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Treatment outcomes in perinatally infected HIV-positive adolescents and young adults after ≥10 years on antiretroviral therapy.

BACKGROUND
The burden of paediatric HIV in South Africa has shifted to older children and adolescents. Nevertheless, information on long-term treatment outcomes of perinatally HIV-infected (PHIV) children is limited.


OBJECTIVES
To examine long-term immunological and virological outcomes of children who were in care for at least 10 years after starting antiretroviral therapy (ART).


METHODS
We performed a retrospective cohort study of 127 PHIV children who initiated ART at a Cape Town clinic between 2002 and 2005 and were followed up for ≥10 years from the ART initiation date. CD4+ counts and viral loads (VLs) were analysed for each successive year on ART. Treatment history, resistance test results, growth data, hospital admissions and opportunistic infection history were described.


RESULTS
The median age at ART initiation was 2.6 years (interquartile range (IQR) 1.3 - 4.9) and the median CD4+ percentage 13.0% (IQR 8.9 - 18.0). The first ART regimen was non-nucleoside reverse transcriptase inhibitor based (63.8%) or protease inhibitor based (36.2%). Median follow-up was 12.2 years (IQR 11.1 - 13.0). At the last assessment, 49.6% of patients were on first-line and 43.3% on second-line ART. At the last assessment, the median CD4+ count was 686 cells/µL (IQR 545 - 859) and 78.7% of children had CD4+ counts >500 cells/µL (92.1% of those on first-line v. 70.9% on second-line ART; p=0.003). At the last assessment, 79.5% of patients were virally suppressed (VL <400 copies/mL), 86.2% of those on first-line v. 76.8% on second-line ART (p=0.183). The 10-year probability of experiencing viral failure (VF) was 56.7% (95% confidence interval (CI) 48.3 - 65.5) and the 10-year probability of switching to second-line ART 45.7% (95% CI 37.5 - 54.8). The probability of experiencing VF between the ages of 10 and 18 years was 37.4% (95% CI 25.4 - 52.8).


CONCLUSIONS
Virological and immunological outcomes were good overall in PHIV children who remained in care for ≥10 years at this clinic, but >40% of children were on second-line ART with poorer immunological outcomes.