CONCLUSIONS

Mortality and hospital admission rates continued to decline since the introduction of HAART in 1997

Viral load suppression 12 months after HAART initiation improved over time

Results suggest a better immunological response in girls, but require further investigation

Low rates of switching to second line therapy were observed

Increased triple class exposure complicates longer term clinical management

Provision of transitional services and continued monitoring will be essential as the cohort ages into adolescence and adulthood

BACKGROUND

The National Study of HIV in Pregnancy and Childhood (NSHPC) is a voluntary confidentialreporting scheme for HIV/AIDS diagnoses in pregnant women and children, covering the whole of the UK and Ireland.

The Collaborative HIV Paediatric Study (CHIPS) is a multicentre cohort study of HIV infected children under care in the UK and Ireland since 1996. 39 hospitals in the UK and Ireland currently collaborate in the CHIPS study, accounting for 90% of all children currently in the NSHPC. CHIPS is being extended to the whole of the UK and Ireland during 2006/7.

COLLABORATORSWe thank staff and families from the hospitals collaborating inCHIPS/NSHPC, as well as the UK Department of Health,Bristol-Myers Squibb, Boehringer-Ingelheim, GlaxoSmithKline, Roche,Abbott and Gilead for financial support.

CHIPS Steering Committee members: Karina Butler, Sheila Donaghy,David Dunn, Trinh Duong, Di Gibb, Ali Judd, Hermione Lyall, Janet Masters,Esse Menson, Vas Novelli, Catherine Peckham, Andrew Riordan,Mike Sharland, Pat Tookey, Gareth Tudor-Williams, Gillian Wait.

SOCIODEMOGRAPHICS

50% female

72% black African, 13% white, 16% other

55% born in the UK and Ireland, 45% born abroad

Median age at presentation varied by country of birth:

- constant for the UK and Ireland at ~0.5 years

- increased from 2 years up to 1991 to 8 years in 2004/5 for those born abroad

13% identified prospectively from birth, 68% prior to an AIDS diagnosis, and 19% at AIDS diagnosis

94% vertically infected, 3% blood transfusion, 3% other

RATES OF PROGRESSION TO AIDS AND DEATH

Rates (per 100 person years) have continued to decline since the introduction of HAART:

Year AIDS/deaths (95%CI) Deaths (95%CI)

-1996 13.4 (11.4-15.6) 8.3 (6.9-9.8)1997-9 5.7 (4.3-7.5) 1.9 (1.2-2.8)2000-2 3.2 (2.3-4.3) 0.9 (0.6-1.5)2003-5 2.7 (1.9-3.6) 0.6 (0.3-1.1)

18 children died in 2003-5: 7 presented with AIDS and/or died within one month Of the remaining 11:

- only 3 were on HAART for 6+ months prior to death- primary cause of death was opportunistic infections (2), HIV encephalopathy (1), sepsis (1), lung disease (1), other (3), and not known (3)

METHODS

Analyses relating to HAART exposure and response are confined to children in CHIPS only (n=1065). All other analyses include all diagnosed children (n=1439)

Our definition of “first line" 3 or 4 drug HAART allows for 1 or 2 drug substitutions (if not made for virological, immunological or clinical failure), and drug intensifications or reductions

Logistic regression was used to explore responses to HAART. All odds ratios (ORs) are adjusted for: age, CD4% and HIV-1 RNA at HAART initiation; sex; CDC B/C events prior to HAART; number of drugs in the initial HAART regimen; year started HAART; and timing of response measurements

KEY PAPERSGibb DM et al. Decline in mortality, AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland. BMJ 2003,327:1019.

Walker AS et al. Response to highly active antiretroviral therapy varies with age: the UK and Ireland Collaborative HIV Paediatric Study. AIDS 2004,18:1915-1924.

Menson EN et al. Systematic inaccurate prescribing of paediatric antiretroviral drugs - a good example of universal bad practice in medicines for children? BMJ - in press

REGIONAL DISTRIBUTION OF CHILDREN

Most children are seen in London hospitals

5%Ireland

1%Wales

66%London

23%Rest of England

5% Scotland

0%N. Ireland

12 MONTH IMMUNOLOGICAL AND VIROLOGICAL RESPONSE TO HAART

76% suppressed viral load <400 copies/ml in 2003/5, compared to only 51% in 1997/9.

*A cut off of <50 copies/ml could not be used due to some hospitals continuing to use the “<400” cut off in recent years. † Multivariable. ‡ Baseline=1997/9

0%

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All 3 classes

NRTI+PI only

NRTI+NNRTI only

NRTI only

PRIOR DRUG CLASS EXPOSURE OVER TIME

At last follow up, 27% of 5-9, 33% of 10-14, and 38% of 15+ year olds had been exposed to all three main classes of HAART

HOW THE NSHPC & CHIPS WORK TOGETHER

Children diagnosed with HIV are initially reported to the NSHPC. Once the infection is confirmed, the NSHPC informs CHIPS, which sends out detailed annual followup questionnaires if the child is seen in a hospital collaborating in CHIPS. For hospitals not in CHIPS, abrief annual follow up form is sent out by the NSHPC. Data are shared between the studies in order toundertake joint analyses.

AIM

The aim of this analysis was to describe changes overtime in demographics, morbidity and mortality, and exposure and response to HAART, in HIV infectedchildren in the UK and Ireland between 1996 and 2005.

AGE GROUP BY CALENDAR YEAR OF REPORT

Median age of the cohort increasing year on year 13% 10 years in 1996 compared to 46% in 2005

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96 97 98 99 00 01 02 03 04 05

Year

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>=15

10-14

5-9

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<1

CD4% increase of >10% HIV-1 RNA <400 copies/ml*

OR† 95% CI p OR† 95% CI p

Age at HAART per year 0.85 0.78-0.92 <0.001 1.03 0.96-1.10 0.469

CD4% at HAART per 5% 0.55 0.47-0.64 <0.001 1.05 0.93-1.18 0.428

Sex female 1.68 1.01-2.81 0.044 0.97 0.60-1.57 0.905

Calendar year at HAART‡ 2000/2 0.92 0.50-1.70 2.27 1.30-3.96

2003/5 1.12 0.59-2.12 0.833 2.99 1.60-5.59 0.001

HAART EXPOSURE AND SWITCHING

595 children in CHIPS started a HAART regimensince 1997 and were ART naïve at the start of HAART

93% remained on first line HAART at 12 months,86% at 24 months, and 79% at 36 months

Median time to switching to second line was7.2 years

Whilst the proportion of child time spent on threedrug ART was stable at ~62% from 2000 onwards,the proportion of time spent off all ART, having previously taken it, increased from 3% in 1997/9to 9% in 2003/5.

CONTACT FOR FURTHER INFORMATION

Ali JuddMRC Clinical Trials Unit222 Euston Road +44 20 7670 4830London NW1 2DA a.judd@ctu.mrc.ac.uk

www.chipscohort.ac.uk

Older and wiser: continued improvements in clinical outcome and highly active antiretroviral therapy (HAART) response in HIV-infected children in the UK and Ireland, 1996-2005A Judd1, T Duong1, K Lee1, AS Walker1, PA Tookey2, M Sharland3, A Riordan4, H Lyall5, J Masters2, E Menson3, G Tudor-Williams5, K Butler6, S Donaghy3, V Novelli7, C Peckham2, DM Gibb1 for the Collaborative HIV Paediatric Study and the National Study of HIV in Pregnancy and Childhood

1 MRC CTU, London; 2 Institute of Child Health, London; 3 St George’s Hospital, London; 4 Royal Liverpool Children’s Hospital, Liverpool; 5 St Mary’s Hospital, London; 6 Our Lady’s Hospital for Sick Children, Dublin;7 Great Ormond Street Hospital, London.