Zimbabwe: Weight monitoring key to paediatric ART dosing in resource limited countries

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Study findings have revealed that a large percentage of children living with HIV were prescribed inappropriate doses of antiretroviral therapy (ART) at a paediatric outpatient clinic at Harare Central Hospital in Zimbabwe.

According to Zimbabwe national guidelines, all children aged 0 to 10 years and 11 to 17 years who weigh <35 kg should receive weight-based dosing for ART. In this cross-sectional study, 309 children were recruited (

The researchers led by S Dakshina at the Biomedical Research and Training Institute, Harare, Zimbabwe found that of the 110 children who were prescribed inappropriate doses of at least 1 drug in their ART regimen, 49 received higher doses and 64 were underdosed.

Children receiving a higher than recommended dose of at least 1 drug were younger compared with correctly dosed children (median age 6 vs 7 years, respectively; P =.001), had been on their current ART regimen for a shorter time (median 7.2 vs 13 months, respectively; P =.003) and were less likely to be treated with a 3-drug fixed-dose combination (42.9% vs 63.3%, respectively; P =.009).

Children who were underdosed were also less likely to be on a 3-drug fixed-dose combination compared with children receiving accurate-for-weight ART dosages (25% vs 63.3%, respectively; P <.001).

In addition, children on a triple-drug fixed-dose combination ART were more likely to have all 3 drugs correctly dosed compared with children on a dual-drug fixed-dose combination (plus a third agent; 77.3% vs 51.1%, respectively; P <.001).

Results showed that more than a third of children were inappropriately dosed on at least one of their ART drugs.

To ensure that children are prescribed correct ART doses, consistent availability of drugs, more user-friendly ART guidelines, and adequate training and treatment monitoring facilities are essential.

“Further work is needed in reviewing antiretroviral prescribing practice against national recommendations and determining the impact this has on antiretroviral dosing and overall clinical outcome,” noted the study authors. Moreover, “a broader range of paediatric fixed-dose combination formulations with a wider range of weight-band dosing is needed, which may alleviate suboptimal antiretroviral dosing,” they concluded.

Abstract
Objectives: The aim of the study was to investigate the extent of and factors associated with incorrect dosing of antiretroviral therapy (ART) in HIV‐infected children in Harare, Zimbabwe.
Methods: All children aged 0–10 years and children aged 11–17 years who weighed < 35 kg and taking ART were recruited from the paediatric HIV clinic at Harare Hospital. Their current doses of ART drugs were compared against doses recommended by the national guidelines.
Results: Among 309 children recruited [55% male; median age 7 years (interquartile range (IQR) 5–10 years)], the median CD4 count was 899 cells/μL and the median duration of their current ART regimen was 11.2 months (IQR 4.9–17.1 months). Overall, 110 (35.6%) children were prescribed incorrect doses of at least one drug component within their ART regimen; 64 (20.7%) under‐dosed and 49 (15.9%) over‐dosed on at least one drug. Children receiving a higher than recommended dose of at least one drug were younger compared with correctly dosed children (median 6 versus 7 years, respectively; P = 0.001), had been on their current ART regimen for a shorter time (median 7.2 versus 13 months, respectively; P = 0.003) and were less likely to be receiving a three‐drug fixed‐dose combination (FDC; 42.9 versus 63.3%, respectively; P = 0.009). Those who were under‐dosed were also less likely to be on a three‐drug FDC (25 versus 63.3%, respectively; P < 0.001).
Conclusions: Over a third of children were prescribed incorrect doses of ART. Children taking triple‐drug FDCs were likely to be correctly dosed. Our study highlights the importance of weight monitoring at each clinical contact, training of health care providers on paediatric drug dosing and the need for wider availability of FDCs for children.

Authors
S Dakshina, ID Olaru, P Khan, L Raman, G McHugh, M Bwakura–Dangarembizi, K Nathoo, S Munyati, H Mujuru, RA Ferrand

Infectious Disease Advisor
HIV Medicine abstract


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