Introduction

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 Table 3. Patient Demographics and Description of Social Interventions Abstract 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. 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 1992-2012 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. Absolute CD4 count (#/CCM) Patient 2 HIV viral load (# copies/ml) CPS home visit Patient 8 Absolute CD4 count (#/CCM) HIV viral load (# copies/ml) Change in caregiver 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. Absolute CD4 count (#/CCM) Patient 11 HIV viral load (# copies/ml) Change in caregiver 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 1992-2012 (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 1992-2012 (n = 635) Patients diagnosed with congenital HIV Infection (n = 19) HIV infected patients followed at UTMB for >1 yr (n = 19) 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 < 0.0024). • 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 • 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 < 0.0024, 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