CHILDREN Enrolled in a Public HIV Care and Treatment Program in Lusaka, ZAMBIA Rapid Scaleup and Fir

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CHILDREN Enrolled in a Public HIV Care and
Treatment Program in Lusaka, ZAMBIA Rapid
Scale-up and First-Year Clinical Outcomes

• Mwangelwa Mubiana-Mbewe
• (BSc, MBChB, MMed, MBA)
• Carolyn Bolton, Jens Levy, Moses Sinkala, Marc
  Bulterys, Benjamin H. Chi, Catherine Wilfert,
  Jeff Stringer, Amanda Dumas, Ron Cantrell,
  Namwinga Chintu, Elizabeth Stringer

USAID
The University of Alabama at Birmingham
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Paediatric HIV in ZAMBIA

• 130,000 children are infected
• 30,000 children are vertically infected each
  year.
• 710,000 HIV/AIDS orphans
• UNAIDS 2005

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Background

• Limited access to infant diagnosis
• Limited access to treatment for children
• Providers not trained reluctant to
• treat children
• WHO target of at least 10 of patients on
  antiretroviral therapy (ART) being children not
  met by most programmes

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Zambian Ministry of Health Goals for end of 2007
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Methods

• Open cohort evaluation of children seeking HIV
  care in Lusaka, Zambia (May 2004 July 2006)
• Data derived from electronic medical record
  database
• Site 13 primary government clinics providing
  paediatric ART services in Lusaka
• Diagnosis serological and clinical
• Basis of ART eligibility WHO staging and
  age-based CD4 criteria

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Cumulative Enrollment in Lusaka

20,148 Adults on ART
1,726 Children on ART
872 Children not on ART
9,635 Adults not on ART
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Baseline Characteristics
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Enrollment by Age Category

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Initial ARV regimens

• D4T 3TC NVP 827(48)
• ZDV 3TC NVP 693 (40)
• D4T 3TC EFV 129 (8)
• ZDV 3TC EFV 77 (4)

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Mean CD4 at ART Initiation

• Age lt 1 year 650/uL (520)
• Age 1 5 years 484/uL (390)
• Age 6 years 254/uL (234)

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CD4 Response by Age
Children lt 5 years CD4
Children gt 5 years CD4 Count

6 mo
6 mo
12 mo
12 mo
Baseline
Baseline
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Mortality

• 105 deaths over 1,205 child-years on ART
• Rate 8.7 / 100 child-years (95CI 7.5, 9.2)

Excludes late and withdrawn patients, and those
with uncertain date of death
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Mortality by WHO Stage at Entry

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Mortality by CD4 at Entry

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Predictors of Mortality

• Low CD4 AHR 2.5 (1.3-5.0)
• Low weight AHR 2.2 (0.9-2.6)
• Age lt2.5 yrs AHR 2.7 (1.4-5.1)

Multivariable Cox Proportional Hazards Regression
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Lessons learned

• Health care providers need specific training on
  protocols for evaluating and treating children
  with ART and ongoing support
• Caregivers must be educated on, and encouraged
  to, focus on adherence to care and treatment
• Community sensitization regarding treatment of
  children is critical

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CONCLUSIONS

• More than two-thirds of children presenting for
  care were eligible for ART
• Better infant diagnostics are needed
• Providing quality HIV care and treatment to
  children on a large scale basis in a
  resource-limited setting is feasible
• Vigorous CD4 response
• Favourable mortality rates (8.7 / 100 pt-years,
  compare to 16.1 / 100 pt-yrs in adults)

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Acknowledgements

• Our patients
• Lusaka Urban District Health Management Team
• Zambian Ministry of Health
• EGPAF
• CDC/PEPFAR
• UAB CFAR