A cross sectional analysis of perinatally HIV-infected (PHIV) adolescents in a paediatric infectious diseases clinic in the Western Cape, South Africa

Thesis (MMed)--Stellenbosch University, 2018.ENGLISH ABSTRACT: Background Approximately 1.8 million adolescents were living globally with HIV in 2015. HIV is the leading cause of death in adolescents in Africa and the second leading cause of death in adolescence worldwide. Perinatally HIV-infected (PHIV) adolescents often have chronic complications due to late access to antiretroviral therapy (ART) and ART side effects. There is relatively little information on their psychosocial outcomes although poor adherence has been described. The aim of this study was to describe a cohort of perinatally HIV infected adolescents (PHIVA) attending Tygerberg Hospital, a tertiary hospital in the Western Cape in 2015. Material and Methods A retrospective descriptive study (folder review) describing all HIV- infected adolescents between the ages of 10 and 19 years attending the Infectious Diseases Clinic (IDC) during a 12 month period in 2015 was performed. Results Ninety-eight of approximately 400 (25%) patients attending the Tygerberg Paediatric IDC were adolescents. Of these, 55 (56%) were female. Median age at first clinic visit was 4.9 years (IQR 1.5- 9.4). Median age at most recent clinic visit was 14 years (IQR: 10-19). The majority were WHO clinical stage 3 and 4 at diagnosis (74%). Twenty-eight (28%) adolescents were on their original ART regimen with no change in drug for side effects, failure or intolerance. Sixty-seven (68%) remained on their first regimen with a single drug switch due to side effects. Fifty of sixty -one adolescents (82%) starting on Efavirenz remained on it. Of 94 adolescents with a viral load available at last clinic visit, 71 (81%) were virologically suppressed. Viral genotyping was done in 7 of the 17 adolescents (41%) with viral loads above 1000 copies/ml. Only 3 (3%) were on third line drugs. Few adolescents had chronic medical complications: 23/98 adolescents (23%) were documented to have chronic lung disease (CLD) with 58 (59%) previously having Pulmonary Tuberculosis (PTB), 2 (2%) having had multidrug resistant (MDR) Tuberculosis and 1 (1%) having had Extremely Drug Resistant (XDR) Tuberculosis. Four (4%) had cardiac disease, 1 (1%) had HIV related renal disease, 80 (80%) had documented dermatological complications. Forty-one (42%) had central nervous system complications such as seizures and neurodevelopmental delay. The median number of documented hospitalizations since diagnosis was 3 (IQR: 1-4) with no deaths in 2015. Sixty-eight percent (68%) of adolescents knew their HIV status. There was no documentation in 20 (20%), while 11 (11 %) were not disclosed to. For the latter, 7 had severe neurological disease. Fortyfive (55%) attended mainstream school and 34 (34%) a special school/care centre. Forty-six (47%) had failed a grade and 33 (33%) failed more than one grade. Five (5%) were on antidepressants. Fifty-six (57%) had been referred to a social worker for complex psychosocial issues. When comparing those diagnosed at an age less than 10 years to those diagnosed older than 10 years the only statistic significant difference was a lower baseline absolute CD4 count in those diagnosed after ten years of age (265 vs 554, p = 0,003). There was no difference in WHO staging at diagnosis, chronic complications or social issues. Conclusions Despite relatively late access to ART, adolescents had good virological outcomes that compare with international cohorts. There are fewer chronic medical complications than noted in other African cohorts. However, there are significant psychosocial and educational issues and more focused interventions are needed to address these.AFRIKAANSE OPSOMMING: Ongeveer 1.8 miljoen adolessente wêreldwyd het in 2015 met MIV geleef. MIV is die grootste oorsaak van sterfte by adolessente in Afrika, en die tweede grootste doodsoorsaak by adolessente wêreldwyd. Perinataal MIV-geïnfekteerde adolessente (PMIV’s) ervaar dikwels chroniese komplikasies weens vertraagde toegang tot antiretrovirale behandeling (ARV’s) sowel as die newe-effekte daarvan. Tog is daar betreklik min inligting beskikbaar oor hulle psigososiale uitkomste, hoewel adolessensie ’n risikofaktor vir ARV-versuim kan wees. Die doel van hierdie studie is om die uitkomste van ’n kohort PMIV-adolessente te beskryf wat in 2015 by Tygerberghospitaal, ’n tersiêre hospitaal in die Wes-Kaap, behandel is. Materiaal en metodes ’n Retrospektiewe beskrywende studie (pasiëntelêerstudie) is uitgevoer om alle MIV-geïnfekteerde adolessente tussen 10- en 19-jarige ouderdom te beskryf wat in 2015 oor ’n tydperk van 12 maande by die Infeksiesiektekliniek van Tygerberghospitaal behandel is. Resultate Van die sowat 400 pasiënte wat by Tygerberghospitaal se Pediatriese Infeksiesiektekliniek behandel is, was 98 (25%) adolessente. Van hierdie 98 adolessente was 55 (56%) vroue. Die mediaanouderdom van die adolessente met hulle eerste kliniekbesoek was 4,9 jaar (interkwartielafwyking 1,5-9,4), en 14 jaar (interkwartielafwyking 10-19) met hulle mees onlangse besoek. Met diagnose was die meeste adolessente (74%) in fase 3 en 4 van die Wêreldgesondheidsorganisasie se MIV-klassifikasiestelsel. Agt-en-twintig (28%) was ten tyde van die studie steeds op hulle aanvanklike ARV-regime, sonder enige middelveranderinge weens newe-effekte, ondoeltreffendheid of intoleransie. Sewe-en-sestig (68%) was steeds op hulle eerste regime met ’n enkele middelverandering weens newe-effekte. Sewe uit die 17 adolessente (41%) met virale ladings meer as 1000 kopiee/ml het gekwalifiseer vir virale genotipering, die res was waarskynlik as gevolg van swak nakoming. Slegs drie (3%) was op derdeliniemiddels. Vyftig van 61 (82%) adolessente wat efavirens begin gebruik het, het daarmee voortgegaan. Van die 94 vir wie daar met die mees onlangse kliniekbesoek ’n virustelling beskikbaar was, was 71 (81%) virologies onderdruk. Min adolessente het chroniese mediese toestande ontwikkel: Drie-en-twintig uit 98 (23%) het volgens hulle lêers aan chroniese longsiekte gely. Voorheen het 58 (59%) pulmonêre tuberkulose (PTB), twee (2%) multimiddelweerstandige tuberkulose, en een (1%) uiters middelweerstandige tuberkulose gehad. Vier (4%) het aan hartsiekte gely, een (1%) het MIV-nefropatie gehad, 80 (80%) gedokumenteerde dermatologiese komplikasies, en 41(42%) komplikasies van die sentrale senustelsel, soos toevalle en vertraagde neuro-ontwikkeling. Die mediaangetal hospitalisasies sedert diagnose was drie (1-4), en geen adolessent het in 2015 gesterf nie. Wat onthulling betref, was daar volle onthulling teenoor 67 (68%) adolessente; vir 20 (20%) was daar geen dokumente nie, terwyl daar teenoor 11 (14%) geen onthulling was nie. Sewe van die 11 teenoor wie daar geen onthulling was nie, het aan ernstige neurologiese siekte gely. Vyf-en-veertig (55%) het na hoofstroomskole gegaan en 34 (34%) na spesiale skole/sorgsentrums. Ses-en-veertig (47%) het een graad en 33 (33%) meer as een graad gedruip. So ver vasgestel kon word, was vyf (5%) op antidepressante. Ses-en-vyftig (57%) is vir psigososiale kwessies na ’n maatskaplike werker verwys. “n Vergelyking is getref tussen die adolessente wat voor die ouderdom van 10 jaar gediagnoseer is teenoor diegene wat na die ouderdom van 10 jaar gediagnoseer is en die enigste statisties betekenisvolle verskil was ‘n laer basislyn absolute CD4 telling in diegene ouer as 10 jaar (265 vs 554, p = 0,003). Daar was geen verskil in Wereldgesondheidsorganisasie Klassifikasie stelsel, chroniese komplikasies en sosiale probleme nie. Gevolgtrekkings Ondanks vertraagde toegang tot ARV’s toon die adolessente betreklik goeie uitkomste wat ooreenstem met internasionale kohorte. Daar is minder chroniese mediese komplikasies as in ander Afrikakohorte. Tog beleef dié kohort beduidende psigososiale en opvoedkundige kwessies, wat slegs deur meer toegespitste intervensies die hoof gebied kan word.Master