AIDS in South Africa takes center stage

Surgeons are failing to recognize children with HIV infection

AIM OF THE STUDY

Despite much clinical experience, there are few published accounts of the surgical manifestations of HIV/AIDS in children and still fewer guidelines for the best or most appropriate treatment. Our primary objective was to document the incidence of HIV infection in children who presented with a surgical emergency to a major pediatric surgical unit in South Africa. If possible, we aimed to provide a description of the impact of the disease in a surgical pediatric population and to raise awareness of the mode of presentation of HIV to the pediatric surgeon in a developing nation, now that specific antiretroviral therapies are available.

METHODS

This was a prospective observational study of consecutive surgical emergency admissions to the Division of Paediatric Surgery at the University of the Witwatersrand, Johannesburg, South Africa, between April 1 and May 31, 2005. Consent for inclusion in the study was sought in all cases. The clinical profile of children presenting during the study period was recorded. If relevant, permission was sought from the parent/guardian to undertake HIV status testing if this were not already known.

MAIN RESULTS

Three hundred ninety-one children were admitted as emergency cases during the study period. Thirty-seven (9.5%) of 391 were excluded, because consent could not be obtained, leaving 354 children. Ages ranged between 1 day and 17 years, with a median age of 3 years. The diagnosis in most was trauma/burns (42%) and abdominal emergencies (27%). Infections occurred in 13% of these patients. Human immunodeficiency virus status was already known in 10 (3%) of 354 patients, and only 18 (5%) of 344 children were tested; of these, 10 (55%) were positive. As expected, the predominant surgical presentation of HIV positive children was sepsis. The prevalence of HIV/AIDS in those children not tested is unknown.

CONCLUSION

It is likely that the incidence of HIV/AIDS infection is higher than the 4% identified in our study group. The surgical manifestations in these HIV-positive children are dominated by sepsis, often severe in nature and with opportunistic pathogens. Despite increased knowledge about the disease and widening therapeutic opportunities, our results suggest that many children with HIV infection are not being recognized, despite entry into the healthcare system. Prompt recognition and surgical management of the complications of pediatric HIV infection can sometimes result in a good outcome. Further studies are therefore required to define the true incidence of HIV/AIDS infection in children presenting as a surgical emergency case. These patients may benefit from early antiretroviral therapy. Surgeons are well placed to identify children who are HIV positive and should do more to ensure HIV testing and enrollment into antiretroviral treatment programs.

Selections from current literature: Recent developments in human HIV-1 vaccine

This article reviews recent changes in the design of HIV-I vaccine. The safety information for current vaccines has been established, and future ethical considerations are reviewed. Of recent significance, gp120 envelope vaccines are being combined with canarypox vectors in an effort to elicit a broad immune response. This will probably be the aim of future research for an ever-growing problem. A total of 10 143 AIDS cases have occurred in the USA in the year 2000.(1) The international burden is grimmer. For example, approximately 13% of South Africans between 20 and 64 years old are HIV positive. Predictions estimate this number to rise to almost 30% by 2010.(2) With many different HIV serotypes, a worldwide effective HIV vaccine is not in the near future.(3) However, the scientific community has bolstered its effort by strengthening resources and developing national and international collaboration groups focused in developing a safe and effective HIV vaccine.