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.
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ABSTRACT: Treatment of HIV infection with highly active antiretroviral therapy (HAART) requires sustained adherence to treatment to maintain efficacy. In pediatric patients, adherence to HAART represents a significant challenge for treated children and for their caregivers and healthcare providers. Many factors can affect adherence to HAART including: (i) factors related to the patient and his/her family; (ii) factors related to the drug/medication; and (iii) factors related to the healthcare system. Different strategies can be employed to tackle the specific obstacles identified in these three groups, and thus to facilitate adherence. Among the key interventions centered on the patient and his/her family are the tailoring of the HAART regimen to the daily activities of the child and his/her family, and the implementation of an intensive education program on adherence for the child and the caregiver, prior to starting the treatment. Specific medication-related problems (depending on drug pharmacokinetic and pharmacodynamic properties, taste and palatability, food interactions, etc.) exist; such problems can not be solved solely by clinicians or by families. Greater commitment of the pharmaceutical industry is needed, and innovative solutions have to be identified by clinicians in partnership with drug manufacturers. Furthermore, the development of an ‘adherence strategy/program’ can be recommended to all institutions working in pediatric HIV infection. Most of the necessary interventions to be included in such progams can be easily implemented, but they require trained and committed staff (and institutions), and time to be spent with patients and their caregivers.Paediatric Drugs 01/2005; 7(3):137-149. DOI:10.2165/00148581-200507030-00001 · 1.72 Impact Factor
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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