Effect of baseline immunological condition, virological response and
duration of HAART on growth in HIV-infected adolescents.
Lazarus E1; Otwombe K1; Mohapi L1; Cescon A2,3; Violari A1; Laher F1
Institutions: 1Perinatal HIV Research Unit, Soweto, South Africa, 2Simon Fraser University, Faculty of Health Sciences, Burnaby, Canada, 3British Columbia Centre for Excellence in
HIV/AIDS, Vancouver, Canada, 1
Effect of HIV on child & adolescent growth from the literature
• HIV is associated with poor growth in children1-3 • Stunting (short-for-age) is the most common
abnormal growth pattern4
• Height-for-age is more closely linked to disease progression than weight-for age5
• Survival related to height growth velocity6
1Gertner JM , J Pediatr 1994; 2Moye J Jr, J Pediatr 1996; 3Carey VJ, AIDS 1998; 4Arpadi, JAIDS 2000; 5Benjamin DK, AIDS 2003; 6Chantry CJ, Pediatr Infect Dis J, 2003
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Effect of HAART on child & adolescent growthfrom the literature
• HAART improves weight and height1-8
• Improved growth may be associated with –Virological response1,5 – Immunological response3,6
– Immunological stage at initiation of ART8
–Age at start of HAART3,7,8
1Guillén S, Pediatr Infect Dis J 2007; 2Kabue MM, AIDS Patient CARE STDS 2008; 3 Nachman SA, Pediatr Infect Dis J 2005; 4Song R, Pediatrics 2007; 5Verweel G, Pediatrics 2002; 6Ghaffari G, Pediatrics 2004; 7Bakeera-Kitaka S, J Pediatr Infect Dis, 2008; 8Kekitiinwa A, JAIDS,2008
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Aim
• To determine the correlation with adolescent growth of: – baseline CD4 – age at initiation of HAART – virological response– treatment duration
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Setting
• Retrospective, cross-sectional analysis • Perinatal HIV Research Unit, Soweto, S Africa• HAART-recipients aged 11-19 years
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How is growth measured?
• Wt & ht plotted on centile chart• Z-score calculated using SAS
software provided by the CDC• Z-score: measure of standard
deviations from mean • 50th centile z-score = 0• Example
– 13 year old female– Wt = 35kg WAZ = -
2.48– Ht = 140 cm HAZ = -1.57
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What is growth?
• Difference between gender adjusted growth measurements between most recent clinic visit and baseline:– Weight for age z-score (WAZ)– Height for age z –score (HAZ)
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Statistical analysis
• Chi-square contingency table analysis: association between growth and – duration of treatment– baseline CD4– age at baseline – most recent viral load.
• Where an association existed, a univariate analysis was performed to determine the predictor of growth.
• 5% significance level
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Background characteristicsBackground Methods Results Conclusions
N=107
Sex: Number (%) Female 57 (53)Age at HAART initiation: median years (IQR) 8.4 (6.1 – 11.4)Duration HAART use: median years (IQR) 6.1 (2.4 – 9.1)
Baseline CD4 count: median cells/ml (IQR)<200: n (%)200 – 350: n (%)>350: n (%)
246482435
(107 – 475)(45)(22)(33)
Most recent viral load: n (%)<400 cp/ml≥400 cp/ml
8423
(79)(21)
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GrowthBackground Methods Results Conclusions
-0.15-0.1
-0.050
0.050.1
0.150.2
0.25
HAZ WAZ
Baseline CD4
CD4 <200CD4 200-350CD4 >350
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GrowthBackground Methods Results Conclusions
-0.4
-0.2
0
0.2
0.4
0.6
HAZ WAZ
Duration of HAART
<6.1 yrs>6.1 yrs
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GrowthBackground Methods Results Conclusions
-0.2
-0.15
-0.1
-0.05
0
0.05
0.1
0.15
HAZ WAZ
Most recent viral load
VL >400VL <400
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ResultsBackground Methods Results Conclusions
Height-for-age z-score (HAZ) Weight-for-age z-score (WAZ)
Variable OR (CI) p-value OR (CI) p-value
Odds Ratio (OR) for gain in HAZ and WAZ
Baseline CD4 ≥200 <200
2.7 (1.18, 6.20)1
0.019 1.2 (0.56, 2.67)1
0.61
Baseline CD4 ≥350<350
2.9 (1.25, 6.66)1
0.013 1.7 (0.74, 3.79)1
0.22
Most recent VL<400 ≥ 400
1.5 (0.55, 3.98)1
0.44 1.1 (0.41, 2.72)1
0.91
Duration Rx>6.1 yrs<6.1 yrs
1.9 (0.84, 4.1)1
0.13 0.7 (0.30, 1.43)1
0.29
Age at BL 0.9 (0.83, 1.05) 0.28 0.9 (0.81, 1.01) 0.1
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Conclusion
• Higher baseline CD4 count predicts better growth in height
• To optimise growth outcomes into adolescence, we recommend HAART initiation at baseline CD4 count >200 cells/ml for children >5 years old
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START early
GROWbetter
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Limitations
• Retrospective• Non-randomised
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Acknowledgments
• Clinic staff of adult & paediatric clinics– Doctors Haseena Cassim, Xolile Dlamini, Mfundo
Kuhlase, Afaaf Liberty, Mpolokeng Melamu, Geraldinah Mjali, Ashaan Naidoo, Faeezah Patel
– Sisters Noreen Boikanyo, Jackie Brown, Sizakele Ncongwane, Rebecca Phofa
– Nurses Gloria Tshabalala, Mpho Kokoele, Cathy Lephoto, Mitha Madiba, Patricia Masiya, Busi Saba
• USAID for providing funding to care for these adolescents.
• Our adolescent patients and their caregivers
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