Gastrostomy tube insertion for improvement of adherence to highly active antiretroviral therapy in pediatric patients with human immunodeficiency virus
ABSTRACT Newer combination antiretroviral therapies used to treat human immunodeficiency virus (HIV)-infected individuals have resulted in dramatic delays in HIV progression, with reduction in mortality and morbidity. However, adherence to highly active antiretroviral therapy (HAART) may be problematic, particularly in HIV-infected children. Reasons for nonadherence include refusal, drug tolerability, and adverse reactions. We assess: 1) the potential benefits of gastrostomy tube (GT) for the improvement of adherence to HAART in HIV-infected children, and 2) the factors that may result in improved viral suppression after GT placement.
The medical records of 17 pediatric HIV-infected patients, in whom GT was used to improve HAART adherence, were retrospectively reviewed for clinical and laboratory parameters. Each record was reviewed for the period of 1 year before and after GT insertion. The main outcome parameters were virologic (plasma HIV RNA polymerase chain reaction quantification) and immunologic (CD4 cell counts). Documentation of adherence to medications in medical records was also assessed during the study. Parental questionnaires were used to determine GT satisfaction and medication administration times. The Wilcoxon rank sum test was used to assess change in viral load (VL) and CD4 cell percentages.
GT was well-tolerated with minor complications, such as local site tenderness, reported by 4 patients (23%). Before GT insertion, only 6 patients (35%) were documented as being adherent, compared with all patients after GT insertion. Ten patients (58%) had >/=2 log(10) VL decline after GT insertion (median: 3.2 log(10)), compared with 7 patients (42%) who had </=2 log(10) VL decline (median: 1.27 log(10)). Both groups of patients (responders and nonresponders) did not differ significantly in baseline parameters, such as VL, CD4 cell percentages, or previous drug therapy. However, in all 10 patients with >/=2 log(10) VL decline, therapy was changed at the time of or soon after GT insertion (median:.8 months; range: 0-6 months), compared with 7 patients with <2 log(10) VL decline who had therapy changed before GT insertion (median: 3.2 months; range: 1-8 months). Parental questionnaires reported significantly shorter medication administration times after GT insertion, with 70% of patients taking >5 minutes before GT, compared with 0% after GT. Questionnaires indicated satisfaction with GT, with perceived benefits being reduced medication administration time and improved behavior surrounding taking medications.
GT is well-tolerated in pediatric HIV-infected patients and should be considered for selected patients to overcome difficulties with medication administration and to improve adherence. For maximal virologic response, combination therapy should be changed at the time of GT insertion.
- SourceAvailable from: Marcela Arrivillaga[Show abstract] [Hide abstract]
ABSTRACT: Advancements in therapy, including the use of highly active antiretroviral therapy, have increased survival and decreased opportunistic infections in HIV pediatric and adolescent population. Previous studies have found that in general HIV persons who maintained consistent ad had lower viral loads and improved health status. Nevertheless, adherence among children, adolescents, and youth has been found to be suboptimal. This systematic review describes interventions that have been conducted to improve adherence among these segments of the population diagnosed with HIV/AIDS, in both developed and developing settings. We found 16 interventions and clinical trials conducted between 2000 and 2011; these were grouped into studies that focused strictly on the medication (n = 6) and others that focused on factors associated with medication adherence (n = 10). The results indicate that, in 11 years, few treatment adherence interventions were conducted, most of which took place in the United States; although some articles reported more comprehensive interventions, all of them ultimately aimed only to promote adherence to antiretrovirals. We conclude that interventions need to be more specifically created for children and youth in order to improve adherence and promote self-care in general, incorporating the social determinants approach with special emphasis on the needs of children, adolescents, and youth according to their age. It is also concluded that interventions should be implemented and evaluated in contexts where children and youth are severely affected by HIV in regions like Africa, Latin America, and the Caribbean.Vulnerable Children and Youth Studies 12/2013; 8(4):321-337. DOI:10.1080/17450128.2013.764031
- Gastrostomy, First edited by Pavel Kohout, 01/2011: pages 25-48; InTech - Open Access Publisher., ISBN: 978-953-307-365-1
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ABSTRACT: Pediatric adherence to daily drug regimens has not been widely assessed in Africa where majority of HIV infected children live. Using in-depth interviews of 42 HIV-infected children taking ART and/or cotrimoxazole prophylaxis, and 42 primary caregivers, at a comprehensive HIV/AIDS clinic in Uganda, we evaluated their adherence experiences for purposes of program improvement. Daily drug regimens provided by the pediatric clinic included cotrimoxazole prophylaxis as well as ART and cotrimoxazole combined. Complete disclosure of HIV status by caregivers to children and strong parental relationships were related to good adherence. Structural factors including poverty and stigma were barriers to adherence even for children who had had complete disclosure and a supportive relationship with a parent. To ensure adherence to life-extending medications, our findings underscore the need for providers to support caregivers to disclose, provide on-going support and maintain open communication with HIV-infected children taking cotrimoxazole prophylaxis and ART.AIDS and Behavior 08/2006; 10(4 Suppl):S85-93. DOI:10.1007/s10461-006-9141-3 · 3.49 Impact Factor