A review of clinical and immunological outcomes as predictors of viral loads among children on HAART for at least 24 weeks at the University Teaching Hospital,Lusaka,Zambia

BACKGOUND: There is increasing evidence that the current clinical and immunological monitoring tools are not sufficient to identify early enough patients who are failing on treatment. Development of resistance to the limited treatment options for children and premature switching are the dangers. The objective of this study was to review patient records to see how well CD4 profiles and viral load estimations relate in children.
METHODS:A retrospective chart reviews of all children aged between 0-19 years that started treatment between January 2004 and Dec 2010 was carried out at the University Teaching Hospital. Systematic sampling was done of every second child who received HAART for more than 24 weeks and with at least one viral load reading after 24 weeks of treatment. Six-monthly immunological and virological data were collected until last follow-up review or five years on treatment The 2010 Zambian Pediatric Guidelines were used to gauge age-related immunological and virological failure (viral load > 1,000).
RESULTS: A total of 517 patient records were reviewed. Mean age at ART initiation was 7 years ((SD 4.7yrs). Mean time after ART initiation when first viral load test was done was 2.7 years (SD 1.5yrs). Of all the viral loads done, 64% (328) had a routine indication for patients on treatment nearing the 3 year mark. In 40% ofchildren the first viral load test result was above 1,000 after 24 weeks or more of treatment. 23% of the patients (121) were consistently failing immunologically and virologically; 48% (246) were consistently not failing; 20% (104) had a high CD4, but failing virologically and 6% (30) had a low CD4 but were virologically suppressed.
CONCLUSIONS: Immunological monitoring in children on ART does not accurately identify those that are failing. A push for routine, affordable virological testing is needed to identify treatment failures early to prevent development of ART resistance and avoid premature switches to second line.