Predicting virologic failure among HIV-1-infected children receiving antiretroviral therapy in Tanzania: a cross-sectional study.

Abstract

BACKGROUND: Many HIV care and treatment programs in resource-limited settings rely on clinical and immunologic monitoring of antiretroviral therapy (ART), but accuracy of this strategy to detect virologic failure (VF) among children has not been evaluated. METHODS: A cross-sectional sample of HIV-infected children aged 1-16 years on ART >or=6 months receiving care at a Tanzanian referral center underwent clinical staging, CD4 lymphocyte measurement, plasma HIV-1 RNA level, and complete blood count. Associations with VF (HIV-1 RNA >or=400 copies/mL) were determined utilizing bivariable and multivariate analyses; accuracy of current clinical and immunologic guidelines in identifying children with VF was assessed. FINDINGS: Of 206 children (median age 8.7 years, ART duration 2.4 years), 65 (31.6%) demonstrated VF at enrollment. Clinical and immunological criteria identified 2 (3.5%) of 57 children with VF on first-line therapy, exhibiting 3.5% sensitivity and 100% specificity. VF was associated with younger age, receipt of nevirapine vs. efavirenz-based regimen, CD4% < 25%, and physician documentation of maladherence (P < 0.05 on bivariable analysis); the latter 2 factors remained significant on multivariate logistic regression. INTERPRETATION: This study demonstrates poor performance of clinical and immunologic criteria in identifying children with virologic failure. Affordable techniques for measuring HIV-1 RNA level applicable in resource-limited settings are urgently needed.

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Citation

Published Version (Please cite this version)

10.1097/QAI.0b013e3181cf4882

Publication Info

Emmett, Susan D, Coleen K Cunningham, Blandina T Mmbaga, Grace D Kinabo, Werner Schimana, Mark E Swai, John A Bartlett, John A Crump, et al. (2010). Predicting virologic failure among HIV-1-infected children receiving antiretroviral therapy in Tanzania: a cross-sectional study. J Acquir Immune Defic Syndr, 54(4). pp. 368–375. 10.1097/QAI.0b013e3181cf4882 Retrieved from https://hdl.handle.net/10161/14574.

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Scholars@Duke

Emmett

Susan D Emmett

Adjunct Associate Professor of Global Health

My research focuses on reducing hearing health disparities globally. I work with colleagues around the world to define the global burden of hearing loss and deepen our understanding of its social, economic, and health impact. We apply a public health approach that spans prevention, diagnosis, and treatment.

Fundamental to prevention is evaluating why hearing loss is so much more common in low-resource settings and investigating risk factors that are potentially modifiable. I have focused my prevention efforts on undernutrition, evaluating the contribution of early life malnutrition and micronutrient deficiencies to risk of hearing loss in Nepal. We are currently expanding this work to the Bolivian Amazon.

Diagnosis of hearing loss in remote settings brings unique challenges, including scarcity of audiologists and otolaryngologists, need for portable equipment, and lack of screening programs to identify affected children. I am currently leading a PCORI (Patient-Centered Outcomes Research Institute)-funded community randomized trial with the Norton Sound Health Corporation in Nome, Alaska to evaluate a new protocol for school hearing screening in 15 villages on the Bering Sea.  This study utilizes mobile health technology and telemedicine referral to identify previously undiagnosed hearing loss and efficiently connect Alaska Native children to care. The intervention has applicability across the state of Alaska, as well as in other remote, low-resource settings with a high prevalence of hearing loss and ear disease.

My research on treatment of hearing loss is focused on expanding access to cochlear implantation, a treatment for severe-to-profound hearing loss traditionally limited to high-resource settings. I have worked with collaborators in 14 countries to demonstrate that cochlear implantation can be a cost-effective treatment option in Sub-Saharan Africa and Latin America. We are expanding these studies to other regions of the world. 

Selected Grants

Addressing Childhood Hearing Loss Disparities in an Alaska Native Population: A Community Randomized Trial (AD-1602-34571), PCORI

Research Training in Otolaryngology (5T32DC000027-25), NIDCD/NIH

Global Control of Micronutrient Deficiency (OPPGH 614), Bill and Melinda Gates Foundation

Feed the Future Innovation Lab for Collaborative Research on Nutrition (AID-OAA-L-1-00006), USAID

Blandina Mmbaga

Adjunct Associate Professor of Global Health
Bartlett

John Alexander Bartlett

Professor of Medicine

My clinical investigation is focused on the pathogenesis and treatment of HIV infection and its complications, especially in resource-limited settings.

Key Words: HIV infection, AIDS, treatment strategies, treatment failure, co-infections, resource-limited settings


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