HIV Drug Resistance Patterns and Characteristics Associated with Clinically Significant Drug Resistance among Children with Virologic Failure on Antiretroviral Treatment in Kenya: Findings from the Opt4Kids Randomized Controlled Trial.

Increasing HIV drug resistance (DR) among children with HIV (CHIV) on antiretroviral treatment (ART) is concerning. CHIV ages 1-14 years enrolled from March 2019 to December 2020 from five facilities in Kisumu County, Kenya, were included. Children were randomized 1:1 to control (standard-of-care) or intervention (point-of-care viral load (POC VL) testing every three months with targeted genotypic drug resistance testing (DRT) for virologic failure (VF) (≥1000 copies/mL)). A multidisciplinary committee reviewed CHIV with DRT results and offered treatment recommendations. We describe DR mutations and present logistic regression models to identify factors associated with clinically significant DR. We enrolled 704 children in the study; the median age was 9 years (interquartile range (IQR) 7, 12), 344 (49%) were female, and the median time on ART was 5 years (IQR 3, 8). During the study period, 106 (15%) children had DRT results (84 intervention and 22 control). DRT detected mutations associated with DR in all participants tested, with 93 (88%) having major mutations, including 51 (54%) with dual-class resistance. A history of VF in the prior 2 years (adjusted odds ratio (aOR) 11.1; 95% confidence interval (CI) 6.3, 20.0) and less than 2 years on ART at enrollment (aOR 2.2; 95% CI 1.1, 4.4) were associated with increased odds of major DR. DR is highly prevalent among CHIV on ART with VF in Kenya. Factors associated with drug resistance may be used to determine which children should be prioritized for DRT.

Pediatric Tetanus in Central Pennsylvania.

Approximately 20% of the nationally reported tetanus infections in children aged 0 to 14 years that occurred in the United States between 2005 and 2015 were treated at Penn State Children's Hospital. With an electronic medical record search, we identified 5 cases of pediatric tetanus; 100% of these cases occurred in unimmunized children. Their median length of stay was 10 days, and the costs were significant.

Vaccine-Preventable Diseases Requiring Hospitalization.

BACKGROUND: Plain children often have lower immunization rates than non-Plain children. Penn State Health Children's Hospital is a tertiary medical center with large nearby Plain (Amish and Mennonite) communities. We sought to describe the characteristics of children hospitalized with vaccine-preventable diseases (VPDs). We hypothesized that Amish children would have a higher risk of VPDs than non-Amish children. METHODS: International Classification of Diseases, Ninth Revision codes were used to identify patients <18 years diagnosed with a VPD from January 1, 2005, to December 31, 2015, at Penn State Children's Hospital. Demographic information, immunization status, and outcomes were obtained from medical records. By using the number of children in our primary service area, we calculated the risk of VPD requiring hospitalization for Amish and non-Amish children. We assessed the relationship between Plain affiliation and vaccination status by using the Pearson correlation coefficient. RESULTS: There were 215 children with 221 VPDs. Most occurred in non-Plain children: 179 of 221 (81%). Except for pneumococcal infections, VPD occurred mostly in unvaccinated or immunocompromised children, regardless of Plain affiliation. There were 15 Haemophilus influenzae type b and 5 tetanus infections that occurred in children with an unvaccinated or unknown vaccination status. The risk of a VPD requiring hospitalization was greater for Amish than for non-Plain children (risk ratio: 2.67 [95% confidence interval: 1.87-3.82]). There was a strong correlation between Plain affiliation and lack of vaccination (r = -0.63, P < .01). CONCLUSIONS: Amish children had an increased risk of a VPD requiring hospitalization than non-Plain children. With the exception of those with pneumococcal disease, most vaccinated children hospitalized with a VPD were immunocompromised.

Health knowledge and health practices in Makeni, Sierra Leone: a community-based household survey.

BACKGROUND: We characterize health knowledge and practices in urban and rural Makeni, Sierra Leone, drawing comparisons between areas served by community health workers (CHWs) with those that are not. We also inquire about causes of infant and maternal mortality and how they are understood in the local context. Our objective was to provide a baseline understanding of health knowledge and practices in Makeni during the implementation of a CHW program. METHODS: We conducted 100 household interviews in Makeni City and rural villages in the surrounding area. We compared data between urban and rural areas to identify differences in health knowledge and practices. RESULTS: Our sample size covered 855 individuals. Insecticide treated bednet ownership was lower in urban settings compared to rural populations (58% vs 94%; p<.001). With regards to maternal mortality, most respondents indicated 'no clinic' (lack of clinical care or skipped antenatal care visits) as the primary cause (n=35), followed by bleeding (n=17), 'lack of blood' (anemia) (n=11) and 'will of God' (n=11). CONCLUSIONS: This initial survey of health knowledge and practices in rural and urban Makeni, Sierra Leone, highlights some simple opportunities for community health promotion, health education programming and behavioral interventions. Findings will inform future iterations of a CHW training module for community health education.

Does a significant reduction in malaria risk make lopinavir/ritonavir-based ART cost-effective for children with HIV in co-endemic, low-resource settings?

BACKGROUND: HIV infection and malaria co-infection is not uncommon among children in co-endemic regions, and evidence suggests that HIV is a risk factor for severe malaria among children. HIV protease inhibitors (PIs) are highly effective in pediatric HIV treatment regimens, however, their effectiveness against malaria has been mixed, with some PIs demonstrating in vitro activity against Plasmodium falciparum. Recent findings suggest lopinavir/ritonavir (LPV/r)-based treatment regimens reduce the incidence of malaria infection by over 40% in pediatric HIV patients compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. METHODS: We assessed whether a significant reduction in malaria risk makes LPV/r-based ART regimens cost-effective compared to NNRTI-based regimens in co-endemic, low-resource settings. We modeled the difference in unit cost per disability adjusted life year (DALY) gained among two theoretical groups of HIV+ children under 5 years old receiving ART in a resource-limited setting co-endemic for malaria. The first group received standard NNRTI-based antiretrovirals, the second group received a standard regimen containing LPV/r. We used recent cohort data for the incidence reduction for malaria. Drug costs were taken from the 2011 Clinton Health Access Initiative Antiretroviral (ARV) ceiling price list. DALYs for HIV and malaria were derived from WHO estimates. RESULTS: Our model suggests a unit cost of US$147 per DALY gained for the LPV/r-based group compared to US$37 per DALY gained for the NNRTI-based group. CONCLUSION: In HIV and malaria co-endemic settings, considerations of PI cost effectiveness incorporating known reductions in malaria mortality suggest a nominal increase in DALYs gained for PIs over NNRTI-based regimens for HIV positive children under five on ART. Our analysis was based on several assumptions due to lack of sound data on malaria and HIV DALY attribution among pediatric populations. Further study in this area is required.

Attitudes and practices of hookah smokers in the San Francisco Bay Area.

As many as 10 million people will die annually by the year 2030 due to tobacco-related causes. While much research has focused on cigarettes, the increasing popularity of smoking hookah (water pipe) has received much less attention. Epidemiological studies have been carried out in India, Pakistan, Syria, Kuwait, and Lebanon, but there are few in the United States. Hookah smoking is typically a social activity and there are many myths and rumors about the relative safety of smoking hookah compared to cigarettes. The aim of this study was to identify the knowledge, attitudes, and practices of hookah smokers in the San Francisco Bay Area. We sampled 50 participants (25 male and 25 female) who were mostly college students at the University of California, Berkeley. Hookah smoking was occasional among those sampled, with only six participants (12%) reporting weekly hookah smoking. The majority of respondents considered hookah smoking to be harmful to their health (88%), yet 52% had no intention of quitting. More definitive studies conveying the possible harm of hookah smoking are necessary to serve as a basis for health education programs and policy changes towards this potentially harmful activity.