414. Successful Pediatric HIV Management within a South African Decentralization Model of ART Delivery
Session: Poster Abstract Session: Pediatric HIV
Thursday, October 3, 2013
Room: The Moscone Center: Poster Hall C
  • ID WEEK 2013 poster DRAMOWSKI.pdf (517.6 kB)
  • Background: Although Sub-Saharan Africa faces the world’s largest pediatric HIV epidemic, only one in four
    children have access to combination antiretroviral therapy (ART). WHO has advocated a decentralized, public
    health-centred approach for HIV care in resource-limited settings, however multiple obstacles to community-
    initiated pediatric ART exist, including human resource and logistical constraints.

    Methods: A retrospective cohort analysis of 613 pediatric patients receiving ART between 2004 and 2009
    was performed in seven physician-run primary health care (PHC) clinics in Cape Town’s Metropole East.
    Baseline characteristics, serial CD4 and viral load levels, and status at study closure were collected.
    Participants were categorized as available for baseline or longitudinal (more than 6 months in PHC) analysis.

     Results: Two distinct sub-groups were identified: children who initiated ART in a PHC (n = 343) and children
    who were down-referred from a higher level of care (n = 270). Numbers of children initiating ART in PHC
    increased seven-fold over the study period. Down-referred children were severely-ill at ART initiation with
    higher viral loads, lower CD4 counts and were more often co-infected with TB (25.3% vs 16.9%; p = 0.01).
    Children without immunosuppression were more likely to have initiated ART in hospital (p=0.02). Median time
    to virologic suppression was 29 weeks in PHC-ART initiates and 44 weeks in children down-referred (p <
    0.0001). Children down-referred from tertiary sites either maintained or gained virologic suppression during
    PHC care. Longitudinal cohort analysis demonstrated successful PHC ART management: sustained viral load
    suppression > 80%, high rates of immune reconstitution and low mortality.

     Conclusion: Increasing numbers of children are initiating ART within PHC settings, and achieve comparable
    immunological, virological and survival outcomes, suggesting successful decentralisation of pediatric HIV
    care. Down-referral of children with adherence-related virologic failure, may assist with attainment of virologic
    suppression and spare use of second-line medications.

    Angela Dramowski, MD, Community Health, Academic Unit for Infection Prevention and Control, Stellenbosch University, Cape Town, South Africa, Megan Morsheimer, MD, Allergy and Immunology, Children's Hospital of Philadelphia, Division of Allergy and Immunology, Philadelphia, PA, Mark Cotton, MMed, PhD, Stellenbosch University, Matieland, South Africa, Helena Rabie, MD, Department of Paediatrics and Child Health, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa and Landon Myer, MD, School of Public Health and Family Medicine, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa


    A. Dramowski, None

    M. Morsheimer, None

    M. Cotton, None

    H. Rabie, None

    L. Myer, None

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