XVIII International AIDS Conference

Abstract

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Outcomes of antiretroviral therapy (ART) among HIV-infected children at clínica de familia MIR (CFMIR), La Romana, Dominican Republic: predictors of switch to second-line ART, response to second-line therapy

C.W. Elgarten1, J.E. Myers2,3, J.N. Mercedes4, J.O. Leonardo Guerrero4, C.T.B. Rodriguez Sirett4, N.P. Torres4, B.S. Taylor5, S. Hermosilla3, M.E. Sobieszczyk2, J.A. Roman Pouriet4, F.J.C. Carazas3,4, S.W. Nicholas1,3

1Columbia University, College of Physicians and Surgeons, New York, United States, 2Columbia University, Division of Infectious Diseases, Department of Medicine, College of Physicians and Surgeons, New York, United States, 3Columbia University Mailman School of Public Health, New York, United States, 4Clínica de Familia MIR, La Romana, Dominican Republic, 5University of Texas Health Science Center at San Antonio, Division of Infectious Diseases, Department of Medicine, San Antonio, United States

Background: Few studies have examined indications for and response to second-line ART among children in resource-limited settings with inconsistently available virologic monitoring.
Methods: We reviewed medical records of HIV-infected children initiating ART from 10/2004-12/2008 at CFMIR. Primary outcome was switch to second-line ART, defined as initiation of a PI-based regimen and concurrent NRTI change.
Results: 114 patients met study criteria; 100 records were reviewed. Median age was 6.1 years [inter-quartile range (IQR)=2.7-9.4], 49% were female, 66% were orphaned, and 18% resided in sugar plantation settlements of primarily Haitian migrants (bateys). 96% were infected by mother-to-child transmission (MTCT), 14% despite MTCT-prevention interventions. Median baseline CD4 was 426 cells/µL [IQR=190-846]. Initial regimen was NNRTI-based for 89% (PI-based for remainder). Six died: median time to death was 26 days [IQR=16.5-288]. No variable examined predicted mortality. Excluding patients who died, 13/94 switched to second-line ART (0.5 switches/10 person-years). Documented criteria for switch were the following: poor virologic response, 1; poor immunologic response, 5; clinical progression, 1; multiple criteria, 4; undocumented criteria, 2. Median time to switch was 18.7 months [IQR=13.4-26.1]. Second-line was didanosine+abacavir+lopinavir/ritonavir. Switch to second-line ART, compared with continued first-line, was associated with lower median baseline CD4 (118 versus 509 cells/µL, p=0.027), baseline CDC clinical category C (100% versus 62%, p=0.007) and lower median 12-month CD4 increase on first-line (145 versus 342 cells/µL, p=0.041). Anemia, malnutrition, batey residence and orphanhood did not predict switch. Of 14 starting second-line, one died 6 months post-switch; 13 survived (median follow-up: 18.6 months [IQR=11.6-26.3]). Median CD4 increases after 6 and 12 months were 166 and 331 cells/µL, respectively.
Conclusions: Regimen switch was associated with advanced clinical and immunological disease at ART initiation. These findings suggest that prompt diagnosis and timely treatment of HIV are associated with durability of first-line regimens, hence minimizing need for switch. Response to second-line ART was excellent.


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