Level of viral load and antiretroviral resistance after 6 months of non-nucleoside reverse transcriptase inhibitor first-line treatment in HIV-1-infected children in Mali.

OBJECTIVES: To evaluate the virological response and to describe the resistance profiles in the case of failure after 6 months of first-line highly active antiretroviral therapy (HAART) in HIV-1-infected children living in resource-limited settings. PATIENTS AND METHODS: Ninety-seven HIV-1-infected children who started two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) (mainly zidovudine/lamivudine/nevirapine) in Mali were prospectively studied. Virological failure (VF) was defined as loss to follow-up, death or HIV-1 RNA viral load (VL) of >400 copies/mL at 6 months. When VL was >50 copies/mL, a genotypic resistance test was performed. RESULTS: Among the 97 children, median age at antiretroviral initiation was 31 months and the majority were in WHO clinical (77.3%) and immunological (70.1%) stage III or IV. At month 6, 44% of children had VL > 400 copies/mL (61% VF). Among the children with detectable VL, 30/37 genotypic resistance tests were available, 8 with wild-type viruses and 22 with resistance mutations (73%): 19 M184V/I, 21 NNRTI mutations and only 3 thymidine analogue mutations (TAMs) (K70R, D67N and L210W in three distinct viruses). At failure, 6/8 children with wild-type viruses had a VL of <1000 copies/mL whereas 21/22 with resistant viruses had a VL of >1000 copies/mL. CONCLUSIONS: Under NNRTI-based regimens, early detection of VF could allow the reinforcement of adherence when VL was <1000 copies/mL, because in most of these cases no resistance mutations were detected, or a change to a protease inhibitor-based regimen if VL was >1000 copies/mL. The low frequency of TAMs suggests that most NRTIs can be used in a second-line regimen after early failure.

Management of malnutrition in rural Mali.

In Mali, according to DHS III (Demographic and Health Survey) in 2001, the global rate of malnutrition (weight for age <2 sd) among under-five children was 38%. The purpose of this study was to assess the management of malnutrition in children (0-59 months old) by the professionals in the intervention areas of 'Strategy for Accelerated Child Survival and Growth', according to IMCI guidelines. We carried out a cross-sectional survey in three randomly selected health districts (Kolokani, Niono and Koro) and involved 27 health centres, 180 children and 180 mothers. We did direct observation of consultations and interrogated the mothers. The study found that the equipement and tools necessary for nutritional status assessment were available but seldom used in practice. Nutrition training was provided only to the health staff of Kolokani where 78% of the staff were trained in IMCI and 55% in IEC (Information Education and Communication). The indicatory weight-for-age was used to assess nutritional status of 64% children in Kolokani vs. 42% in Koro and 4% in Niono. IMCI classification was used only in Kolokani (57% of children). The management of severe malnbutrition in children was more correct in Kolokani (100%) than in Koro (33%) and Niono (0%). Twenty- eight percent of mothers/caretakers knew the appropiate duration of exclusive breastfeeding, but only 5% knew that vitamin A supplementation should be done every 6 months. Our findings suggest that nutritional status assessment is performed better in the health districts where staffs are training in IMCI. We recommend training the health staff in the other health districts and the intensification of behavioural change communication for mothers.