Luque Marco T, Jenkins Cathy A, Shepherd Bryan E, Padgett Denis, Rouzier Vanessa, Succi Regina Célia M, Machado Daisy M, McGowan Catherine C, Vermund Sten H, Pinto Jorge A
Department of Pediatrics, Social Security Honduran Institute, Tegucigalpa, Honduras.
Departments of Biostatistics, Medicine, and Pediatrics, Vanderbilt University School of Medicine, and Vanderbilt Institute for Global Health, Nashville, TN.
J Pediatr. 2017 Mar;182:245-252.e1. doi: 10.1016/j.jpeds.2016.12.034. Epub 2017 Jan 9.
To assess the risks of and factors associated with mortality, loss to follow-up, and changing regimens after children with HIV infected perinatally initiate combination antiretroviral therapy (cART) in Latin America and the Caribbean.
This 1997-2013 retrospective cohort study included 1174 antiretroviral therapy-naïve, perinatally infected children who started cART age when they were younger than 18 years of age (median 4.7 years; IQR 1.7-8.8) at 1 of 6 cohorts from Argentina, Brazil, Haiti, and Honduras, within the Caribbean, Central and South America Network for HIV Epidemiology. Median follow-up was 5.6 years (IQR 2.3-9.3). Study outcomes were all-cause mortality, loss to follow-up, and major changes in cART. We used Cox proportional hazards models stratified by site to examine the association between predictors and times to death or changing regimens.
Only 52% started cART at younger than 5 years of age; 19% began a protease inhibitor. At cART initiation, median CD4 count was 472 cells/mm (IQR 201-902); median CD4% was 16% (IQR 10-23). Probability of death was high in the first year of cART: 0.06 (95% CI 0.04-0.07). Five years after cART initiation, the cumulative mortality incidence was 0.12 (95% CI 0.10-0.14). Cumulative incidences for loss to follow-up and regimen change after 5 years were 0.16 (95% 0.14-0.18) and 0.30 (95% 0.26-0.34), respectively. Younger children had the greatest risk of mortality, whereas older children had the greatest risk of being lost to follow-up or changing regimens.
Innovative clinical and community approaches are needed for quality improvement in the pediatric care of HIV in the Americas.
评估拉丁美洲和加勒比地区围产期感染艾滋病毒的儿童开始联合抗逆转录病毒治疗（cART）后死亡、失访和改变治疗方案的风险及相关因素。
这项1997 - 2013年的回顾性队列研究纳入了1174名未接受过抗逆转录病毒治疗、围产期感染的儿童，他们在阿根廷、巴西、海地和洪都拉斯6个队列中的1个开始cART治疗，年龄小于18岁（中位年龄4.7岁；四分位间距1.7 - 8.8岁），属于加勒比、中美洲和南美洲艾滋病毒流行病学网络。中位随访时间为5.6年（四分位间距2.3 - 9.3年）。研究结局为全因死亡率、失访率和cART的重大改变。我们使用按地点分层的Cox比例风险模型来检验预测因素与死亡或改变治疗方案时间之间的关联。
只有52%的儿童在5岁之前开始cART治疗；19%的儿童开始使用蛋白酶抑制剂。开始cART治疗时，CD4细胞计数中位数为472个/立方毫米（四分位间距201 - 902）；CD4%中位数为16%（四分位间距10 - 23）。cART治疗第一年的死亡概率很高：0.06（95%置信区间0.04 - 0.07）。开始cART治疗5年后，累积死亡率为0.12（95%置信区间0.10 - 0.14）。5年后失访和治疗方案改变的累积发生率分别为0.16（95% 0.14 - 0.18）和0.30（95% 0.26 - 0.34）。年龄较小的儿童死亡风险最高，而年龄较大的儿童失访或改变治疗方案的风险最高。
美洲地区需要创新的临床和社区方法来提高儿科艾滋病毒护理的质量。
