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Immunologic response and survival of infants initiating antiretroviral treatment (ART) at less than one year of age compared to older children enrolled at MTCT-Plus Initiative sites in 8 African countries and Thailand
R.J. Carter, M. Katyal, P. Toro, E.J. Abrams, for the MTCT Plus Initiative
International Center for AIDS Care and Treatment Programs, Columbia University, Mailman School of Public Health, New York, United States
Background: WHO guidelines recommend ART initiation for all HIV-infected infants age < 12 months (m), regardless of clinical or immunological stage, but there is limited knowledge of how infants initiating ART in resource limited settings (RLS) fare over time.
Methods: We analyzed routine service delivery data from HIV-infected children initiating ART at MTCT-Plus Initiative sites in 8 African countries and Thailand. Change in CD4% from baseline was analyzed using linear modeling adjusting for time on ART, country, baseline CD4%, nevirapine (NVP) exposure at birth, and age at ART initiation.
Results: 542 (50%) children initiated ART between February 2003-September 2008 and were followed for a median of 30m [IQR: 12-39]. At initiation, 190 (35%) were age< 12m, 342 (65%) ≥12m [median 36m; IQR: 19.5-67], 51% male, 18% CDC stage C. Initial regimens included D4T/ZDV+3TC and NNRTI (84%), PI (12%), NRTI (4%). The mortality rate was significantly higher among infants compared with older children: 7.5 vs. 3.2/100 person-years. Of 31 (54%) infant deaths, 81% occurred within 3m of initiation. Among 383 children with baseline and >1 follow-up CD4%, the mean increase in CD4% from baseline was 12% (6m), 15% (12m), 17% (18m), 18% (24m), 19% (30m), and 19% (36m) with no difference between infants and older children. Baseline CD4% (p< .01) and time on ART (p< .001) remained significantly associated with a positive change in CD4% in multivariate analysis. While all children had good immunological response, those initiating ART at the lowest baseline CD4% continued to have the lowest CD4% values throughout follow-up compared to children initiating at higher baseline CD4%. PMTCT NVP-exposure was not associated with CD4% response among 98 infants initiating NVP-inclusive ART regimens.
Conclusions: Infants initiating ART had higher mortality at the beginning of treatment. However, surviving infants showed good immunological response over >3 years of follow-up, indistinguishable from older children.
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