Paediatric ARV's at McCord

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Paediatric ARV's at McCord

• Background to the Programme
• Baseline Characteristics of the Cohort
• Outcomes for first 151 children

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• State subsidised hospital
• July 2004 PEPFAR funding
• Team of part time paediatrician,2 generalist
  doctors,social worker,intern psychologist and
  counsellors.

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Process of Care

• All HIV positive children assessed clinically
• Not eligible for ARV's-3monthly follow up
• Eligible for ARV's
• 3 training sessions
• Baseline bloods
• CXR
• Investigations to exclude TB

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Eligibility for ART

• National Guidelines
• WHO Stage 3 or 4
• CD4 lt 20 if child lt18 months
• CD4 lt15 if child lt 18 months

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• No clinical problems-HAART at training 3
• TB at baseline-HAART delayed
• Monthly visits

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• Numerous reports confirming efficacy of HAART in
  adults
• Very few published studies in paeds in Africa
• Small cohorts in Senegal and Cote d'Ivoire
  suggest good outcomes achievable.

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Audit of our first 151 patients

• Anand Reddi and Sarah Leeper
• All children initiating HAART at Sinikithemba
  31/08/03-31/10/05
• Chart Review
• Hospital electronic data base

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• 151 Children
• 13 Deaths
• 0 Lost to follow up
• Median follow up time 8 months

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Baseline Charateristics

• 51 (77) female
• Median age 5,7 years at initiation(range 4 months
  to 15,4 years
• 70 WHO Stage 3 or 4
• 97 Severelyimmunocompromised
• 52 weight lt 5th centile
• 33 TB at baseline

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TB Diagnosis

• Positive Tb contacts
• Suggestive CXR/Persistent CXR changes
• Mantoux
• Symptoms
• Sputum/gastric washings
• US abdomen/LP/lymph node biopsy

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1 These patients received PMTCT outside of
McCord Hospitals PMTCT program
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Primary caregivers

• 1-3 primary caregivers identified for each child
• 52 at least 1 HIV positive primary caregiver
• 38 at least 1 primary caregiver in care at
  Sinikithemba

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n14
n25
n14
n15
n19
n12
n38
n26
n36
n19
n36
n36
15
n151 n100 n61
n11 n6
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How does this compare?

• Comparable immunologically and in anthropometry
• Very high levels of viral suppression
• ?Adherence
• ?Differences in subtype
• Further investigation needed

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Mortality

• 8.6 compares favourably
• All 13 in first 5 months
• None related to adverse events
• Significant hazard ratios
• WHO stage 4
• Weight lt 5th centile
• Baseline Tb
• Baseline pneumonia
• Baseline chronic gastro
• Age/orphanhood/Hb /CD4 not predictive
• Primary caregiver HIV positive PROTECTIVE

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Regimen Durability

• 134 (89) still on first line
• 15 (9.9) on second line
• 1 on third line
• 1 on fourth line

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17 Regimen Changes

• 2 adverse events
• 6 initiation/completion of Tb treatment
• 2 kaletra efavirenz
• 7 treatment failures

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Limitations

• Possible information bias in chart review
• Possible patient selection bias towards patients
  with greater financial resources

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Conclusion

• HAART effective and sustainable in paediatrics in
  resource limited settings
• Children respond very favourably
  immunologically/virologically/clinically and with
  less side effects than adults