Incidence and prevalence of HIV encephalopathy in children with HIV infection receiving highly active anti-retroviral therapy (HAART)

Prevalence of detectable HIV-DNA and HIV-RNA in cerebrospinal fluid of youth with perinatal HIV and impaired cognition on antiretroviral therapy

OBJECTIVE

Central nervous system (CNS) HIV infection can impact cognition and may be an obstacle to cure in adolescents and young adults with perinatal HIV (AYAPHIV). IMPAACT2015 enrolled AYAPHIV on suppressive antiretroviral therapy (ART) with cognitive impairment to detect and quantify HIV in blood and cerebrospinal fluid (CSF).

DESIGN

IMPAACT2015 was a U.S.-based multi-site, exploratory, observational study.

METHODS

Cognitive impairment was defined as NIH Toolbox Fluid Cognition Composite score (FCCS) more than 1 standard deviation below age-adjusted normative group mean. Cell-free HIV-RNA and cell-associated HIV pol/gag -DNA and 10 biomarkers of inflammation/neuronal injury were measured in paired CSF and blood. ART exposure concentrations were quantified in hair.

RESULTS

Among 24 participants, 20 had successful CSF collection and 18 also met viral suppression criteria. Nine of 18 (50%) were female sex-at-birth, and 14 of 18 (78%) were black. Median (range) age was 20 years (13-27), time on ART was 18.3 years (8.0-25.5), and FCCS was 68 (53-80). HIV-DNA was detected in PBMCs from all participants. In CSF, two of 18 (11%, 95% CI: 1.4-34.7%) participants had detectable cell-free HIV-RNA, while HIV gag or pol -DNA was detectable in 13 of 18 (72%, 95% confidence interval: 47-90). Detectable HIV-DNA in CSF was associated with male sex-at-birth ( P  = 0.051), lower CD4 + cell count at enrollment ( P  = 0.016), and higher PBMC HIV pol -DNA copies ( P  = 0.058). Hair antiretroviral concentrations and biomarkers were not associated with CSF HIV-DNA detection.

CONCLUSION

We found that a high proportion of AYAPHIV with neurocognitive impairment had CSF cells harboring HIV-DNA during long-term virologic suppression. This evidence of persistent HIV-DNA in CSF suggests that the CNS should be considered in treatment and cure studies.

Identifying the Mental Health Effects of Cumulative Traumatic Exposure in HIV-Affected Youth: A Longitudinal Assessment

INTRODUCTION

Traumatic events (TEs) in early life can precede adult psychopathology. Limited research exists on this relationship in young adults with perinatally acquired HIV-infection (PHIV) or perinatal HIV-exposure without infection (PHEU), who often experience social and health disparities. This study examined TEs experienced in childhood/adolescence and their association with psychiatric and substance use disorders in young adults with PHIV and PHEU.

METHODS

Participants in a New York City-based longitudinal cohort study were assessed for TE exposure at enrollment (mean age = 12 years) and the first 2 follow-up interviews. Past-year psychiatric and substance use disorders were evaluated via psychiatric interview (DISC-IV) at the fifth follow-up interview (mean age = 22 years). Unadjusted and adjusted logistic regression models assessed associations between cumulative childhood/adolescence TEs and young adult psychiatric and substance use outcomes. Group differences were tested for PHIV and PHEU subgroups.

RESULTS

Among 236 participants (60% Black, 51% Latinx), mean cumulative traumatic event count was 3.09 (SD = 1.77); 26% had a past-year psychiatric diagnosis, and 28% had a past-year substance use diagnosis. Increased TEs were associated with past-year psychiatric diagnoses in young adulthood [average marginal effects (AME) 4.21, 95% confidence interval (CI): 0.83 to 7.58]; for PHEU participants, increased TEs were associated with a past-year substance use disorder (AME 15.67, 95% CI: 8.08 to 23.25).

CONCLUSIONS

High levels of TEs in childhood/adolescence may contribute to psychiatric and substance use disorders in young adults with PHIV or PHEU. Research exploring relationships between TE exposure and later psychiatric problems is needed to inform interventions for HIV-affected youth.

Neurocognitive outcomes of children exposed to and living with HIV aged 3-5 years in Kilifi, Kenya

Introduction

Globally, 1.7 million children are living with HIV, with the majority of them residing in sub-Saharan Africa. Due to reduced rates of vertical transmission of HIV, there is an increasing population of children born to HIV-infected mothers who remain uninfected. There is a growing concern around the development of these children in the antiretroviral therapy era. This study examined the neurocognitive outcomes of children who are HIV-exposed infected (CHEI), HIV-exposed uninfected (CHEU) and HIV-unexposed uninfected (CHUU) and explored the relationship between child neurocognitive outcomes and child's biomedical and caregivers' psychosocial factors.

Methods

CHEI, CHUU and CHEU aged 3-5 years and their caregivers were recruited into the study. Neurocognitive outcomes were assessed using a validated battery of assessments. One-way analysis of variance and covariance (ANOVA and ANCOVA) were used to evaluate differences among the three groups by neurocognitive outcomes. Linear regression models were used to investigate the association between child neurocognitive outcomes and biomedical factors (nutritional status, HIV disease staging) and caregivers' psychosocial factors [symptoms of common mental disorders (CMDs) and parenting behaviour].

Results

The study included 153 children and their caregivers: 43 (28.1%) CHEI, 52 (34.0%) CHEU and 58 (39.9%) CHUU. ANOVA and ANCOVA revealed a significant difference in cognitive ability mean scores across the child groups. Post hoc analysis indicated that CHEU children had higher cognitive ability mean scores than the CHUU group. Better nutritional status was significantly associated with higher cognitive ability scores (β = 0.68, 95% CI [0.18-1.18], p = 0.008). Higher scores of CMDs were negatively associated with inhibitory control (β = -0.28, 95% CI [-0.53 to 0.02], p = 0.036). While comparing HIV stages 2 and 3, large effect sizes were seen in working memory (0.96, CI [0.08-1.80]) and cognitive ability scores (0.83 CI [0.01-1.63]), indicating those in stage 3 had poor performance.

Conclusions

Neurocognitive outcomes were similar across CHEI, CHEU and CHUU, although subtle differences were seen in cognitive ability scores where CHEU had significantly higher cognitive mean scores than the CHUU. Well-designed longitudinal studies are needed to ascertain these findings. Nonetheless, study findings underscore the need for strategies to promote better child nutrition, mental health, and early antiretroviral therapy initiation.

Similar cortical morphometry trajectories from 5 to 9 years in children with perinatal HIV who started treatment before age 2 years and uninfected controls

BACKGROUND

Life-long early ART (started before age 2 years), often with periods of treatment interruption, is now the standard of care in pediatric HIV infection. Although cross-sectional studies have investigated HIV-related differences in cortical morphology in the setting of early ART and ART interruption, the long-term impact on cortical developmental trajectories is unclear. This study compares the longitudinal trajectories of cortical thickness and folding (gyrification) from age 5 to 9 years in a subset of children perinatally infected with HIV (CPHIV) from the Children with HIV Early antiRetroviral therapy (CHER) trial to age-matched children without HIV infection.

METHODS

75 CHER participants in follow-up care at FAMCRU (Family Centre for Research with Ubuntu), as well as 66 age-matched controls, received magnetic resonance imaging (MRI) on a 3 T Siemens Allegra at ages 5, 7 and/or 9 years. MR images were processed, and cortical surfaces reconstructed using the FreeSurfer longitudinal processing stream. Vertex-wise linear mixed effects (LME) analyses were performed across the whole brain to compare the means and linear rates of change of cortical thickness and gyrification from 5 to 9 years between CPHIV and controls, as well as to examine effects of ART interruption.

RESULTS

Children without HIV demonstrated generalized cortical thinning from 5 to 9 years, with the rate of thinning varying by region, as well as regional age-related gyrification increases. Overall, the means and developmental trajectories of cortical thickness and gyrification were similar in CPHIV. However, at an uncorrected p < 0.005, 6 regions were identified where the cortex of CPHIV was thicker than in uninfected children, namely bilateral insula, left supramarginal, lateral orbitofrontal and superior temporal, and right medial superior frontal regions. Planned ART interruption did not affect development of cortical morphometry.

CONCLUSIONS

Although our results suggest that normal development of cortical morphometry between the ages of 5 and 9 years is preserved in CPHIV who started ART early, these findings require further confirmation with longitudinal follow-up through the vulnerable adolescent period.

Comorbid disease in children and adolescents with perinatal HIV infection: A pilot study

Background. With the increased use of combination antiretroviral therapy, the mortality of people living with HIV has decreased significantly, which has led to an increase of comorbidity and secondary HIV-related pathology in both adults and also in children and adolescents living with HIV infection. The incidence of children and adolescents with HIV infection and those in the general population varies significantly.The aim. To assess the frequency and range of chronic comorbidities in children and adolescents with perinatal HIV infection Methods. We carried out an observational study. Data on the incidence of 161 children with perinatal HIV infection registered in the Irkutsk Regional AIDS Center were copied.Results. Overall incidence of tuberculosis (18633.5 per 100 000 children), diseases of the digestive system (24844.7 per 100 000 children), diseases of the eye and adnexa (28571.4 per 100 000 children), diseases of the nervous system (18012.4 per 100 000 children), mental and behavioral disorders (13,664.6 per 100 000 children) in children with perinatal HIV infection is the higher than in children of comparable age. The overall incidence values of the endocrine system diseases, eating and metabolic disorders, diseases of the ear and mastoid process, diseases of the circulatory system, diseases of the genitourinary system, as well as congenital disorders and chromosomal disorders in children and adolescents with and without perinatal HIV infection are comparable.Conclusion. The prevalence of diseases of the circulatory, respiratory and genitourinary systems in children with perinatal HIV infection is comparable to that in the corresponding population. Prevalence of tuberculosis, anemia, diseases of the gastrointestinal tract, diseases of the eye and adnexa, diseases of the nervous system, mental and behavioral disorders is higher compared to children not exposed to HIV.

School functioning of children with perinatal HIV-infection in high-income countries: A systematic review

INTRODUCTION

Since the introduction of combination antiretroviral therapy, human immunodeficiency virus (HIV) infection is a manageable chronic disease. However, school-age children (4-18 years) living with HIV could still experience problems with functioning at school, due to the impact of the virus itself, medication, comorbidities and social stigma. School functioning covers academic achievement, school attendance, and social relationships and is of utmost importance to optimize normal participation.

METHODS

To gain insight in school functioning problems of perinatally HIV-infected children, we performed a systematic review of the literature in multiple databases from January 1997 up to February 2019. Studies were included if they described outcomes of school functioning of school-age children perinatally infected with HIV, in high-income countries. Meta-analyses were performed for sufficiently comparable studies.

RESULTS AND DISCUSSION

Results from 32 studies show that HIV-infected children experience more problems in various areas of school functioning in comparison with national norms, matched healthy controls, siblings and HIV-exposed uninfected (HEU) children. The most pronounced differences concerned the usage of special educational services, general learning problems, and mathematics and reading performance scores. Comparisons with both national norms and siblings/HEU children show that the differences between HIV-infected children and siblings/HEU children were less pronounced. Moreover, siblings/HEU children also reported significantly worse outcomes compared to national norms. This suggests that problems in school functioning cannot be solely attributed to the HIV-infection, but that multiple socio-economic and cultural factors may play a role herein.

CONCLUSION

Perinatally HIV-infected children seem vulnerable to problems in various areas of school functioning. Therefore, monitoring of school functioning should be an important aspect in the care for these children. A family-focused approach with special attention to a child's socio-environmental context and additional attention for siblings and HEU children, is therefore recommended.

Recovery of HIV encephalopathy in perinatally infected children on antiretroviral therapy

AIM

To describe the trajectory of clinical signs in children who developed human immunodeficiency virus encephalopathy (HIVE) after starting early antiretroviral therapy (ART).

METHOD

This was a retrospective case-cohort description of HIVE among Cape Town participants from the Children with HIV Early AntiRetroviral treatment (CHER) trial. Criteria for HIVE diagnosis were at least two of: (1) acquired central motor deficit, (2) impaired brain growth, and (3) failure to attain or loss of developmental milestones in the absence of an alternative aetiology.

RESULTS

Of 133 surviving participants who initiated ART at a median age of 9 weeks and who were followed until a median age of 6 years, 20 (12%) developed HIVE at a median age 31 months (interquartile range 19-37). In these, the first neurological deterioration was noticed at a median age of 19 months, when 16 were on ART and nine had undetectable HIV viral load for a median of 12 months. Signs of upper motor neurons were present in 18, of whom 12 resolved and four had persistent spastic diplegia; 19 had motor delay, of whom 14 resolved; 12 had language delay, of whom 11 resolved; and 16 had impaired brain growth, of whom only five recovered. For the 16 participants already on ART at HIVE diagnosis, regimens were not altered in response to diagnosis.

INTERPRETATION

HIVE may occur despite early ART initiation and virological suppression and then resolve on unchanged ART, most likely as intrathecal inflammation subsides.

WHAT THIS PAPER ADDS

Despite suppressive antiretroviral therapy, children can develop human immunodeficiency virus encephalopathy, The most common manifestations are motor deficits and impaired brain growth. Most experience improvement, with many resolving without additional intervention.

State of the Mind: Growing up with HIV

Human immunodeficiency virus (HIV) is a neurotropic virus that has a detrimental impact on the developing central nervous system (CNS) of children growing up with perinatal HIV (PHIV) due to a combination of pathophysiological processes related to direct viral cytopathic effects and immune activation. This leads to a spectrum of neurocognitive impairment ranging from severe encephalopathy to subtle domain-specific cognitive impairments, as well as psychological disorders that are compounded by HIV-related stigma and sociodemographic factors that disproportionately affect PHIV children. Early commencement and consistent use of combination antiretroviral therapy (cART) has resulted in a dramatic improvement in neuropsychological outcomes for PHIV children; however, they remain vulnerable to cognitive impairment and psychological disorders, as evidenced by imaging findings, randomised clinical trials and observational studies. An optimal neuroprotective cART regimen remains elusive in children, but systemic viral suppression, regular neurocognitive and psychological screening and ready access to neuropsychological management strategies are key components for optimising neuropsychological outcomes. However, a lack of standardised and validated screening tools, particularly in resource-limited settings, hinders a precise understanding of the nature, prevalence and associations between neuropsychological symptomatology and HIV health. This article reviews the natural history, cellular pathophysiology and structural and functional imaging findings for children growing up with HIV, as well as summarising management strategies related to antiretroviral therapy, screening tools and specific interventions for neurocognitive impairments and psychological disorders.

The neuroimaging magnitude of pediatric brain atrophy in northern Tanzania

Introduction

The loss of parenchymal brain volume per normative age comparison is a distinctive feature of brain atrophy. While the condition is the most prevalent to elderly, it has also been observed in pediatric ages. Various causes such as trauma, infection, and malnutrition have been reported to trigger the loss of brain tissues volume. Despite this literature based knowledge of risk factors, the magnitude of brain atrophy in pediatric age group is scantly addressed in most developing countries including Tanzania. The current study aims to understand the magnitude of brain atrophy in children residing in Northern Zone, Tanzania.

Methods

A cross-sectional hospital survey was performed in which 455 children who were presented with various brain pathologies from the year 2013 to 2019 and whose brains examined by Computerized tomography (CT)-Scanners were recruited in the study. The brain statuses were examined using three linear radiological methods including the measure of sulcal-width, Evans index, and lateral ventricular body width.

Results

Results showed a significant number of atrophied brains among children in Northern Tanzania and that the condition was observed to have a 1:1 male to female ratio. The prevalence of pediatric brain atrophy was found to be 16.04%.

Conclusion

The cortical subtype of brain atrophy presented as the most prevalent type of brain volume loss. The findings of this study suggest existence of considerable trends of brain atrophy in children which need special attention and mitigation plans.

Educational delays among children living with perinatally-acquired HIV in Johannesburg, South Africa

Little is known about how growing up with HIV impacts educational outcomes in sub-Saharan African children. We evaluated if South African children living with HIV (CLWH) were in the appropriate school grade-for-age compared to uninfected control children. We observed higher rates of not being in the correct grade-for-age in CLWH compared with controls (OR 3.32, 95% CI: 2.07-5.34), adjusted for study site, sex, whether the child's biological father was alive, and caregiver education. Initiation of ART before 6 months of age reduced but did not eliminate this association. Whether these associations are due to biological factors or other social and environmental determinants, and how best to support CLWH to achieve educational goals, warrants further investigation.

Mapping abnormal subcortical neurodevelopment in a cohort of Thai children with HIV

Alterations in subcortical brain structures have been reported in adults with HIV and, to a lesser extent, pediatric cohorts. The extent of longitudinal structural abnormalities in children with perinatal HIV infection (PaHIV) remains unclear. We modeled subcortical morphometry from whole brain structural magnetic resonance imaging (1.5 T) scans of 43 Thai children with PaHIV (baseline age = 11.09±2.36 years) and 50 HIV- children (11.26±2.80 years) using volumetric and surface-based shape analyses. The PaHIV sample were randomized to initiate combination antiretroviral treatment (cART) when CD4 counts were 15-24% (immediate: n = 22) or when CD4 < 15% (deferred: n = 21). Follow-up scans were acquired approximately 52 weeks after baseline. Volumetric and shape descriptors capturing local thickness and surface area dilation were defined for the bilateral accumbens, amygdala, putamen, pallidum, thalamus, caudate, and hippocampus. Regression models adjusting for clinical and demographic variables examined between and within group differences in morphometry associated with HIV. We assessed whether baseline CD4 count and cART status or timing associated with brain maturation within the PaHIV group. All models were adjusted for multiple comparisons using the false discovery rate. A pallidal subregion was significantly thinner in children with PaHIV. Regional thickness, surface area, and volume of the pallidum was associated with CD4 count in children with PaHIV. Longitudinal morphometry was not associated with HIV or cART status or timing, however, the trajectory of the left pallidum volume was positively associated with baseline CD4 count. Our findings corroborate reports in adult cohorts demonstrating a high predilection for HIV-mediated abnormalities in the basal ganglia, but suggest the effect of stable PaHIV infection on morphological aspects of brain development may be subtle.

A Feasibility RCT Evaluating a Play-Informed, Caregiver-Implemented, Home-Based Intervention to Improve the Play of Children Who Are HIV Positive

Background/aim

In South Africa, contextual factors have been identified as barriers to outdoor, unstructured play. The human immunodeficiency virus (HIV) and resulting progressive HIV encephalopathy (PHE) is a pandemic in this area, associated with development delays that are not addressed by highly active antiretroviral treatment (HAART). This study aimed to describe the playfulness in children with HIV and PHE on HAART living in challenging socioeconomic areas in South Africa aged 6 months to 8 years and to evaluate the feasibility and preliminary effectiveness of a play-informed, caregiver-implemented, home-based intervention (PICIHBI) for improving play.

Methods

A feasibility randomized control trial allowed for comparison of PICIHBI and conventional one-on-one occupational therapy interventions. Children were filmed playing pre-, mid-, and postintervention, using the Test of Playfulness (ToP) to assess playfulness. The PICIHBI comprised of 10 monthly sessions facilitated by an occupational therapist, involving group discussions with caregivers and periods of experiential play.

Results

Twenty-four children with HIV and/or PHE were randomized into one of the two intervention groups. Overall, the group (n = 24) had a median score of 0 (lowest item score) on nine of 24 ToP items and only had a median score of 3 (highest score) on two items. Pre- to postintervention overall ToP scores improved marginally for the PICIHBI group (n = 12) and the conventional group (n = 12). Between-group differences were not significant. The PICIHBI group demonstrated a significant increase in one ToP item score at midassessment. No significant ToP item changes were found in the conventional group.

Conclusion

Children with HIV were found to have the most difficulty on ToP items relating to the play elements of internal control and freedom from constraints of reality. The PICIHBI did not significantly improve children's play and was not more effective than the conventional intervention. Considerations for feasibility and effectiveness, including barriers to attendance, are discussed.

Screening for developmental disabilities in HIV positive and HIV negative children in South Africa: Results from the Asenze Study

Background

While neurodevelopmental abnormalities are common in children with HIV infection, their detection can be challenging in settings with limited availability of health professionals. The aim of this study was to assess the ability to identify developmental disability among HIV positive and HIV negative children living in South Africa with an internationally used screen.

Methods and findings

This analysis uses a sample of 1,330 4–6 year old children and 1,231 of their caregivers in KwaZulu-Natal, South Africa, including administration of the Ten Questions (TQ) screen, a standardized medical history and physical examination conducted by a medical doctor, with hearing and vision screening, psychological assessment for cognition and language delay, and voluntary HIV testing. There was a high prevalence of disability among the sample. Compared to HIV negative children, HIV positive children were more likely to screen positive on at least one TQ item (59.3 vs 42.8%, p = 0.01), be delayed in sitting, standing or walking (OR 3.89, 95% CI = 2.1–7.2) and have difficulty walking or weakness in the arms or legs (OR = 2.7, 95%CI = 0.8–9.37). By medical doctor assessment, HIV positive children were more likely to be diagnosed with gross motor disability (OR = 3.5, 95%CI = 1.3–9.2) and hearing disability (OR = 2.5, 95%CI = 1.2–5.3). By independent psychological assessment, HIV positive children were more likely to have cognitive delay (OR = 2.2, 95%CI = 1.2–3.9) and language delay (OR = 4.3, 95%CI = 2.2–8.4). Among HIV positive children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 100% and 51.2%, respectively. Among HIV-negative children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 90.2% and 63.9%, respectively.

Conclusions

In this first report of the use of the TQ screen in the isiZulu language, it was found to have high sensitivity for detecting serious developmental disabilities in children, especially HIV positive children. The performance of the TQ in this sample indicates utility for making best use of limited neurodevelopmental resources by screening HIV positive children.

A study of neuropsychological profile of human immunodeficiency virus-positive children and adolescents on antiretroviral therapy

AIMS

The aim is to study the neuropsychological and functional profile of children and adolescents with human immunodeficiency virus (HIV) infection on antiretroviral therapy (ART) and the association between the neuropsychological status and medical illness variables, treatment variables, and functional status in the cases of the sample and compare with normal controls.

MATERIALS AND METHODS

Forty-two HIV-positive children and adolescents on ART were evaluated and compared with 40 matched controls not known to be HIV-positive. The tools used were the Wechsler Intelligence Scale for Children-III R for neuropsychological evaluation, the Brief Impairment Scale to assess functional impairment, and a semi-structured questionnaire to obtain other relevant details.

RESULTS

There were significant differences between the verbal, performance intelligence quotients (IQs), global IQ score, and several individual subtests between cases and controls. The HIV group was also found to have a significant functional impairment.

CONCLUSION

Our findings show that HIV infection is associated with significant cognitive and functional impairment. The role of ART in these impairments requires further study. Such understanding can help to introduce wholesome and relatively safer management strategies for youngsters with HIV infection and improve their quality of life.

NeuroAIDS in children

The human immunodeficiency virus-1 (HIV-1) enters the central nervous system compartment within the first few weeks of systemic HIV infection and may cause a spectrum of neurologic complications. Without combination antiretroviral therapy (cART), 50-90% of all HIV-infected infants and children develop some form of neuroAIDS. Of the estimated 2.3 million children less than 15 years of age who were living in sub-Saharan Africa at the end of 2014, only 30% were receiving cART, suggesting that there is a large burden of neuroAIDS among HIV-infected children in sub-Saharan Africa. There is complex interplay between the disease process itself, the child's immune reaction to the disease, the secondary complications, the side-effects of antiretroviral drugs, and inadequate antiretroviral drug uptake into the central nervous system. In addition there is the layering effect from the multiple socioeconomic challenges for children living in low- and middle-income countries. Adolescents may manifest with a range of neurocognitive sequelae from mild neurocognitive disorder through to severe neurocognitive impairment. Neuroimaging studies on white-matter tracts have identified dysfunction, especially in the frontostriatal networks needed for executive function. Psychiatric symptoms of depression, attention deficit hyperactivity disorder, and behavioral problems are also commonly reported in this age group. Antiretroviral drugs may cause treatment-limiting neurologic and neuropsychiatric adverse reactions. The following chapter addresses the neurologic complications known to be, and suspected of being, associated with HIV infection in children and adolescents.

Mental health challenges among adolescents living with HIV

INTRODUCTION

Mental health is a critical and neglected global health challenge for adolescents infected with HIV. The prevalence of mental and behavioural health issues among HIV-infected adolescents may not be well understood or addressed as the world scales up HIV prevention and treatment for adolescents. The objective of this narrative review is to assess the current literature related to mental health challenges faced by adolescents living with HIV, including access to mental health services, the role of mental health challenges during transition from paediatric to adult care services and responsibilities, and the impact of mental health interventions.

METHODS

For each of the topics included in this review, individual searches were run using Medline and PubMed, accompanied by scans of bibliographies of relevant articles. The topics on which searches were conducted for HIV-infected adolescents include depression and anxiety, transition from paediatric to adult HIV care and its impact on adherence and mental health, HIV-related, mental health services and interventions, and the measurement of mental health problems. Articles were included if the focus was consistent with one of the identified topics, involved HIV-infected adolescents, and was published in English.

RESULTS AND DISCUSSION

Mental and behavioural health challenges are prevalent in HIV-infected adolescents, including in resource-limited settings where most of them live, and they impact all aspects of HIV prevention and treatment. Too little has been done to measure the impact of mental health challenges for adolescents living with HIV, to evaluate interventions to best sustain or improve the mental health of this population, or to create healthcare systems with personnel or resources to promote mental health.

CONCLUSIONS

Mental health issues should be addressed proactively during adolescence for all HIV-infected youth. In addition, care systems need to pay greater attention to how mental health support is integrated into the care management for HIV, particularly throughout lifespan changes from childhood to adolescence to adulthood. The lack of research and support for mental health needs in resource-limited settings presents an enormous burden for which cost-effective solutions are urgently needed.

HIV healthcare transition outcomes among youth in North America and Europe: a review

INTRODUCTION

The transition from paediatric to adult care poses risks to the health of young adults living with HIV if unsuccessful, including interruptions in care and poor health outcomes. Evolving best practices in HIV healthcare transition should ideally be informed by real-world qualitative and quantitative clinical healthcare transition outcomes. There has been a recent proliferation of HIV healthcare transition outcome research, largely from Europe and North America.

METHODS

A literature search was undertaken using the online databases PubMed, Web of Science, and Google Scholar. Medical subject and text word searches were combined for terms relating to HIV, paediatric transition outcomes, and internal and external factors were used to identify peer-reviewed articles.

RESULTS

In this paper, we review data on HIV healthcare transition outcomes in North America and Europe. Internal and external factors which may impact the success of HIV healthcare transition are examined. We describe ongoing research efforts to capture transition outcomes in the North America and Europe. Clinical, operational, and implementation science research gaps that exist to date are highlighted. Efforts to improve HIV healthcare transition research through country-level surveillance networks and large multicentre cohorts, including data integration and linkage between paediatric and adult cohorts are discussed.

CONCLUSIONS

We identified the need for a comprehensive approach to implementing empirically supported protocols to support healthcare transition for ALHIV. While there is limited prospective longitudinal cohort data available at this time, cohorts linking the paediatric and adolescent with ongoing surveillance into adulthood are being developed. Through a review of existing qualitative and quantitative healthcare transition outcomes studies, we identify emerging areas of consensus surrounding healthcare transition research implementation. Successful healthcare transition programmes in Europe and North America often share several characteristics, including implementation of a youth friendly multidisciplinary approach, consistent communication and integration between paediatric and adult care teams, and an individualized approach which is attuned the adolescent's transition readiness. Moving forward, the voices of youth and young adults living with HIV should be included in the development and evaluation of healthcare transition protocols to ensure that the definition of successful transition reflects all of the stakeholders in the transition process.

HIV encephalopathy with bilateral lower limb spasticity: upper limb motor function and level of activity and participation

AIM

To describe upper limb motor function and level of activity and participation in children with HIV encephalopathy (HIVE) and bilateral lower limb (BLL) spasticity.

METHOD

Thirty ambulant children with HIVE and BLL spasticity and 20 typically developing children, between 5 years and 12 years, were recruited. Upper limb motor function was assessed using the Purdue Pegboard and level of activity and participation using the Computer-Adapted Pediatric Evaluation of Disabilities Inventory (PEDI-CAT).

RESULTS

The HIVE group comprised 14 males and 16 females (mean age [SD] 8y 8mo [2y 2mo], Gross Motor Function Classification System (GMFCS) level I [n=10], II [n=11], and III [n=9]) and the typically developing group comprised 11 males and 9 females (mean age 8y 8mo [2y 3mo]). The HIVE group had lower scores than the typically developing group for all pegboard tasks and three of the four PEDI-CAT domains (p≤0.001). However, individual outcome scores varied substantially within each GMFCS level.

INTERPRETATION

Children with HIVE and BLL spasticity may have significantly poorer upper limb motor performance and lower levels of activity and participation than typically developing children. These findings suggest that an assessment of upper limb motor function should form part of optimal care for this population.

HIV encephalopathy with bilateral lower limb spasticity: gross motor function and antiretroviral therapy

AIM

To describe gross motor function in children with bilateral lower limb (BLL) spasticity due to human immunodeficiency virus encephalopathy (HIVE), and to investigate the association between age, CD4 percentage, and viral load at initiation of antiretroviral therapy (ART) and current gross motor function.

METHOD

Thirty ambulant children with HIVE and BLL spasticity were recruited. Clinical parameters, including ART, were obtained from medical records. Gross motor function was assessed using the 88-item Gross Motor Function Measure (GMFM-88).

RESULTS

The participant group was comprised of 14 males and 16 females (median age 8y; interquartile range [IQR] 7-11y). ART was initiated at a median age of 7 months (IQR 5-11mo) with a median CD4 percentage of 4.7% (IQR 2.3-8.0) and viral load of log₁₀ 6.0 (IQR 5.6-6.4). The median total GMFM-88 score was 89% (IQR 78-94%), with a wide range of scores in the 'Standing' domain (26-97%) and 'Walking, Running, and Jumping' domain (8-99%). No associations were detected between age at initiation of ART, CD4 percentage, or viral load and total GMFM-88 score.

INTERPRETATION

Limitations in gross motor function in children with HIVE and BLL spasticity range from mild to severe. ART initiation factors were not able to predict functional status in this sample.

Executive Functioning in Children and Adolescents With Perinatal HIV Infection and Perinatal HIV Exposure

BACKGROUND

Executive functions (EFs) are critical for management of life activities, but few studies have evaluated EFs in children and adolescents with perinatally acquired HIV (PHIV), who are at risk for problems in academics, behavior, and medication adherence. We compared EFs in youth with PHIV and in perinatally HIV-exposed but uninfected (PHEU) youth.

METHODS

Four Delis-Kaplan Executive Function System (D-KEFS) subtests were administered to 173 youth with PHIV and 85 PHEU youth, aged 9 to <19 years, who were enrolled in the Pediatric HIV/AIDS Cohort Study (PHACS) Memory and Executive Functioning Study. Youth with PHIV, with or without history of a Centers for Disease Control and Prevention Class C (AIDS-defining) condition (PHIV/C [n = 45] and PHIV/non-C [n = 128], respectively), were compared with each other and with PHEU youth. Among youth with PHIV, associations with measures of current and past disease severity were evaluated using adjusted linear regression models.

RESULTS

The PHIV/C group (mean age, 15.5 years), compared with the PHIV/non-C and PHEU groups (mean ages, 14.5 and 12.9 years, respectively), were significantly slower on the Inhibition and Color Naming/Reading Combined conditions of the Color-Word Interference subtest and made more errors on Inhibition; differences between the PHIV/C and PHEU groups persisted in adjusted models. No differences in adjusted means for fluency or problem-solving were found. The PHIV/non-C and PHEU groups did not differ on any measure. Associations of specific EF measures with HIV RNA viral load, CD4-positive T-lymphocyte percentage, and age at greatest disease severity were observed.

CONCLUSIONS

Youth with PHIV and previous AIDS-defining conditions performed more poorly on some EF measures. Relationships of EF development with the degree and timing of disease severity require further study. Implications for long-term outcomes and interventions are important avenues for follow-up.

Selective developmental alterations in The HIV-1 transgenic rat: Opportunities for diagnosis of pediatric HIV-1

Since the advent of combination antiretroviral therapy (cART), pediatric HIV-1 (PHIV) has evolved from a fatal disease to a chronic disease as children perinatally infected with HIV-1 survive into adulthood. The HIV-1 transgenic (Tg) rat, which expresses 7 of the 9 HIV-1 genes constitutively throughout development, was used to model the early development of chronic neurological impairment in PHIV. Male and female Fischer HIV-1 Tg and F344 N control rats, sampled from 35 litters, were repeatedly assessed during early development using multiple experimental paradigms, including somatic growth, locomotor activity, cross-modal prepulse inhibition (PPI) and gap-prepulse inhibition (gap-PPI). Later eye opening was observed in HIV-1 Tg animals relative to controls. HIV-1 Tg animals exhibited a shift in the development of locomotor activity implicating alterations in the maturation of the forebrain cholinergic inhibitory system. Alterations in the development of PPI and perceptual sharpening were observed in both auditory and visual PPI as indexed by a relative insensitivity to the dimension of time (msec for ISI; days of age for perceptual sharpening) as a function of the HIV-1 transgene. Presence of the HIV-1 transgene was diagnosed with 97.1 % accuracy using auditory and visual PPI measurements from PD 17 and 21. Early selective developmental alterations observed in the HIV-1 Tg rats provide an opportunity for the development of a point-of-care screening tool, which would permit the early diagnosis of PHIV and improve the long-term outcome for children perinatally infected with HIV-1.

The role of neuropsychology in UK pediatric HIV care: Relevance to clinical practice and research

There has been a dramatic improvement in the survival of children with perinatally-acquired HIV (PHIV) following the introduction of effective treatment in 1990s. The care for children living with PHIV is now focused on more accurately understanding the effects of both HIV and HIV treatment on the developing body and brain. An evaluation of current HIV neuroimaging, and neurocognitive research, when combined with clinical experience in the area of HIV, could help to inform United Kingdom (UK) PHIV service provision. This paper argues that an understanding from a neuropsychological perspective will help these young people to optimize their health, quality of life, and future functioning. The aim of the paper is to bring together research and clinical understanding of HIV and its treatment effects on the developing brain, together with an understanding of other potential neurological risk factors. It is argued here that there is a need for targeted neuropsychology assessment and preventative interventions, supported by clinical and preliminary research on the neurocognitive effects of HIV and its treatments.

Neurocognition and quality of life after reinitiating antiretroviral therapy in children randomized to planned treatment interruption

OBJECTIVE

Understanding the effects of antiretroviral treatment (ART) interruption on neurocognition and quality of life (QoL) are important for managing unplanned interruptions and planned interruptions in HIV cure research.

DESIGN

Children previously randomized to continuous (continuous ART, n = 41) vs. planned treatment interruption (PTI, n = 47) in the Pediatric European Network for Treatment of AIDS (PENTA) 11 study were enrolled. At study end, PTI children resumed ART. At 1 and 2 years following study end, children were assessed by the coding, symbol search and digit span subtests of Wechsler Intelligence Scale for Children (6-16 years old) or Wechsler Adult Intelligence Scale (≥17 years old) and by Pediatrics QoL questionnaires for physical and psychological QoL. Transformed scaled scores for neurocognition and mean standardized scores for QoL were compared between arms by t-test and Mann-Whitney U test, respectively. Scores indicating clinical concern were compared (<7 for neurocognition and <70 for QoL tests).

RESULTS

Characteristics were similar between arms with a median age of 12.6 years, CD4⁺ of 830 cells/μl and HIV RNA of 1.7 log10copies/ml. The median cumulative ART exposure was 9.6 in continuous ART vs. 7.7 years in PTI (P = 0.02). PTI children had a median of 12 months off ART and had resumed ART for 25.2 months at time of first assessment. Neurocognitive scores were similar between arms for all tests. Physical and psychological QoL scores were no different. About 40% had low neurocognitive and QoL scores indicating clinical concern.

CONCLUSION

No differences in information processing speed, sustained attention, short-term memory and QoL functioning were observed between children previously randomized to continuous ART vs. PTI in the PENTA 11 trial.

Resolved lower limb muscle tone abnormalities in children with HIV encephalopathy receiving standard antiretroviral therapy

Background

This short report arose from a follow-up study of children previously diagnosed with human immunodeficiency virus (HIV) encephalopathy and spastic diplegia and is among the first to describe that increased lower limb muscle tone in children with a confirmed HIV encephalopathy diagnosis may resolve over time in some cases.

Results

Of 19 children previously diagnosed with HIV encephalopathy and increased lower limb muscle tone, some were found to have resolved muscle tone abnormalities during a follow-up physical examination [resolved group, n = 13, median age 9 years 7 months (interquartile range 7 years 3 months–10 years 9 months)] whereas others continued to show increased lower limb muscle tone at follow-up [unresolved group, n = 6 median age 8 years 6 months (interquartile range 7 years 9 months–9 years 7 months)]. A review of clinical records showed no significant differences in age or follow-up time between the resolved and unresolved groups. However, the unresolved group appeared to have severe disease at an earlier age than the resolved group, based on the age at antiretroviral treatment initiation [median age at start of treatment 2 years 3 months (interquartile range 7 months–5 years 3 months) vs. 8 months (interquartile range 6–12 months), p = 0.08] and had more severe neurological signs at the initial assessment.

Conclusions

It is anticipated that this information may be of immediate value to those involved in the treatment of children with HIV encephalopathy and increased lower limb muscle tone whilst awaiting the outcome of future controlled clinical trials.

The physical and psychological effects of HIV infection and its treatment on perinatally HIV-infected children

INTRODUCTION

As highly active antiretroviral therapy (HAART) transforms human immunodeficiency virus (HIV) into a manageable chronic disease, new challenges are emerging in treating children born with HIV, including a number of risks to their physical and psychological health due to HIV infection and its lifelong treatment.

METHODS

We conducted a literature review to evaluate the evidence on the physical and psychological effects of perinatal HIV (PHIV+) infection and its treatment in the era of HAART, including major chronic comorbidities.

RESULTS AND DISCUSSION

Perinatally infected children face concerning levels of treatment failure and drug resistance, which may hamper their long-term treatment and result in more significant comorbidities. Physical complications from PHIV+ infection and treatment potentially affect all major organ systems. Although treatment with antiretroviral (ARV) therapy has reduced incidence of severe neurocognitive diseases like HIV encephalopathy, perinatally infected children may experience less severe neurocognitive complications related to HIV disease and ARV neurotoxicity. Major metabolic complications include dyslipidaemia and insulin resistance, complications that are associated with both HIV infection and several ARV agents and may significantly affect cardiovascular disease risk with age. Bone abnormalities, particularly amongst children treated with tenofovir, are a concern for perinatally infected children who may be at higher risk for bone fractures and osteoporosis. In many studies, rates of anaemia are significantly higher for HIV-infected children. Renal failure is a significant complication and cause of death amongst perinatally infected children, while new data on sexual and reproductive health suggest that sexually transmitted infections and birth complications may be additional concerns for perinatally infected children in adolescence. Finally, perinatally infected children may face psychological challenges, including higher rates of mental health and behavioural disorders. Existing studies have significant methodological limitations, including small sample sizes, inappropriate control groups and heterogeneous definitions, to name a few.

CONCLUSIONS

Success in treating perinatally HIV-infected children and better understanding of the physical and psychological implications of lifelong HIV infection require that we address a new set of challenges for children. A better understanding of these challenges will guide care providers, researchers and policymakers towards more effective HIV care management for perinatally infected children and their transition to adulthood.

White matter micro-structural changes in ART-naive and ART-treated children and adolescents infected with HIV in South Africa

OBJECTIVE

To describe the effect of HIV on white matter integrity and neurocognitive function in children vertically infected with HIV, compared to a HIV-negative healthy control group.

DESIGN

Cross-sectional.

METHODS

We compared 75 HIV-infected children aged 6-16 years, including children on antiretroviral therapy (ART) and those who were ART-naive, with 30 controls on diffusion tensor imaging and a neuropsychological battery sensitive to fronto-striatal pathology. In a secondary analysis, we compared 'slow progressor' ART-naive children, children on ART without a diagnosis of encephalopathy and children on ART with HIV encephalopathy.

RESULTS

Compared to controls (n = 30), HIV-infected children (n = 75) displayed decreased fractional anisotropy and axial diffusion, and increased mean diffusivity and radial diffusion, indicating damaged neuronal microstructure. HIV-infected children performed poorly on the neuropsychological battery (P = <0.001). Within the HIV-infected group, children with HIV encephalopathy (n = 14) had poor white matter integrity when compared to ART-treated children without encephalopathy (n = 41), and there was significant myelin loss in ART-naive children (n = 20), compared with ART-treated children. ART-treated children had significant axonal damage in the corpus callosum (P = 0.009).

CONCLUSION

Children infected with HIV, irrespective of treatment status, displayed significantly poorer white matter integrity and impaired cognition compared to HIV-negative controls. Our findings suggest that despite immune recovery in children on ART, they remain at risk for developing central nervous system disease, and that initiation of ART as early as possible may reduce the risk of developing white matter damage in ART-naive slow progressors.

Executive Functioning in Children and Adolescents With Perinatal HIV Infection

BACKGROUND

Perinatal HIV (PHIV) infection may place youth at risk for impairments in executive functioning (EF). We examined associations of EF with HIV infection, disease severity and other factors among youth with PHIV and perinatally HIV-exposed, uninfected youth (PHEU).

METHODS

Within the US-based Pediatric HIV/AIDS Cohort Study, 354 PHIV and 200 PHEU youth completed a standardized EF measure (Children's Color Trails Test, CCTT) and youth and/or caregivers completed a questionnaire measuring everyday EF (Behavior Rating Inventory of Executive Function, BRIEF). Covariates included HIV status, current and historical disease severity, demographic and caregiver variables and other cognitive measures. Analyses used linear and logistic regression and proportional odds models.

RESULTS

No significant HIV status group differences were found on CCTT scores. Caregiver BRIEF ratings indicated significantly fewer problems for PHIV than PHEU youth. However, PHIV youth with past encephalopathy self-endorsed significantly greater metacognitive (ie, cognitive regulation) problems on the BRIEF and performed more slowly on the CCTT than PHEU youth. CCTT and caregiver BRIEF scores had significant associations with indicators of past and present disease severity. Both PHIV and PHEU had significantly worse scores than population means on CCTT and BRIEF; scores had significant associations with demographic covariates.

CONCLUSIONS

Youth with PHIV show EF problems likely associated with risk factors other than HIV. However, cognitive slowing and self-reported metacognitive problems were evident in PHIV youth with a history of encephalopathy. Assessment and treatment of EF impairment may be important to identifying PHIV youth at particular risk for poor health and behavioral outcomes.

Of mice and monkeys: can animal models be utilized to study neurological consequences of pediatric HIV-1 infection?

Pediatric human immunodeficiency virus (HIV-1) infection remains a global health crisis. Children are much more susceptible to HIV-1 neurological impairments than adults, which can be exacerbated by coinfections. Neurological characteristics of pediatric HIV-1 infection suggest dysfunction in the frontal cortex as well as the hippocampus; limited MRI data indicate global cerebral atrophy, and pathological data suggest accelerated neuronal apoptosis in the cortex. An obstacle to pediatric HIV-1 research is a human representative model system. Host-species specificity of HIV-1 limits the ability to model neurological consequences of pediatric HIV-1 infection in animals. Several models have been proposed including neonatal intracranial injections of HIV-1 viral proteins in rats and perinatal simian immunodeficiency virus (SIV) infection of infant macaques. Nonhuman primate models recapitulate the complexity of pediatric HIV-1 neuropathogenesis while rodent models are able to elucidate the role specific viral proteins exert on neurodevelopment. Nonhuman primate models show similar behavioral and neuropathological characteristics to pediatric HIV-1 infection and offer a stage to investigate early viral mechanisms, latency reservoirs, and therapeutic interventions. Here we review the relative strengths and limitations of pediatric HIV-1 model systems.

Treatment initiation factors and cognitive outcome in youth with perinatally acquired HIV infection

OBJECTIVES

Although cognitive outcomes among perinatally infected youth have improved with highly active antiretroviral therapy (HAART), the impact of the age of initiation of treatment and the central nervous system (CNS) penetration effectiveness (CPE) of the regimen on cognitive outcomes is unknown. We aimed to describe the association between initiation age/regimen CPE score and cognitive outcomes in perinatally HIV-infected youth.

METHODS

Linear regression was used to retrospectively assess the association between full-scale IQ score (FSIQ) and age of initiation of HAART, regimen CPE, and the presence/absence of an AIDS diagnosis before initiation of HAART in an urban US cohort.

RESULTS

A total of 88 of 181 subjects (48.6%) had an AIDS diagnosis. In 69, AIDS preceded the start of HAART. Mean FSIQ (mean age 155.4 months) was 86.3 [standard deviation (SD) 15.6]. Neither age of initiation of HAART (P = 0.45) nor regimen CPE score (P = 0.33) was associated with FSIQ. Mean FSIQ for patients with an AIDS diagnosis before HAART initiation [82 (SD 17.0)] was significantly lower than for patients initiating HAART before an AIDS diagnosis [90 (SD 13)] (P = 0.001). Of the 129 subjects without AIDS by age 5 years, 41 (31.8%) initiated HAART before age 5 years; four of 41 later developed AIDS, compared with 32 of 88 of those who did not initiate HAART before age 5 years. The relative risk of AIDS if HAART was initiated before age 5 years was 0.19 (95% confidence interval 0.05-0.60).

CONCLUSIONS

Earlier age at HAART initiation and higher CPE score of a regimen did not improve cognitive outcomes. However, initiating HAART prior to AIDS protected against AIDS and was associated with a significantly higher FSIQ.

Starting treatment in pediatric HIV infection: try to clarify a gray area

The introduction of combination antiretroviral therapy (ART) in HIV-infected children led to a dramatic reduction in HIV-related morbidity and mortality. The decision about which ART regimen to use on children and when to start the treatment needs to focus on assuring normal growth and neuropsychological development. According to the available treatment guidelines, all infants under 1 year of age with HIV should be started on an ART at diagnosis. It is difficult to balance between the benefits of providing treatment to asymptomatic children >1 year and the concerns about long-term resistance and antiretroviral drug side effects if the treatment is started too early. Current guidelines agree that the need for antiretroviral treatment among asymptomatic children >12 months depends on age-specific CD4+ T-cell count thresholds and viral loads. Recent studies showed that the introduction of combination ART during the first year of life preserves a good function of B-cell and T-cell compartments. Starting treatment earlier might have fundamental roles both in preserving the not yet depleted immune function and in preventing the progressive HIV encephalopathy. The comparison of the international guidelines available for starting HIV treatment in children in developed countries highlights a gray area. New randomized controlled studies are needed to clarify the appropriate approach in asymptomatic children between 2 and 5 years of age.

Correlates of age at attainment of developmental milestones in HIV-infected infants receiving early antiretroviral therapy

BACKGROUND

Infant HIV-1 infection is associated with impaired neurologic and motor development. Antiretroviral therapy (ART) has the potential to improve developmental outcomes but the relative contributions of pre-ART disease status, growth, treatment regimen and ART response during infancy are unknown.

METHODS

Kenyan ART-naive infants <5-months old initiated ART and had monthly assessment of age of full neck control, unsupported walking and monosyllabic speech during 24 months of follow-up. Pre-ART and post-ART correlates of age at milestone attainment were evaluated using t tests or multivariate linear regression.

RESULTS

Among 99 infants, pre-ART correlates of later milestone attainment included: underweight and stunted (neck control, walking and speech, all P values <0.05), missed prevention of mother-to-child transmission (P = 0.04) (neck control), previous hospitalization, World Health Organization (WHO) Stage III/IV, low CD4 count, and wasting (speech and walking, all P values <0.05), and low maternal CD4 (speech, P = 0.04). Infants initiated ART at a median of 14 days following enrollment. Infants receiving nevirapinevs lopinavir/ritonavir-based ART attained later speech (18.1 vs. 15.5 months, P = 0.003) [corrected]. Adjusting for pre-ART level, lower 6-month gain in CD4% was associated with later walking (0.18 months earlier per unit increase in CD4%; P = 0.004) and speech (0.12 months earlier per unit increase in CD4%; P = 0.05), and lower 6-month gains in weight-for-age (P = 0.009), height-for-age (P = 0.03) and weight-for-height (P = 0.02) were associated with later walking.

CONCLUSION

In HIV-infected infants, compromised pre-ART immune and growth status, poor post-ART immune and growth responses, and use of nevirapine- vs. lopinavir/ritonavir-based ART were each associated with later milestone attainment [corrected]. The long-term consequences of these delays are unknown.

Spastic diplegia in children with HIV encephalopathy: first description of gait and physical status

AIM

The aim of this study was to explore the physical status and gait patterns of children with spastic diplegia secondary to human immunodeficiency virus encephalopathy (HIVE).

METHOD

A cross-sectional study was conducted on children diagnosed with HIVE and spastic diplegia. Sociodemographic and clinical background information was obtained, followed by three-dimensional gait analysis (3DGA) and a physical examination including assessments of muscle tone, strength, motor control, contractures, and bony deformities of the lower extremities.

RESULTS

Fourteen children (eight males, six females; mean age 5 y 8 mo [SD 9 mo], range 4 y 4 mo-6 y 10 mo) were studied. The cohort was divided into two groups based on distinctive gait patterns. Nine participants in group I showed only limited abnormalities. Group II displayed a more pathological gait pattern including stiff knee and equinus ankle abnormalities. Results of 3DGA, as with the physical examination outcomes, showed increased impairments from proximal to distal (except for hip extension).

INTERPRETATION

This study provides a first description of distinctive gait patterns and related physical characteristics of children with HIVE and spastic diplegia. Further research is necessary.

Neurologic disease in HIV-infected children and the impact of combination antiretroviral therapy

The prevalence of HIV-associated neurocognitive impairment in perinatally HIV-infected children has declined since the introduction of combination antiretroviral therapy (cART). Early initiation of cART in infancy has been shown to positively impact neurodevelopment; however, children continue to be diagnosed with HIV outside of the early infancy period and can experience subtle to severe neurocognitive deficits despite cART. The causes of these neurocognitive deficits despite effective cART are multifactorial and likely include continued viral replication in the CNS, ongoing neuroinflammation, irreversible CNS injury prior to cART initiation, neurotoxic effects of cART, and socioeconomic and psychosocial effects. Many aspects of our understanding of HIV-associated neurocognitive disorders have emerged from research in adult patients, but perinatally HIV-infected children represent a very different population. These children were exposed to HIV during a period of rapid brain development and have lifelong infection and potential lifelong cART exposure. HIV is no longer a rapidly fatal disease, and most HIV-infected children in resource-rich countries are living into adulthood. It is therefore critical to optimize neurocognitive outcomes of these youth. This review summarizes current understanding of the pathogenesis of HIV-associated CNS infection and the impact of cART on neurocognitive function in children and adolescents and discusses important areas for future research.

Perinatally acquired HIV infection: long-term neuropsychological consequences and challenges ahead

Over the past three decades, perinatal HIV infection in the United States has evolved from a fatal disease to a manageable chronic illness. As the majority of youth with perinatal HIV infection age into adolescence and adulthood, management of this stigmatizing, transmittable disease in the backdrop of a cadre of environmental stressors presents challenges beyond those of other chronic illnesses. The neurologic and neuropsychological consequences of this neurotropic virus have important implications for the successful navigation of responsibilities related to increasingly independent living of this aging population. This article will review the neurologic and neuropsychological consequences of perinatal HIV infection and concomitant factors in the era of highly active antiretroviral therapy and will provide an overview of the neuropathology, pathogenesis, neuroimaging findings, and treatment of perinatal HIV infection, as well as recommendations for service provision and future research.

Neurologic complications of pediatric human immunodeficiency virus: implications for clinical practice and management challenges in the African setting

Approximately 3.4 million children worldwide are affected with human immunodeficiency virus (HIV)/AIDS with more than 90% of them residing in sub-Saharan Africa, according to the World Health Organization. A significant proportion of the children eligible for treatment with antiretroviral therapy are not currently receiving it. Neurologic manifestations of HIV are common in both adults and children. There is a large spectrum of neurologic conditions that may be caused by the virus; however, early invasion of the central nervous system by the virus, affecting the developing fetal and infant brain, is believed to result in the most common primary HIV-related central nervous system complication, HIV encephalopathy. This article summarizes the spectrum of neuro-HIV in children, focuses on the neurocognitive and behavioral sequelae, reviews the effects of treatment on the primary neurologic effects of the disease, and discusses the specific challenges of identifying and managing these problems in resource-limited contexts, such as those found on the African continent.

A pilot study to investigate the muscle strength of children infected with HIV

Background/aims

Paediatric HIV remains a significant challenge to children and caregivers in South Africa. Little is known about the effect of HIV infection on muscle strength in children, however potential decrease in muscle strength has been inferred to affect functional ability in these children. The aim of this pilot study was to compare the muscle strength of children infected with HIV who had been receiving highly active antiretroviral therapy (HAART) to that of children infected with HIV not receiving HAART.

Methods

The study population included a group of 16 children receiving HAART and 16 children not receiving HAART. A one-off test of muscle strength was undertaken using a hand-held dynamometer for the child, and a demographic questionnaire and social status index to their primary caregiver. Two-sample student t tests, Pearson correlation analyses, and backward regression analyses were used to analyse data.

Results

The cluster of differentiation (CD4) count of the group on HAART was significantly higher than the group not receiving HAART. The group not receiving HAART was stronger than the HAART group. No significant correlation was shown between length of time having received HAART and muscle strength, or between CD4 count and muscle strength in the group receiving HAART. A significant negative correlation was shown between CD4 count and muscle strength in the group not receiving HAART.

Conclusion

Further research is needed to establish the impact of earlier administration of HAART on muscle strength in children infected with HIV.

The neurodevelopment of HIV-infected infants on HAART compared to HIV-exposed but uninfected infants

The aim of this study was to compare the neurodevelopment of HIV-infected (HI) infants in combination with antiretroviral therapy also known as HAART (highly active antiretroviral therapy) to HIV-exposed uninfected (HEU) infants. Twenty-seven HIV infected and 29 HEU infants under the age of one year attending the Empilweni Clinic at Rahima Moosa Mother and Child Hospital were studied. HI infants were assessed prior to initiating HAART and then for six months whilst on HAART. Neurodevelopment was assessed using the Bayley Scales of Infant and Toddler Development, 3rd ed (Bayley III). The HI infants scored significantly lower when compared to HEU infants for motor and language development at baseline, three months and six months follow up. No significant improvement in language (p = 0.46) and motor function (p = 0.91) occurred over time; however, developmental scores did not decrease. Cognitive development in the HI group was significantly lower when compared to the HEU group at visit one (p = 0.003). By six months follow-up, there were no significant differences between the two groups for cognitive development (p = 0.18). This study suggests that HIV-positive infants are delayed when compared to HEU infants. HAART may help to prevent further delay; however, it does not reverse the neurological damage already present. There is a need for therapists to be involved in pediatric HIV clinical services in order to provide early developmental screening as well as rehabilitative services to those children in need.

Neurodevelopment in perinatally HIV-infected children: a concern for adolescence

Globally, an estimated 3.4 million children are living with HIV, yet little is known about the effects of HIV and antiretroviral treatment (ART) on the developing brain, and the neurodevelopmental and behavioural outcomes of perinatally HIV-infected (PHIV+) adolescents. We reviewed the literature on neurodevelopmental outcomes in PHIV+ children and adolescents, and summarized the current evidence on behaviour, general cognition, specific domains, hearing and language, school performance and physical disabilities due to neurological problems. Evidence suggests that PHIV+ children do not perform as well as controls on general cognitive tests, processing speed and visual-spatial tasks, and are at much higher risk for psychiatric and mental health problems. Children with AIDS-defining diagnoses are particularly at risk for poorer outcomes. A striking finding is the lack of published data specific to the adolescent age group (10-25 years), particularly from resource-constrained countries, which have the highest HIV prevalence. In addition, extreme heterogeneity in terms of timing and source of infection, and antiretroviral experience limits our ability to summarize findings of studies and generalize results to other settings. Due to the complex nature of the developing adolescent brain, environmental influences and variation in access to ART, there is an urgent need for research on the longitudinal trajectory of neurodevelopment among children and adolescents perinatally infected with HIV, especially in high burden resource-constrained settings.

Neurologic abnormalities in HIV-1 infected children in the era of combination antiretroviral therapy

Background

Pediatric HIV-1 infection is associated with neurologic abnormalities. In recent years, the neurological outcome of HIV-1 infected children has substantially improved with combination antiretroviral therapy (cART). However, data regarding the long-term effect of cART and neurologic outcome are limited.

Methods

In the Pediatric Amsterdam Cohort on HIV-1 study, 59 perinatally HIV-1 infected children were evaluated from 1992–2010. All children underwent neurological examination and neuro-imaging studies, including CT-scan and/or MRI imaging. Fisher exact and Kruskal-Wallis tests were used to compare clinical deviations of neuro-imaging studies with HIV-1 related parameters, including CD4⁺ T cell count, HIV-1 viral load in blood and cerebrospinal fluid (CSF), and duration of cART as well as neurological examination.

Results

Abnormal neurologic examinations in these HIV-1 infected children included language impairment (22%), abnormal muscle tone (hyper/hypotonia) (14%) and delay in reaching developmental milestones (12%). Ventricular enlargement and sulcal widening (29%) and white matter lesions (38%) were prominent findings. White matter lesions were positively correlated with HIV-1 viral load levels. In a small follow-up sub study white matter lesions did not improve while children with ventricular enlargement and sulcal widening showed improvements whilst being treated with cART.

Conclusions

In the current era of cART HIV-1 infected children still frequently show neurological impairments together with abnormal neuro-imaging.

Cognitive function and neurodevelopmental outcomes in HIV-infected Children older than 1 year of age randomized to early versus deferred antiretroviral therapy: the PREDICT neurodevelopmental study

BACKGROUND

We previously reported similar AIDS-free survival at 3 years in children who were >1 year old initiating antiretroviral therapy (ART) and randomized to early versus deferred ART in the Pediatric Randomized to Early versus Deferred Initiation in Cambodia and Thailand (PREDICT) study. We now report neurodevelopmental outcomes.

METHODS

Two hundred eighty-four HIV-infected Thai and Cambodian children aged 1-12 years with CD4 counts between 15% and 24% and no AIDS-defining illness were randomized to initiate ART at enrollment ("early," n = 139) or when CD4 count became <15% or a Centers for Disease Control (CDC) category C event developed ("deferred," n = 145). All underwent age-appropriate neurodevelopment testing including Beery Visual Motor Integration, Purdue Pegboard, Color Trails and Child Behavioral Checklist. Thai children (n = 170) also completed Wechsler Intelligence Scale (intelligence quotient) and Stanford Binet Memory test. We compared week 144 measures by randomized group and to HIV-uninfected children (n = 319).

RESULTS

At week 144, the median age was 9 years and 69 (48%) of the deferred arm children had initiated ART. The early arm had a higher CD4 (33% versus 24%, P < 0.001) and a greater percentage of children with viral suppression (91% versus 40%, P < 0.001). Neurodevelopmental scores did not differ by arm, and there were no differences in changes between arms across repeated assessments in time-varying multivariate models. HIV-infected children performed worse than uninfected children on intelligence quotient, Beery Visual Motor Integration, Binet memory and Child Behavioral Checklist.

CONCLUSIONS

In HIV-infected children surviving beyond 1 year of age without ART, neurodevelopmental outcomes were similar with ART initiation at CD4 15%-24% versus <15%, but both groups performed worse than HIV-uninfected children. The window of opportunity for a positive effect of ART initiation on neurodevelopment may remain in infancy.

Neurocognitive function in HIV-positive children in a developing country

OBJECTIVES

We aimed to characterize neurological outcomes and determine the prevalence of HIV encephalopathy in a cohort of HIV-infected children in Jamaica.

METHODS

Data for 287 HIV-infected children presenting between 2002 and 2008 were reviewed and neurological outcomes characterized. A nested case-control study was conducted between July and September 2009 used 15 randomly selected encephalopathic HIV-infected children aged 7-10 years and 15 matched controls (non-encephalopathic HIV-infected). Their neurocognitive functions were evaluated using clinical assessment and standardized tests for intelligence, short term memory (visuo-spatial and auditory), selective attention, and fine motor and coordination functions. Outcomes were compared using Fisher's exact test and the Mann-Whitney U-test.

RESULTS

Sixty-seven (23.3%) children were encephalopathic. The median age at diagnosis of HIV encephalopathy was 1.6 years (interquartile range (IQR) 1.1-3.4 years). Predominant abnormalities were delayed milestones (59, 88.1%), hyperreflexia (59, 86.5%), spasticity (50, 74.6%), microcephaly (42, 61.7%), and quadriparesis (21, 31.3%). The median age of tested children was 8.7 years (IQR 7.6-10.8 years) in the encephalopathic group and 9 years (IQR 7.4-10.7 years) in the non-encephalopathic group. Encephalopathic children performed worse in all domains of neurocognitive function (p<0.05).

CONCLUSIONS

A high prevalence of HIV encephalopathy was noted, and significant neurocognitive dysfunction identified in encephalopathic children. Optimized management through the early identification of neurological impairment and implementation of appropriate interventions is recommended to improve quality of life.

Neurodevelopment in children born to HIV-infected mothers by infection and treatment status

BACKGROUND

We reviewed the impact of HIV, HIV exposure, and antiretroviral therapy/prophylaxis on neurodevelopmental outcomes of HIV-infected and HIV-exposed-uninfected infants and children.

METHODS

A literature search of Medline, Embase, PsychINFO, Web of Science, PubMed, and conference Web sites (1990-March 2011) using the search terms, infant, child, HIV, neurodevelopment, cognition, language, and antiretroviral therapy, identified 31 studies of HIV/antiretroviral exposure using standardized tools to evaluate infant/child development as the main outcome. Articles were included if results were reported in children <16 years of age who were exposed to HIV and antiretrovirals in fetal/early life, and excluded if children did not acquire HIV from their mothers or were not exposed to antiretrovirals in fetal/early life.

RESULTS

Infants who acquired HIV during fetal and early life tended to display poorer mean developmental scores than HIV-unexposed children. Mean motor and cognitive scores were consistently 1 to 2 SDs below the population mean. Mean scores improved if the infant received treatment before 12 weeks and/or a more complex antiretroviral regimen. Older HIV-infected children treated with highly active antiretroviral therapy demonstrated near normal global mean neurocognitive scores; subtle differences in language, memory, and behavior remained. HIV-exposed-uninfected children treated with antiretrovirals demonstrated subtle speech and language delay, although not universally.

CONCLUSIONS

In comparison with resource-rich settings, HIV-infected and HIV-exposed-uninfected infants/children in resource-poor settings demonstrated greater neurodevelopmental delay compared with HIV-unexposed infants. The effects on neurodevelopment in older HIV-infected children commenced on antiretroviral therapy from an early age and HIV-exposed-uninfected children particularly in resource-poor settings remain unclear.

Early antiretroviral therapy improves neurodevelopmental outcomes in infants

OBJECTIVES

To evaluate the effect of early versus deferred antiretroviral therapy (ART) on the neurodevelopment of infants from Cape Town participating in the Children with HIV Early Antiretroviral Therapy (CHER) trial.

DESIGN

HIV-infected infants were randomized to early (<3 months) or deferred ART. HIV-uninfected infants (HIV-exposed and HIV-unexposed) provide background data.

METHODS

Neurological examination and Griffiths Mental Development Scales (GMDS) were administered between 10-16 months of age by testers blind to HIV status and randomized allocation. Mean quotients were compared using paired Student's t-tests.

RESULTS

Sixty-four infants on early ART and 26 on deferred ART (of potential 77 and 38 respectively on CHER trial) were assessed at median age 11 months (range 10-16). On the GMDS, all scores were lower in the deferred arm and the General Griffiths and Locomotor Scores were significantly lower: mean (SD) =100.1 (13.8) vs. 106.3 (10.6) P=0.02; and 88.9 (16.3) vs. 97.7 (12.5), P<0.01, respectively. Children with HIV who received early ART performed as well as children without HIV except on the Locomotor subscale. Both infected and uninfected mean GMDS scores were within the average range.

CONCLUSION

Infants initiated on early ART have significantly better Locomotor and general scores on the GMDS at median age 11 months compared to infants on deferred ART, despite careful monitoring and ready access to ART in the latter.

HIV-1 alters neural and glial progenitor cell dynamics in the central nervous system: coordinated response to opiates during maturation

HIV-associated neurocognitive disorders (HANDs) are common sequelae of human immunodeficiency virus (HIV) infection, even when viral titers are well controlled by antiretroviral therapy. Evidence in patients and animal models suggests that neurologic deficits are increased during chronic opiate exposure. We have hypothesized that central nervous system (CNS) progenitor cells in both adult and developing CNS are affected by HIV infection and that opiates exacerbate these effects. To examine this question, neural progenitors were exposed to HIV-1 Tat(1-86) in the developing brain of inducible transgenic mice and in vitro. We examined whether Tat affected the proliferation or balance of progenitor populations expressing nestin, Sox2, and Olig2. Disease relevance was further tested by exposing human-derived progenitors to supernatant from HIV-1 infected monocytes. Studies concentrated on striatum, a region preferentially targeted by HIV and opiates. Results were similar among experimental paradigms. Tat or HIV exposure reduced the proliferation of undifferentiated (Sox2(+)) progenitors and oligodendroglial (Olig2(+)) progenitors. Coexposure to morphine exacerbated the effects of Tat or HIV-1(SF162) supernatant, but partially reversed HIV-1(IIIB) supernatant effects. Populations of Sox2(+) and Olig2(+) cells were also reduced by Tat exposure, although progenitor survival was unaffected. In rare instances, p24 immunolabeling was detected in viable human progenitors by confocal imaging. The vulnerability of progenitors is likely to distort the dynamic balance among neuron/glial populations as the brain matures, perhaps contributing to reports that neurologic disease is especially prevalent in pediatric HIV patients. Pediatric disease is atypical in developed regions but remains a serious concern in resource-limited areas where infection occurs commonly at birth and through breast feeding.

Impact of HIV severity on cognitive and adaptive functioning during childhood and adolescence

BACKGROUND

The influence of disease severity on cognitive and adaptive functioning in perinatally HIV-infected youth with (PHIV+/C) and without (PHIV+/NoC) a previous AIDS-defining illness (Centers for Disease Control and Prevention Class C event), compared with perinatally HIV-exposed but uninfected youth (PHEU) is not well understood.

METHODS

This was a cross-sectional analysis of cognitive and adaptive functioning in PHIV+/C (n = 88), PHIV+/NoC (n = 270) and PHEU (n = 200) youth aged 7-16 years, from a multisite prospective cohort study. Youth and caregivers completed the Wechsler Intelligence Scale for Children, Fourth Edition and the Adaptive Behavior Assessment System, Second Edition, respectively. We compared means and rates of impairment between groups, and examined associations with other psychosocial factors.

RESULTS

Overall mean scores on measures of cognitive and adaptive functioning were in the low average range for all 3 groups. After adjustment for covariates, mean full-scale intelligence quotient scores were significantly lower for the PHIV+/C group than the PHIV+/NoC and PHEU groups (mean = 77.8 versus 83.4 and 83.3, respectively), whereas no significant differences were observed between the PHEU and PHIV+/NoC groups in any domain. Lower cognitive performance for the PHIV+/C group was primarily attributable to a prior diagnosis of encephalopathy. No significant differences between groups were observed in adaptive functioning.

CONCLUSION

For long-term survivors, youth with HIV infection and a prior Centers for Disease Control and Prevention Class C event have higher risk for cognitive but not adaptive impairment regardless of current health status; this finding appears attributable to a previous diagnosis of encephalopathy. Early preventive therapy may be critical in reducing risk of later neurodevelopmental impairments.