Effectiveness of first-line antiretroviral therapy and correlates of longitudinal changes in CD4 and viral load among HIV-infected children in Ghana

Abstract

Background: Antiretroviral therapy (ART) scale-up in resource-limited countries, with limited capacity for CD4 and HIV viral load monitoring, presents a unique challenge. We determined the effectiveness of first-line ART in a real world pediatric HIV clinic and explored associations between readily obtainable patient data and the trajectories of change in CD4 count and HIV viral load.

Methods: We performed a longitudinal study of a cohort of HIV-infected children initiating ART at the Korle-Bu Teaching Hospital Pediatric HIV clinic in Accra, Ghana, aged 0-13 years from 2009-2012. CD4 and viral load testing were done every 4 to 6 months and genotypic resistance testing was performed for children failing therapy. A mixed linear modeling approach, combining fixed and random subject effects, was employed for data analysis.

Results: Ninety HIV-infected children aged 0 to 13 years initiating ART were enrolled. The effectiveness of first-line regimen among study participants was 83.3%, based on WHO criteria for virologic failure. Fifteen of the 90 (16.7%) children met the criteria for virologic treatment failure after at least 24 weeks on ART. Sixty-seven percent virologic failures harbored viruses with ≥ 1 drug resistant mutations (DRMs); M184V/K103N was the predominant resistance pathway. Age at initiation of therapy, child's gender, having a parent as a primary care giver, severity of illness, and type of regimen were associated with treatment outcomes.

Conclusions: First-line ART regimens were effective and well tolerated. We identified predictors of the trajectories of change in CD4 and viral load to inform targeted laboratory monitoring of ART among HIV-infected children in resource-limited countries.

Figure 1

Correlates of longitudinal changes in CD4 absolute count among HIV-infected children on antiretroviral therapy in Ghana from 2009 to 2012. CD4 count was log-transformed for statistical modeling. (A) Effect of gender on CD4 trajectory. (B) Effect of age at ART initiation on CD4 trajectory. (C) Effect of WHO Clinical Staging at HIV diagnosis on CD4 trajectory. (D) Effect of primary care giver of child on CD4 trajectory.

Figure 2

Correlates of longitudinal changes viral load among HIV-infected children on antiretroviral therapy in Ghana from 2009 to 2012. Viral load was log-transformed for statistical modeling. (A) Effect of gender on viral load trajectory. (B) Effect of type of ART regimen on viral load trajectory. (C) Effect of number of clinic visits since ART initiation on viral load trajectory.