 (20%) were lost to follow-up before ART, 259 (15%) remained in care without ART, and 977 (55%) started ART (median age: 63 months). The overall mortality rate during ART was significantly higher in the first 3 months than in months 4-12: 32.8 and 6.9 per 100 child-years of follow-up, respectively. Loss-to-programme rates were roughly double mortality rates and followed the same trend with duration of ART. Independent predictors of 12-month mortality on ART were pre-ART weight-for-age z-score < -2, percentage of CD4+ T lymphocytes < 10, World Health Organization HIV/AIDS clinical stage 3 or 4, and blood haemoglobin < 8 g/dl. CONCLUSION: The large-scale programme to scale up paediatric ART in Côte d'Ivoire was effective. However, ART was often given too late, and early mortality and losses to programme before and just after ART initiation were major problems.

Respiratory manifestations in HIV-infected children pre- and post-HAART in Abidjan, the Ivory Coast.

Among children infected with human immunodeficiency virus (HIV), respiratory diseases are a frequent cause of morbidity and mortality. This review describes respiratory manifestations of paediatric HIV infection before and after the beginning of HAART in Abidjan, Ivory Coast. In an observational cohort, HIV infected children had quarterly clinical visits and a day-clinic available all week for ill children. CD4 and viral load were measured at baseline and every 6 months thereafter. All children with a CD4 percentage below 25% were prescribed daily cotrimoxazole prophylaxis. Ninety-eight children (of a total of 282) were recruited before HAART and treated during the follow-up, there were 56 boys and 42 girls, with a mean age of 6.2 years at inclusion. The mean percentage of CD4 before HAART was 8.7%. Twelve children had a history of pulmonary tuberculosis and five were on antituberculosis treatment at inclusion. Fifty-one per cent presented with abnormalities on chest X-ray at inclusion. Before initiation of HAART, respiratory manifestations represented 32.4% of morbidity events and the incidence for 100 child/months was 9.29 for URTI, 15.2 for bronchitis, 6.07 for LRTI, 0.71 for tuberculosis and 0.36 for Pneumocystis carinii. After the initiation of HAART, respiratory manifestations represented 40.9% of all morbidity events and the incidence for 100 child/months was 5.35 for URTI, 9.48 for bronchitis, 2.17 for LRTI and 0.16 for tuberculosis. During HAART treatment, the incidence of respiratory infections decreased dramatically compared to before the antiretroviral treatment. However, respiratory events still represented 40% of all events occurring following the start of HAART therapy.

[Zidovudine-associated mitochondriopathy: three possible observations in Abidjan, Côte d'Ivoire]. / Mitochondriopathie associée à la zidovudine. A propos de 3 cas possibles à Abidjan, Côte d'Ivoire.

In Africa, prevention of mother-to-child transmission of HIV (PMTCT) with antiretrovirals is becoming a key component of the response to the pandemic. Toxicity issues remain however a concern and require careful monitoring. We report here three observations of mild neurological deterioration among children for whom a diagnosis of mitochondrial dysfunction was considered possible. These children were identified within a PMTCT research program (ANRS 049) conducted in Abidjan, Côte d'Ivoire, and evaluating a short regimen of maternal zidovudine monotherapy for PMTCT of HIV type 1. Maternal HIV-1 infection was diagnosed during pregnancy before enrolment in the randomised trial (two cases) or in the subsequent open cohort (one case). These three women had been allocated to the ZDV group and had no particular medical history. Pregnancy check-up was negative except the diagnosis of HIV-1 infection. The three children were diagnosed as uninfected by HIV-1. Symptoms developed by the age of six months (two cases) and 13 months (one case): growth failure, anthropometric abnormalities, impaired psycho-motor development, generalised and repeated seizures. The evolution of these three HIV-uninfected children was favourable after 12 to 18 months. The transient nature of these abnormalities is compatible with mild complications of mitochondrial dysfunction. We conclude however that the anticipated benefits of PMTCT with antiretrovirals in Africa greatly outweigh the potential risks and should not lead to reconsider their public health interest

[HIV-1 infection in children in African countries]. / Infection par le VIH-1 de l'enfant dans les pays Africains.

The prognosis of HIV infection is dramatic for children living in poor countries. Over 50% die within two years. The World Health Organization has estimated that 1500 children will be infected daily until large-scale national programs for prevention of mother-to-child transmission are implemented. A better understanding of the causes underlying early morbidity could lead to a substantial reduction in mortality pending use of antiretroviral drugs which have demonstrated promising results in preliminary tests on children in poor countries.