Sheahan Anna, Feinstein Lydia, Dube Queen, Edmonds Andrew, Chirambo Chawanangwa Mahebere, Smith Emily, Behets Frieda, Heyderman Robert, Van Rie Annelies
From the *Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; †Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital, Blantyre, Malawi; ‡Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; §Division of Infection and Immunity, University College London, London, United Kingdom; and ¶Department of Epidemiology and Social Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
Pediatr Infect Dis J. 2017 Jul;36(7):654-658. doi: 10.1097/INF.0000000000001539.
Based on clinical trial results, the World Health Organization recommends infant HIV testing at age 4-6 weeks and immediate antiretroviral therapy (ART) initiation in all HIV-infected infants. Little is known about the outcomes of HIV-infected infants diagnosed with HIV in the first weeks of life in resource-limited settings. We assessed ART initiation and mortality in the first year of life among infants diagnosed with HIV by 12 weeks of age.
Cohort of HIV-infected infants in Kinshasa and Blantyre diagnosed before 12 weeks to estimate 12-month cumulative incidences of ART initiation and mortality, accounting for competing risks. Multivariate models were used to estimate associations between infant characteristics and timing of ART initiation.
One hundred and twenty-one infants were diagnosed at a median age of 7 weeks (interquartile range, 6-8). The cumulative incidence of ART initiation was 46% [95% confidence interval (CI), 36%, 55%] at 6 months and 70% (95% CI 60%, 78%) at 12 months. Only age at HIV diagnosis was associated with ART initiation by age 6 months, with a subdistribution hazard ratio of 0.70 (95% CI 0.52, 0.91) for each week increase in age at DNA polymerase chain reaction test. The 12-month cumulative incidence of mortality was 20% (95% CI 13%, 28%).
Despite early diagnosis of HIV, ART initiation was slow and mortality remained high, underscoring the complexity in translating clinical trial findings and World Health Organization's guidance into real-life practice. Novel and creative health system interventions will be required to ensure that all HIV-infected infants achieve optimal treatment outcomes under routine care settings.
基于临床试验结果，世界卫生组织建议对4至6周龄的婴儿进行HIV检测，并对所有感染HIV的婴儿立即开始抗逆转录病毒治疗（ART）。在资源有限的环境中，对于在生命最初几周被诊断出感染HIV的婴儿的结局知之甚少。我们评估了在12周龄前被诊断出感染HIV的婴儿在出生后第一年开始ART治疗的情况和死亡率。
在金沙萨和布兰太尔对12周前被诊断出感染HIV的婴儿进行队列研究，以估计开始ART治疗和死亡的12个月累积发生率，并考虑竞争风险。使用多变量模型估计婴儿特征与开始ART治疗时间之间的关联。
121名婴儿被诊断出感染HIV，中位年龄为7周（四分位间距为6 - 8周）。6个月时开始ART治疗的累积发生率为46%[95%置信区间（CI），36%，55%]，12个月时为70%（95%CI 60%，78%）。仅HIV诊断时的年龄与6个月龄时开始ART治疗有关，DNA聚合酶链反应检测时年龄每增加一周，亚分布风险比为0.70（95%CI 0.52，0.91）。12个月时的累积死亡率为20%（95%CI 13%，28%）。
尽管HIV诊断较早，但开始ART治疗的速度缓慢且死亡率仍然很高，这凸显了将临床试验结果和世界卫生组织的指导意见转化为实际临床实践的复杂性。需要新颖且有创造性的卫生系统干预措施，以确保所有感染HIV的婴儿在常规护理环境下获得最佳治疗效果。
