1. The Effect of Family Social Intervention on Treatment Response in Children with HIV Infection
Francine Cheng DO, Janak Patel MD, Debbie Konopik SWA, and Tia Jaynes LMSW
University of Texas Medical Branch (UTMB) Pediatric Residency Program, PGY 3
Abstract
Table 3. Patient Demographics and Description of Social Interventions
Patient
Date of Birth
Age at treatment failure
Gender
Ethnicity
Types of Intervention
Caregiver before intervention
Caregiver after Intervention 1
08/09/03
2 yo F
Black
caregiver change just prior to first UTMB visit
mother
foster
parents 2
11/06/96
12 yo M
Hispanic
pharmacy checks, CPS referral, home visit
father 3
02/13/09
8 mo
CPS referrals, home visits, caregiver change 4
05/10/06
6 yo
pharmacy checks, home visits, CPS referral, temporary caregiver change
MGM 5
10/15/09
1 yo
pharmacy check, suboptimal antiviral choices (limited by liquid formulations)
Maternal
Aunt 6
11/10/98
7 yo
White
CPS referral, pill swallowing videos, started kaletra pills
PGM 7
12/04/07
2 mo
CPS referral, pharmacy checks 8
06/09/92
4 yo
CPS referral, home visits, caregiver change 9
11/25/93
pharmacy check, CPS referral, caregiver change 10
04/17/97
pharmacy checks, CPS referral, caregiver change 11
04/28/94
10 yo
pharmacy check, CPS referral, home visits, caregiver change 12
10/26/92
CPS referral, home visits, temporary change in caregiver 13
08/21/03
pharmacy check, CPS referral, home visits
OBJECTIVE: To determine if a change in the primary caregiver of children with congenital HIV who have poor virologic suppression with anti-retroviral therapy (ART) will improve viral and/or immunologic parameters.
METHODS: The medical records of a cohort of 13 perinatally HIV-infected children born from whose care was managed at the University of Texas Medical Branch Maternal Child HIV Clinic for a period of ≥1 year were reviewed. Data collected included date of birth, dates and explanation of clinic visits, HIV viral loads, CD4 counts, and social interventions (pharmacy checks, home visits, CPS referrals, and caregiver change) used to enhance adherence to the medication regimen.
RESULTS: Social interventions lead to significant improvement in HIV viral suppression, even to undetectable levels. And immunologic parameters (CD4 count) increased in all patients 6 month post-intervention.
CONCLUSIONS: Rates of improvement in HIV viral suppression after social intervention were relatively high. These findings highlight the importance of social interventions to ensure viral suppression and maintaining an appropriate level of cellular immunity in patients with congenital HIV infection.
Introduction
HIV treatment failure may be due to poor compliance with HIV medications, anti-viral resistance, or inappropriate dosing
A child’s medication compliance is entirely dependent on their caregiver
To date, there are no generalized guidelines identified regarding how to approach poor medication compliance, with only a handful of pilot studies with very small samples1
Roberts et al2 suggests a stepwise interventionist approach to HIV-infected children for whom caregiver non-adherence was suspected as the cause of treatment failure
Step 1: Home visit by nurse (typically not covered by
insurance)
Step 2: Directly observed therapy (DOT) involving a 4-day
hospitalization (not practical and costly)
Step 3: Physician-initiated medical-neglect report to state authorities
All home health nurse visits failed to result in sustained improvements in adherence, and sustained viral load decreases in the DOT were categorized with a HIV viral load <30,000 copies.
We have identified that there is a gap in the literature describing major effects on HIV viral control after a change in primary caregiver through legal social intervention by the Children's Protective Services (CPS)
The purpose of this study is to determine if a change in the primary caregiver of children with congenital HIV who have poor virologic suppression with anti-retroviral therapy (ART) will have improved viral and/or immunologic parameters.
HIV viral load (# copies/ml)
Absolute CD4 count (#/CCM)
Figure 2. Examples of HIV viral loads and CD4 counts detected over time among prenatally HIV-infected patients for whom social interventions were undertaken to improve medication compliance.
Patient 2
Change in
caregiver
Patient 8
Patient 11
CPS home visit
Methods
Retrospective case analysis of HIV positive pediatric patients who were born to HIV positive mothers and followed at the University of Texas Medical Branch at Galveston between (20 years)
Analyze data on the types and frequency of social interventions (pharmacy checks, CPS referrals, home visits, and/or change in primary caregiver)
Comparison of treatment responses (HIV viral load and CD4 count) before and after interventions (paired t-test)
Summary of Results
Figure 1. Study Flow Diagram
Perinatally exposed infants evaluated at UTMB Maternal Child HIV Clinics from
(n = 635)
Patients diagnosed with congenital HIV Infection
(n = 19)
HIV infected patients followed at UTMB for >1 yr
Patients who required social intervention due to poor medication responses
(n = 13)
The majority of social intervention methods required to induce viral suppression in our cohort was CPS involvement (92%, 12 of 13 patients), either CPS referral and/or primary caregiver change.
92% (11 of 12 patients) who had CPS involvement achieved HIV viral suppression (<75 copies). 67% (7 of 12 patients) involved caregiver change, either temporary or permanent.
Social interventions lead to significant improvement in HIV viral suppression to undetectable levels (92%, 12 of 13 patients) at the 6 month post-intervention period (p < ).
The CD 4 counts increased in all patients at the 6 months post-intervention period.
The one case (patient 4) where CPS involvement did not induce improved HIV viral load, all the pharmacy checks and home visits were all appropriate. Even temporary removal from caregiver was done to attempt to determine a reason for uncontrolled viral load. In this case, poor drug absorption or metabolism was suspected.
Results
Table 1. Pre- and Post- Intervention Values for HIV Viral Load and CD4 Count
Conclusions
HIV Viral Load (# copies)
Absolute CD4 Count
Patient
Pre-intervention
6 months post-intervention 1
500,000
<75
736
2186 2
11443
184
354 3
17457
892
1281 4
2470
3017
1059
1542 5
50170
1310
1471 6
2851
775
872 7
6930
2248
3888 8
1425
639
863 9
25013 14
646 10
25442
838
1039 11
3777
1035
1084 12
3713
833
1072 13
15735
313
422
Management of pediatric HIV patients may require early change in caregiver to ensure viral suppression and maintaining an appropriate level of cellular immunity
Physicians should aggressively consider caregiver medication compliance for HIV treatment failure prior to medication changes, as options for different classes of medications become fewer for optimal treatment of HIV and viral suppression
Poor medication compliance can lead to drug resistance
References
The last HIV viral load and CD4 count prior to social intervention were compared to the viral loads and CD4 counts 6 months after intervention. The decrease in HIV viral load 6 months after intervention was statistically significant with a p value < , with all but 1 patient achieving viral suppression. The difference in CD4 count was not significant with a p value <0.15, but all CD4 counts were increased at the 6 month post-intervention period.
Simoni JM, Montgomery A, Martin E, et al. Adherence to Antiretroviral Therapy for Pediatric HIV Infection: A Qualitative Systematic Review with Recommendations for Research and Clinical Management. Pediatrics. 2007;119(6)
Roberts GM, Wheeler JG, Tucker NC, et al. Nonadherence with pediatric human immunodeficiency virus therapy as medical neglect. Pediatrics. 2004;114(3)
2012 Texas Pediatric Society Electronic Poster Contest