Brophy Jason C, Hawkes Michael T, Mwinjiwa Edson, Mateyu Gabriel, Sodhi Sumeet K, Chan Adrienne K
Dignitas International, Zomba, Malawi.
Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada.
PLoS One. 2016 Nov 3;11(11):e0165772. doi: 10.1371/journal.pone.0165772. eCollection 2016.
Pediatric uptake and outcomes in antiretroviral treatment (ART) programmes have lagged behind adult programmes. We describe outcomes from a population-based pediatric ART cohort in rural southern Malawi.
Data were analyzed on children who initiated ART from October/2003 -September/2011. Demographics and diagnoses were described and survival analyses conducted to assess the impact of age, presenting features at enrolment, and drug selection.
The cohort consisted of 2203 children <15 years of age. Age at entry was <1 year for 219 (10%), 1-1.9 years for 343 (16%), 2-4.9 years for 584 (27%), and 5-15 years for 1057 (48%) patients. Initial clinical diagnoses of tuberculosis and wasting were documented for 409 (19%) and 523 (24%) patients, respectively. Median follow-up time was 1.5 years (range 0-8 years), with 3900 patient-years of follow-up. Over the period of observation, 134 patients (6%) died, 1324 (60%) remained in the cohort, 345 (16%) transferred out, and 387 (18%) defaulted. Infants <1 year of age accounted for 19% of deaths, with a 2.7-fold adjusted mortality hazard ratio relative to 5-15 year olds; median time to death was also shorter for infants (60 days) than older children (108 days). Survival analysis demonstrated younger age at ART initiation, more advanced HIV stage, and presence of tuberculosis to each be associated with shorter survival time. Among children <5 years, severe wasting (weight-for-height z-score </ = -3.0) was also associated with reduced survival.
Cumulative incidence of mortality was 5.2%, 7.1% and 7.7% after 1, 3, and 5 years, respectively, with disproportionate mortality in infants <1 year of age and those presenting with tuberculosis. These findings reinforce the urgent need for early diagnosis and treatment in this population, but also demonstrate that provision of pediatric care in a rural setting can yield outcomes comparable to more resourced urban settings of poor countries.
儿科抗逆转录病毒治疗（ART）项目的接受情况和治疗效果落后于成人项目。我们描述了马拉维南部农村地区一个基于人群的儿科ART队列的治疗效果。
对2003年10月至2011年9月开始接受ART治疗的儿童数据进行分析。描述了人口统计学和诊断情况，并进行了生存分析，以评估年龄、入组时的表现特征和药物选择的影响。
该队列由2203名15岁以下儿童组成。入组时年龄小于1岁的有219名（10%），1 - 1.9岁的有343名（16%），2 - 4.9岁的有584名（27%），5 - 15岁的有1057名（48%）。分别有409名（19%）和523名（24%）患者的初始临床诊断为结核病和消瘦。中位随访时间为1.5年（范围0 - 8年），随访患者年数为3900。在观察期内，134名患者（6%）死亡，1324名（60%）仍在队列中，345名（16%）转出，387名（18%）失访。1岁以下婴儿占死亡人数的19%，相对于5 - 15岁儿童，调整后的死亡风险比为2.7倍；婴儿的中位死亡时间（60天）也比大龄儿童（108天）短。生存分析表明，开始接受ART治疗时年龄较小、HIV疾病阶段较晚以及患有结核病均与较短的生存时间相关。在5岁以下儿童中，严重消瘦（身高别体重Z评分≤ - 3.0）也与生存率降低有关。
1年、3年和5年后的累积死亡率分别为5.2%、7.1%和7.7%，1岁以下婴儿和患有结核病的儿童死亡率不成比例。这些发现强化了对该人群进行早期诊断和治疗的迫切需求，但也表明在农村地区提供儿科护理可以取得与资源更丰富的贫穷国家城市地区相当的治疗效果。
