Preventing HIV morbidity & mortality: fast-tracking infants on to ART

Transcription

1 Preventing HIV morbidity & mortality: fast-tracking infants on to ART Brian Eley Paediatric Infectious Diseases Unit Red Cross War Memorial Children s Hospital Department of Paediatrics & Child Health University of Cape Town

2 Lancet 2010;375:

3 Under-5 mortality in SA, 2008 (Countdown to 2015 Decade Report ( ) Diarrhoea 9% Preterm, 41% Asphyxia, 23% Neonatal 29% Infection, 18% Other, 9% Congenital, 8% Tetanus, 1% Diarrhoea, 1% Other, 9% Pneumonia, 6% Injuries, 2%

4 Country No progress towards MDG4 Mortality rate (deaths per 1000 live births) Afghanistan Angola Burundi Cameroon Central African Republic Chad Congo (Brazaville) DR Congo Kenya Mauritania North Korea Somalia South Africa Sudan Swaziland Zambia Zimbabwe Bhutta ZA, et al. Lancet 2010;375:

5 Cumulative mortality of HIV-infected children in sub-saharan Africa Cumulative probability of death Infected (n=707) Overall (n=3468) Unknown HIV status (n=578) Not infected (n=2183) Age at last visit or death (days) Newell ML et al. Lancet 2004; 364:

6 Early infant mortality due to AIDS Bourne DE, et al. AIDS 2009;23:

7 CHER: mortality rates - 32 week analysis Variable Immediate treatment (n = 252) Deferred treatment n = 125 Total (n = 377) Death, n (%) 10 (4%) 20 (16%) 30 (8%) Follow-up (person years) Mortality rate per 100 person years (95% CI) Hazard Ratio (95% CI) (2.9; 10) 25.3 (15.5; 39.0) 12.2 (8.2; 17.4) 0.24 (0.11; 0.51) P-value Violari A, et al. N Engl J Med 2008;359:

8 WHO guideline revision: April 2008 (Strength of recommendation for when to start ART) Age categories < 12 mo 1 4 yrs 5 yrs When should ART be started? Strength of recommendation All regardless of clinical / CD4 Clinical or CD4 criteria Clinical or CD4 criteria Strong Strong Strong On World AIDS Day (1 December 2009) President Zuma announced that all children less than 12 months old with HIV infection should commence ART as soon as possible following diagnosis WHO.

9 HIV PCR testing: (includes KZN) Year Estimated No. of HIV-exposed infants Total tests Positive tests % positivity , ,959 30, , ,499 25, , ,899 22, Sherman G & Lilian R, NHLS & Wits Health Consortium, 1 Mar 2011

10 Province Early diagnosis: (excludes KZN) Total PCR tests: all ages Total PCR tests: <2 months % of total PCR: <2 months % positivity: <2 months EC 29,741 30,650 17,895 17, FS 12,413 14,833 4,474 7, GP 57,842 63,567 27,552 27, LP 18,551 21,649 10,539 11, MP 20,192 23,740 10,912 11, NC 3,695 4,814 2,232 2, NW 17,084 18,976 9,811 9, WC 17,811 18,025 7,079 6, Total 177, ,254 93,494 94, Sherman G & Lilian R, NHLS & Wits Health Consortium, 1 Mar 2011

11 Paediatric ART cohorts in SA (Initiation on ART between 1 June 1999 and 29 February 2008) Cohort Level of care 1 st year of ART Number on ART Median (IQR) age No (%) <1 yr at initiation Harriet Shezi All levels ( ) 328 (15.0) Rahima Moosa All levels ( ) 202 (19.8) Red Cross Children s Tertiary ( ) 351 (41.8) Tygerberg Tertiary ( ) 240 (34.8) Khayelitsha Primary ( ) 94 (14.5) Gugulethu Primary ( ) 42 (16.0) McCord Secondary ( ) 33 (7.7) All cohorts All levels ( ) 1290 (21.2) Davies M-A, et al. S Afr Med J 2009;99:

12 Early mortality / loss to follow-up Fenner L, et al. J Acquir Immune Defic Syndr 2010;54:

13 Vulnerability of rural children Fatti G, et al. J Int AIDS Soc 2010;13:46

14 Expedited ART initiation (fast tracking) Policy of NDoH since 25 February 2009 Focuses on vulnerable groups of adults and children Explicit recommendations: Vulnerable patients should not experience a delay in referral to an ART site of > 1 wk ART should be started within 2-4 wks of entry to ART site NDoH memorandum, signed bt Dr ND Kalombo, 25 February 2009

15 Fast tracking HIV-infected infants Fast tracking should ideally imply that HIVinfected infants are started on ART within 2 4 weeks of drawing blood for DNA PCR testing. This implies: Diagnosing HIV infection, giving post-test counselling and referral of HIV-infected infants must be completed within 1 2 weeks of drawing blood for the DNA PCR test Pre-initiation preparations at the ART clinic should be completed and ART commenced within a further 1 2 weeks Hospitalised HIV-infected infants: initiate ART before discharge Eley B. Sensitive Midwifery Nov 2010:16-18

16 ART at RCWMCH New ART enrolments Inpatient ART enrolments 127 (64.8%) 168 (78.9%) ICU ART enrolments 30 (14.1%) ART enrolments < 6 mo % enrolments of WC programme 89 (45.5%) 126 (59.2%) 196 (85.6%) 40 (17.5%) 117 (51.5%) 175 (85.8%) 28 (13.7%) 93 (45.6%) 19.2% 17.5% 19.4% 23.7% Down referrals No. HIV outpatients at the end of the year

17 Number HIV-related deaths at RCWMCH Number : 68.9% decline in HIV-related deaths 2010: 46/354 (13.0%) deaths were HIV-related A Westwood, personal communication

18 Conclusion Early infant diagnosis coverage should be improved Speed & efficiency are critical during ART initiation for reducing morbidity and mortality among HIV-infected infants