The effects of highly active antiretroviral therapy on survival and CD4 cell percentage in HIV-infected children in Kinshasa, Democratic Republic of Congo

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  • March 22, 2019
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  • Edmonds, Andrew J.
    • Affiliation: Gillings School of Global Public Health, Department of Epidemiology
Abstract
  • In HIV-infected children, the effects of highly active antiretroviral therapy (HAART) on survival and CD4 responses are understood incompletely. As most pediatric HIV infections occur in lower-income countries, our objective was to provide the first estimates of these effects among children in a resource-deprived setting. Observational data from HAART-naive children enrolled into an HIV care and treatment program in Kinshasa, Democratic Republic of Congo between December 2004 and May 2010 were analyzed. Marginal structural models were used to quantify the effects of HAART on survival and CD4 percentage while accounting for time-dependent confounders affected by prior exposure to HAART. At the start of follow-up, the median age of the 790 children was 5.9 years; 528 (67%) had advanced or severe immunodeficiency and 405 (51%) were in HIV clinical stage 3 or 4. The children were observed for a median of 31 months and contributed 2,090 person-years. Eighty children (10%) died, 619 (78%) initiated HAART, six (1%) transferred care to another facility, and 76 (10%) were lost to follow-up. The mortality rate was 3.2 per 100 person-years (95% CI: 2.4, 4.2) during HAART and 6.0 (95% CI: 4.1, 8.6) during receipt of primary HIV care only. The mortality hazard ratio comparing HAART to no HAART was 0.25 (95% CI: 0.06, 0.95). Compared to no HAART, the estimated absolute rise in CD4 percentage was 6.8% (95% CI: 4.7%, 8.9%) after six months of HAART, 8.6% (95% CI: 7.0%, 10.2%) after 12 months, and 20.5% (95% CI: 16.1%, 24.9%) after 60 months. HAART-mediated CD4 percentage gains were slowest but greatest among children who had a baseline CD4 percentage <15. The cumulative incidence of recovery to not significant WHO age-specific immunodeficiency was lower if HAART was initiated when immunodeficiency was severe rather than mild or advanced. HAART reduced the hazard of mortality and increased CD4 percentages among HIV-infected children in a resource-deprived setting to a similar degree as previously noted for children in the United States. The more gradual and protracted immunological recovery observed in children with lower baseline CD4 percentages supports earlier initiation of pediatric HAART.
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  • ... in partial fulfillment of the requirements of the degree of Doctor of Philosophy in the Department of Epidemiology.
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  • Behets, Frieda
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