Piaa 030
Piaa 030
Piaa 030
ORIGINAL ARTICLE
Background. As the World Health Organization (WHO) and its joint partners such as USAIDS target achieving 90% sus-
tained virological suppression among children and adolescents living with Human Immunodeficience Virus (HIV)/AIDS, it is
imperative to elucidate the current prevalence and factors associated with virological treatment failure for formulation of appro-
priate strategies. This study was conducted determine the prevalence and factors associated with virological treatment failure
among children and adolescents with HIV/AIDS on antiretroviral therapy (ART) attending HIV/AIDS care clinics in Dodoma,
Central Tanzania.
Methods. This was a cross-sectional study of children aged 1–19 years attending 3 HIV/AIDS care clinics in Dodoma (central
Tanzania) from November 2018 to February 2019. Sociodemographic and clinical factors were documented, HIV viral load and
CD4+ T lymphocytes were evaluated for children on ART for ≥6 months. The primary outcomes were the prevalence and factors
associated with viralogic treatment failure.
Results. Of 300 children enrolled, 102 (34%) had virological treatment failure. Poor adherence to ART (adjusted odds ratio
[AOR] = 3.221; 95% confidence interval [CI], 1.867–5.558; P = .032), nevirapine regimen (AOR = 3.185; 95% CI, 1.473–6.886; P ≤
.001), not using cotrimoxazole prophylaxis (AOR = 25.56; 95% CI, 3.15–27.55; P = .002) and nondisclosure of HIV status to others
(AOR = 7.741; 95% CI, 2.351–25.489; P = .001) were independently associated with virological treatment failure.
Conclusions. Current prevalence of virological treatment failure among children and adolescents living with HIV on ART re-
main high. Factors such as ART adherence, nevirapine based regimen, HIV status disclosure to those caring for the child need to be
addressed to achieve sustained virological suppression.
Keywords. adolescents; antiretroviral therapy; children; HIV/AIDS; virological treatment failure.
Treatment of human immunodeficiency virus (HIV) infection use of ART allows ongoing HIV replication and chronic inflam-
with antiretroviral therapy (ART) aims to maintain suppressed mation. Inappropriate use of ART may lead to treatment failure
plasma HIV RNA below detectable levels using highly sensitive and limit future treatment options for children and adolescents
HIV-RNA polymerase chain reaction (PCR) assays [1]. ART re- living with HIV [2].
duces morbidity and mortality, promotes normal growth and Tanzania ranks third among sub-Saharan countries with
development, and improves the quality of life for children and the highest prevalence of HIV among children and harbors 5%
adolescents living with HIV; however, its effectiveness depends of the world’s adolescents living with HIV [3]. About 62 781
on sustained suppression of viral replication [2]. Inconsistent children aged <14 years were estimated to be living with HIV in
Tanzania in 2019 and only 65% were on ART [4].
prophylaxis and 8% (24/300) having TB infection. Other base- poor adherence to ART (AOR = 3.409; 95% CI, 1.109–10.476;
line characteristics of the study participants are listed in Table 2. P = .032), and not being on cotrimoxazole prophylactic therapy
(AOR = 25.56; 95% CI, 3.15–27.55; P = .002), as shown in
Prevalence of Virological Treatment Failure Among Children and Table 3.
Adolescent Living With HIV on ART
Overall, 34% (102/300) of children and adolescents met our DISCUSSION
definition of virological treatment failure (viral load ≥1000
copies/mL). Of the 34%, 56.9% (58/102) were from DRRH, Achievement of sustained virological suppression in children
26.5% (27/102) from Makole Health Centre, and 16.6% (17/102) living with HIV is crucial to ensuring long-term survival and
from Village of Hope. The proportion of virological treatment reducing HIV-related morbidity. Attainment of this goal in
failures to the number of children per clinic attended was 39% children compared with adults is affected by several challenges,
(58/150) at DRRH, 30% (27/90) at Makole Health Centre, and including the inherent risk for rapid HIV disease progression,
28% (17/60) at Village of Hope. limited availability of appropriate drug formulations, and drug
palatability that leads to subtherapeutic drug levels. The socio-
Factors Associated With Virological Treatment Failure Among Children cultural environment that surrounds the child, such as parental
and Adolescents Living With HIV health status, primary caretaker, and availability of compre-
On multivariate logistic regression analysis, children and ado- hensive HIV/AIDS care and treatment services, has a signifi-
lescents on a nevirapine-based regimen (34% [102/300]) were cant impact as well. In this cross-sectional study, we report a
more likely to have virological treatment failure compared high prevalence of virological treatment failure, 34% (102/300)
with those on efavirenz (48.7% [146/300]) or protease in- among children living with HIV on ARTs who attended routine
hibitor–based regimens (17.% [52/300]; adjusted odds ratio care clinics.
[AOR] = 3.221; 95% CI, 1.867–5.558; P = <.001). Several other Plasma HIV viral load testing in children living with HIV is the
factors were independently associated with virological treat- recommended gold standard test. Despite this recommenda-
ment failure, including TB infection (AOR = 8.881; 95% CI, tion, plasma HIV virological testing is not widely available in
2.012–39.202; P = .004), nonparent caregiver (AOR = 6.598; most developing countries. Until recently, most HIV/AIDS care
95% CI, 1.146–37.995; P = .035), nondisclosure of HIV status and treatment centers in resource-limited settings have used
to others (AOR = 7.741; 95% CI, 2.351–25.489; P = .001), the CD4 + lymphocyte level (absolute count or percentage) as
Viral Load
Bivariate Odds Ratio Multivariate Adjusted Odds
Variable Suppressed (N = 198) Unsuppressed (N = 102) (95% CI, P value) Ratio (95% CI, P value)
Age of client, y
<10 85 (42.9%) 54 (52.9%) 0.669 (0.414–1.081, .100)
≥10 113 (57.1%) 48 (47.1%)
Sex
Male 96 (48.5%) 49 (48.0%) 1.018 (0.631–1.642, .942)
Female 102 (51.5%) 53 (52.0%)
Education level
No schooling 36 (18.2%) 25 (24.5%)
Primary 129 (65.2%) 62 (60.8%) 1.486 (0.672–3.288, .328)
Secondary 33 (16.7%) 15 (14.7) 1.066 (0.539–2.107, .855)
Residence
Viral Load
Bivariate Odds Ratio Multivariate Adjusted Odds
Variable Suppressed (N = 198) Unsuppressed (N = 102) (95% CI, P value) Ratio (95% CI, P value)
Caregiver relationship
Parent 123 (62.1%) 43 (42.2%) 2.250 (1.383–3.661, .001) 6.598 (1.146–37.995, .035)
Non-parent 75 (37.9%) 59 (57.8%)
ART changes
Yes 85 (42.9%) 60 (58.8%) 1.899 (1.170–3.083, .009) 0.614 (0.163–2.309, .470)
No 113 (57.1%) 42 (41.2%)
Cotrimoxazole prophylaxis
Yes 100 (50.5%) 31 (30.4%) 2.337 (1.410–3.875, .001) 25.56 (3.15–27.55, .002)
No 98 (49.5%) 71 (69.6%)
Isoniazid prophylaxis
Yes 71 (35.9%) 32 (31.4%) 1.223 (0.735–2.035, .439)
No 127 (64.1%) 70 (68.6%)
Abbreviations: ART, antiretroviral therapy; CI, confidence interval; HIV, human immunodeficiency virus.
for children living with HIV. This will ensure early detection with other studies, a nevirapine-based regimen was associ-
of those failing treatment and administration of prompt inter- ated with development of virological treatment failure [10, 26,
ventions including enhanced adherence counseling and timely 27]. The increased likelihood for virological treatment failure
ART regimen transitions [24]. for nevirapine-based regimens in children is mainly attributed
When compared with adults living with HIV, children and to the use of this drug as a monotherapy during prevention of
adolescents living with HIV are at significantly higher risk of de- mother-to-child transmission of HIV. Virological treatment
veloping virological treatment failure [25]. Children and adoles- failure has also been reported among children living with
cents depend heavily on a high level of caretaker involvement. HIV on a nevirapine-based regimen with no prior exposure to
In addition, other sociocultural factors influence their situation. nevirapine monotherapy [28, 29].
These unique needs should be taken into consideration when Nevirapine is known to have a low genetic barrier to resist-
planning and implementing treatment to ensure good adherence. ance development, which may partly explain the development
Similar to previous studies in Tanzania, Emmett et al found of virological treatment failure among children not previously
that children on a nevirapine-based regimen were 2 times exposed to this drug [30, 31]. The association of a nevirapine-
more likely to have virological treatment failure than those on based regimen and virological treatment failure among children
efavirenz or protease inhibitor–based regimens [47]. In line living with HIV who attend care clinics could also reflect HIV