Profile of Children with HIV in an Anti-Retroviral Therapy ( ART ) Clinic of Western Nepal

Acknowledgements: None Funding: Nil Conflict of Interest: None Permission from IRB: Yes 1Dr. Jagat Jeevan Ghimire, MBBS, MD, Consultant Paediatrician, Pokhara Academy of Health Sciences(PAHS), 2Dr. Ram HariChapagain, MBBS, MD, Assistant Professor National Academy of Medical Sciences (NAMS)/Senior Consultant Paediatrician, Kanti Children’s Hospital, 3Dr. Shree Krishna Shrestha, MBBS, MD Chief Consultant Paediatrician and Head of the Department of Paediatrics, Pokhara Academy of Health Sciences (PAHS), 4Dr. Ram Chandra Bastola, MBBS, MD, Consultant Pediatrician, Pokhara Academy of Health Sciences (PAHS). Abstract


Introduction
H IV in children have been an important public health problem 1 .
Globally there are 2.1 million children living with HIV 1 .Of them 43% are receiving life-saving antiretroviral therapy (ART) 1 .Children account for about 6 per cent of all people living with HIV, nine per cent of new HIV infections and 11 % of all AIDS-related deaths 1,2 .In 2016, 160,000 children were newly infected with HIV, mainly through transmission of the virus from their mothers during pregnancy, delivery or while breastfeeding 1,2 .Evidence shows that early initiation of antiretroviral drugs in infants with HIV can save lives 3 .The number of paediatric HIV cases continues to rise due to high prevalence of HIV infection in mother and failure of adoption of appropriate measures in the prevention of perinatal transmission 3 .In Nepal there are approximately 1600 children living with HIV4-5.However with the effective use of ART in children there has been decrease in the progression to AIDS and mortality 6,7 .The aims of the study were to fi nd out the demographic profi le as well as the modes of transmission, clinical stage during diagnosis, immunological status as indicated by CD4 count,nutritional status and status of TB infection amongst children with HIV infection.

Material and Methods
This was a retrospective study done using the hospital record and charts of the children who are registered in the ART clinic of Pokhara academy of health sciences, over a period of 10 years from Shrawan 2064 (July 2007)to Asar 2074(June 2017).Age, sex, occupation of mother, clinical stage, nutritional status and CD4 at diagnosis was noted.Clinical stage was done using WHO clinical staging 8 .Nutritional status was assessed using WHO growth charts and classifi ed using WHO classifi cation 9 .The initial regimen of Anti-retroviral therapy(ART), Second line ART(if used) along with indication for change in regimen was noted.Approval for the study was taken from the hospital administration.Data was recorded using Microsoft excel and analysed using SPSS 22.

Results
There were 112 children and adolescent enrolled in the ART clinic of the hospital.Out of them 57 were males and 55 were females with M:F ratio of 1.1:1.Majority of them from age group 1 to 5 years at the time of presentation.The median age of patients enrolled in the study was 13 years.Eighty-two percent of mothers and 75% of fathers were receiving ART at the time of presentation.All the mothers of the children were housewife by profession.All children acquired infection by mother to child transmission.Fifty-two percent of our children were undernourished.Forty-six % were in the clinical stage III, 25% were in clinical stage IV and 24% were in clinical stage II.TB HIV co-infection was noted in one case.The median CD4 of the patients was 283.Twenty nine percent of our children had CD4 counts below 200.Hundred children were started on AZT/TC/ NVP as fi rst line ART.Six were started on AZT/3TC/EFV, four were started on TDF/3TC/NVP as fi rst line ART and one was started on stavudine containing regimen.Forty children had their regimen switched to another regimen for immunological and/or virological failure.

Discussion
HIV in children has been a challenge to global health 3 .Moreover the increased case load in the poorest part of the world adds further diffi culties in the management 6 .Mother to child transmission of HIV infection is the most common infection in developing countries like Nepal.Lack of proper ANC care and lack of ART during pregnancy have been important reasons for mother to child transmission of HIV in children 4,8 .All children enrolled in our clinic got infected by 'mother to child transmission' which shares similarities with the global and national level data on transmission of HIV in children 4 .This fi nding is comparable to fi nding of the studies done in India and Nepal with all of the enrolled children acquiring infection by mother to child transmission with all of enrolled patients infected by mother to child transmission 6,10 .
Our study showed delay in diagnosis of HIV in children as most of children were in the age group 1-5 years during diagnosis.This shares similarities with the other studies done in India and Nepal by Madhivan etal, Gomber et al and Poudel et al with median age of 58 months, 4.0 years and 6.24 years respectively 6,7,11 .These fi ndings suggest there is delay in diagnosis of HIV in children in the region.Our study showed 52 % of children being undernourished.Undernutrition is an important sign of HIV infection in children 12 .It also shows severity of HIV infection as poor nutritional status signifi es higher clinical stage which in turn refl ects poor prognosis 8 .Improvement in nutritional status is associated with improved outcome 12 .A study done byPoudelet.al. in eastern Nepal showed 54 % of HIV infected children being undernourished 6 .Different studies done in Northern India by Ravi Ambey et al and Kapavarapu et al showed 60% and 72% respectively 12,13 .So the fi nding of our studies were comparable to these studies in relation to nutritional status 6,12,13 .The poor nutritional status of the children showed more focus is needed in nutritional assessment and management of these children.
Tuberculosis is the most common opportunistic infection in HIV children 4 .Well studied epidemiological and biological features between HIV and TB infl uence the distribution, progression and outcomes of both 14 .HIV is an important risk factor for the development of TB and the HIV epidemic is a key factor behind the resurgence in TB 15,16 .TB in HIV infected individual represent One in eight incident cases of TB 15 .Tuberculosis signifi es higher clinical stage of HIV infection and TB in an HIV infected child is considered to be a clinical indication for initiation of antiretroviral treatment 17 .However the ever challenging diagnosis of TB in children is complicated by altered immune response in HIV infected children 14 .Only one child in our study had diagnosis of TB.The prevalence of TB among HIV infected children in different studies ranged from 16 % to 52% [18][19][20][21] .Our study differed from these studies in regards to TB infection.This may be due to low screening for TB in children enrolled in our study.
Clinical stage as defi ned by WHO is an important assessment of severity of HIV infection 8 .Higher clinical stage signify severe infection and need of ART 6,8 .In different studies done in Nepal and Indiashowed most of the children were in the clinical stage 1 at diagnosis 6,11 .Most of our children were at who clinical Stage-3 at diagnosis which was comparable to the study done by Chapagain et al 22 .The higher clinical stage at diagnosis signifi es delay in the diagnosis.CD4 cells which remain as important part of immune response against viruses like HIV are important part of assessment of HIV infection 23 .Decrease in CD4 not only signifi es severity of infection but also indicate need of treatment and response to treatment 23,24 .In different studies done in India and Nepal the median CD4 were 543 and 298 respectively 6,7 .The fi nding of our study was comparable to these results with median CD4 value of 284 and 29 % of our children showing severe immunosuppression with CD4 below 200.Higher clinical stage at presentation and severe immunosuppression indicated delay in diagnosis.These fi nding also point towards lack of adherence of Prevention of Mother to Childhood Transmission (PMTCT) program.

Conclusion
Although perinatal route was the most common route of transmission of HIV, diagnosis was late and most of them were diagnosed in the advanced clinical stage wit h low CD4 count.Undernutrition was common among HIV infected children.

Table 1 :
Showing study characters of children with HIV