Long-term trends in mortality and AIDS-defining events after combination ART initiation among children and adolescents with perinatal HIV infection in 17 middle- and high-income countries in Europe and Thailand: A cohort study. PLoS Medicine
Judd et al. on behalf of the European Pregnancy and Paediatric HIV Cohort Collaboration (EPPICC) study group in EuroCoord aimed to describe rates and risk factors for death and AIDS-defining events in children and adolescents after initiation of combination antiretroviral therapy (cART) in 17 middle- and high-income countries. Children with perinatal HIV aged < 18 years initiating cART were followed until their 21st birthday, transfer to adult care, death, loss to follow-up, or last visit up until 31 December 2013.
At cART initiation, median age was 5.2 (IQR 1.4±9.3) years; 35% of children aged < 5 years had a CD4 lymphocyte percentage < 15% in 1997-2003, which fell to 15% of children in 2011 onwards (p < 0.001). Similarly, 53% and 18% of children ≥5 years had a CD4 count 400 c/mL predicted late death.
In conclusion, this study shows that mortality rates fell after the introduction of cART in 1997 but have remained stable since 2006, and the prevalence of low CD4 at initiation of cART decreased over the period. Five-year survival probability after initiating cART across the whole period studied was 97.6%. Almost half of the deaths observed were in the first 6 months of cART, suggesting that close clinical follow-up is recommended over the first 6 months after cART initiation, with enhanced prophylaxis against infections in those presenting with advanced disease. The indication of raised early mortality risk in infants and those in Eastern Europe and Thailand raises concern and warrants vigilance. It highlights the need to direct additional clinical resources to the care of these groups, as well as further prospective studies evaluating morbidity and mortality in older adolescents.