Diagnosis of HIV infection in children

Improving early identification of HIV-infected neonates with birth PCR testing in a large urban hospital in Johannesburg, South Africa: successes and challenges

Introduction: Timely diagnosis is necessary to avert early death in HIV-infected neonates. Birth PCR testing may improve early identification and facilitate access to care. We implemented a birth HIV diagnosis programme in Johannesburg, South Africa and present successes and challenges of the first two and a half years of operation.

Methods: Between June 2014 and December 2016, we sought to identify all HIV-exposed births and offer newborn HIV PCR testing before discharge after delivery. The programme identified newly delivered women who had tested positive during pregnancy and provided post-partum HIV antibody testing for women without recent negative results. HIV-positive women were required to consent for neonatal birth testing and asked to return a week later to obtain their results. Neonatal venous blood was sampled and tested at the national laboratory using Roche COBAS® TaqMan® HIV-1 Qualitative Test (Version 2.0). Non-negative results triggered active follow-up for confirmatory testing and appropriate treatment.

Results: Of 30,591 women with live births, 6864 (22.4%) were known to be HIV positive and an additional 221 women (1.4% of those tested) were identified during maternal postnatal testing. Of 7085 HIV-positive women, 6372 (89.9%) were interviewed and agreed to data collection, 6358 (99.8%) consented to birth testing for 6467 neonates and a blood sample was collected for 6377 (98.6%). If tested, 6210 (97.4%) tested negative, 91 (1.4%) positive, 57 (0.9%) revealed errors and 19 (0.3%) were indeterminate . Seven of the 19 neonates with indeterminate results and one with initial error result were found to be infected on subsequent testing yielding an intrauterine transmission rate of 1.6% (95% CI: 1.3–1.9). Sixteen (16%) of 99 infected infants were born to women (n = 221) identified during postnatal testing. With active outreach, 95/99 (96%) infected infants were initiated on antiretroviral therapy. Of 6261 neonates with negative results, 3251 (52%) returned to receive their test results.

Conclusion: Our programme successfully achieved high coverage and uptake of birth PCR testing and was able, with active tracking, to start almost all identified HIV-infected neonates on antiretroviral therapy. Implementation required additional staff for counselling, quality control and outreach. Return for negative results was low and neonates with indeterminate results required multiple repeat tests.

Protective efficacy of prolonged co-trimoxazole prophylaxis in HIV-exposed children up to age 4 years for the prevention of malaria in Uganda: a randomised controlled open-label trial

BACKGROUND

WHO recommends daily co-trimoxazole for children born to HIV-infected mothers from 6 weeks of age until breastfeeding cessation and exclusion of HIV infection. We have previously reported on the effectiveness of continuation of co-trimoxazole prophylaxis up to age 2 years in these children. We assessed the protective efficacy and safety of prolonging co-trimoxazole prophylaxis until age 4 years in HIV-exposed children.

METHODS

We undertook an open-label randomised controlled trial alongside two observational cohorts in eastern Uganda, an area with high HIV prevalence, malaria transmission intensity, and antifolate resistance. We enrolled HIV-exposed infants between 6 weeks and 9 months of age and prescribed them daily co-trimoxazole until breastfeeding cessation and HIV-status confirmation. At the end of breastfeeding, children who remained HIV-uninfected were randomly assigned (1:1) to discontinue co-trimoxazole or to continue taking it up to age 2 years. At age 2 years, children who continued co-trimoxazole prophylaxis were randomly assigned (1:1) to discontinue or continue prophylaxis from age 2 years to age 4 years. The primary outcome was incidence of malaria (defined as the number of treatments for new episodes of malaria diagnosed with positive thick smear) at age 4 years. For additional comparisons, we observed 48 HIV-infected children who took continuous co-trimoxazole prophylaxis and 100 HIV-unexposed uninfected children who never received prophylaxis. We measured grade 3 and 4 serious adverse events and hospital admissions. All children were followed up to age 5 years and all analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00527800.

FINDINGS

203 HIV-exposed infants were enrolled between Aug 10, 2007, and March 28, 2008. After breastfeeding ended, 185 children were not infected with HIV and were randomly assigned to stop (n=87) or continue (n=98) co-trimoxazole up to age 2 years. At age 2 years, 91 HIV-exposed children who had remained on co-trimoxazole prophylaxis were randomly assigned to discontinue (n=46) or continue (n=45) co-trimoxazole from age 2 years to age 4 years. We recorded 243 malaria episodes (2·91 per person-years) in the 45 HIV-exposed children assigned to continue co-trimoxazole until age 4 years compared with 503 episodes (5·60 per person-years) in the 46 children assigned to stop co-trimoxazole at age 2 years (incidence rate ratio 0·53, 95% CI 0·39-0·71; p< 0·0001). There was no evidence of malaria incidence rebound in the year after discontinuation of co-trimoxazole in the HIV-exposed children who stopped co-trimoxazole at age 2 years, but incidence increased significantly in HIV-exposed children who stopped co-trimoxazole at age 4 years (odds ratio 1·78, 95% CI 1·19-2·66; p= 0·005). Incidence of grade 3 or 4 serious adverse events, hospital admissions, or deaths did not significantly differ between HIV-exposed, HIV-unexposed, and HIV-infected children.

Missed opportunities for early access to care of HIV-infected infants in Burkina Faso

OBJECTIVE

The World Health Organization (WHO) has recommended a universal antiretroviral therapy (ART) for all HIV-infected children before the age of two since 2010, but this implies an early identification of these infants. We described the Prevention of Mother-to-Child HIV Transmission (PMTCT) cascade, the staffing and the quality of infrastructures in pediatric HIV care facilities, in Ouagadougou, Burkina Faso.

METHODS

We conducted a cross-sectional survey in 2011 in all health care facilities involved in PMTCT and pediatric HIV care in Ouagadougou. We assessed them according to their coverage in pediatric HIV care and WHO standards, through a desk review of medical registers and a semi-structured questionnaire administered to health-care workers (HCW).

RESULTS

In 2011, there was no offer of care in primary health care facilities for HIV-infected children in Ouagadougou. Six district hospitals and two university hospitals provided pediatric HIV care. Among the 67 592 pregnant women attending antenatal clinics in 2011, 85.9% were tested for HIV. The prevalence of HIV was 1.8% (95% Confidence Interval: 1.7%-1.9%). Among the 1 064 HIV-infected pregnant women attending antenatal clinics, 41.4% received a mother-to-child HIV transmission prevention intervention. Among the HIV-exposed infants, 313 (29.4%) had an early infant HIV test, and 306 (97.8%) of these infants tested received their result within a four-month period. Among the 40 children initially tested HIV-infected, 33 (82.5%) were referred to a health care facility, 3 (9.0%) were false positive, and 27 (90.0%) were initiated on ART. Although health care facilities were adequately supplied with HIV drugs, they were hindered by operational challenges such as shortage of infrastructures, laboratory reagents, and trained HCW.

CONCLUSIONS

The PMTCT cascade revealed bottle necks in PMTCT intervention and HIV early infant diagnosis. The staffing in HIV care and quality of health care infrastructures were also insufficient in 2011 in Ouagadougou.

Reasons for hospitalization in HIV-infected children in West Africa

INTRODUCTION

Current knowledge on morbidity and mortality in HIV-infected children comes from data collected in specific research programmes, which may offer a different standard of care compared to routine care. We described hospitalization data within a large observational cohort of HIV-infected children in West Africa (IeDEA West Africa collaboration).

METHODS

We performed a six-month prospective multicentre survey from April to October 2010 in five HIV-specialized paediatric hospital wards in Ouagadougou, Accra, Cotonou, Dakar and Bamako. Baseline and follow-up data during hospitalization were recorded using a standardized clinical form, and extracted from hospitalization files and local databases. Event validation committees reviewed diagnoses within each centre. HIV-related events were defined according to the WHO definitions.

RESULTS

From April to October 2010, 155 HIV-infected children were hospitalized; median age was 3 years [1-8]. Among them, 90 (58%) were confirmed for HIV infection during their stay; 138 (89%) were already receiving cotrimoxazole prophylaxis and 64 children (40%) had initiated antiretroviral therapy (ART). The median length of stay was 13 days (IQR: 7-23); 25 children (16%) died during hospitalization and four (3%) were transferred out. The leading causes of hospitalization were WHO stage 3 opportunistic infections (37%), non-AIDS-defining events (28%), cachexia and other WHO stage 4 events (25%).

CONCLUSIONS

Overall, most causes of hospitalizations were HIV related but one hospitalization in three was caused by a non-AIDS-defining event, mostly in children on ART. HIV-related fatality is also high despite the scaling-up of access to ART in resource-limited settings.

Morbidity and health care resource utilization in HIV-infected children after antiretroviral therapy initiation in Côte d'Ivoire, 2004-2009

BACKGROUND

We describe severe morbidity and health care resource utilization (HCRU) among HIV-infected children on antiretroviral therapy (ART) in Abidjan, Côte d'Ivoire.

METHODS

All HIV-infected children enrolled in an HIV-care program (2004-2009) were eligible for ART initiation until database closeout, death, ART interruption, or loss to follow-up. We calculated incidence rates (IRs) of density per 100 child-years (CYs) for severe morbidity, HCRU (outpatient care and inpatient care), and associated factors using frailty models with a Weibull distribution.

RESULTS

Of 332 children with a median age of 5.7 years and median follow-up of 2.5 years, 65.4% were severely immunodeficient by World Health Organization (WHO) criteria, and all received cotrimoxazole prophylaxis. We recorded 464 clinical events in 228 children; the overall IR was 57.6/100 CYs [95% confidence interval (CI): 52.1 to 62.5]. Severe morbidity was more frequent in children on protease inhibitor (PI)-based ART compared to those on other regimens [adjusted hazards ratio (aHR): 1.83; 95% CI: 1.35 to 2.47] and to those moderately/severely immunodeficient compared to those not (aHR: 1.57; 95% CI: 1.13 to 2.18 and aHR: 2.53; 95% CI: 1.81 to 3.55, respectively). Of the 464 events, 371 (80%) led to outpatient care (IR: 45.6/100 CYs) and 164 (35%) to inpatient care (IR: 20.2/100 CYs). In adjusted analyses, outpatient care was significantly less frequent in children older than 10 years compared with children younger than 2 years (aHR: 0.49; 95% CI: 0.31 to 0.78) and in those living furthest from clinics compared with those living closest (aHR: 0.65; 95% CI: 0.47 to 0.90). Both inpatient and outpatient HCRU were negatively associated with cotrimoxazole prophylaxis.

CONCLUSIONS

Despite ART, HIV-infected children still require substantial utilization of health care services.

Health care resource utilization in untreated HIV-infected children in a pediatric programme, Abidjan, Côte d'Ivoire, 2004-2009

BACKGROUND

We describe health care resource utilization among HIV-1-infected children who have not yet undergone antiretroviral treatment (ART) in Abidjan, Côte d'Ivoire.

METHODS

HIV-infected children enrolled prospectively in an HIV care programme in 2 health facilities in Abidjan (2004-2009) were followed up from date of inclusion until database closeout, death, ART initiation, or loss to follow-up (no clinical contact for more than 6 months). Incidences of health care resource utilization (outpatient care, inpatient day care, and hospitalization) were described according to severe morbidity and mixed effect log linear models were computed to identify associated factors.

RESULTS

Overall, 405 children were included, entering care at a median age of 4.5 years, 66.9% were receiving cotrimoxazole prophylaxis, and 27.7% met 2006 WHO criteria for immunodeficiency by age. The median follow-up time was 11.6 months (interquartile range: 1.4; 30.7). Overall, 371 clinical events occurred in 162 children yielding to an incidence rate (IR) of 60.9/100 child-years (CY) [95% confidence interval (CI): 55.1 to 67.2]: 57% of clinical events led to outpatient care (IR: 33/100 CY), 38% to inpatient day care (IR: 22/100 CY), and 10% to hospitalization (IR: 5.9/100 CY). Further medical examinations were made allowing confirmed diagnoses in 40% of those (IR: 22.4/100 CY). Outpatient care was less common among immunodeficient children than those not (relative risk [RR] = 0.32, 95% CI: 0.18 to 0.56), in those whose main caregivers are both parents compared with those who are primarily cared for by their mother only (RR = 0.34, 95% CI: 0.15 to 0.77).

CONCLUSION

Untreated HIV-infected children require substantial inpatient and outpatient care in a context where ART is scaling up but still not available to all.

Development and application of a high-throughput microneutralization assay: lack of xenotropic murine leukemia virus-related virus and/or murine leukemia virus detection in blood donors

BACKGROUND

Xenotropic murine leukemia virus (MLV)-related virus (XMRV) and other related MLVs have been described with chronic fatigue syndrome and certain types of prostate cancer. In addition, prevalence rates as high as 7% have been reported in blood donors, raising the risk of transfusion-related transmission. Several laboratories have utilized microneutralization assays as a surrogate marker for detection of anti-MLV serologic responses--with up to 25% of prostate cancer patients reported to harbor neutralizing antibody responses.

STUDY DESIGN AND METHODS

We developed a high-throughput microneutralization assay for research studies on blood donors using retroviral vectors pseudotyped with XMRV-specific envelopes. Infection with these pseudotypes was neutralized by sera from both macaques and mice challenged with XMRV, but not preimmune serum. A total of 354 plasma samples from blood donors in the Reno/Tahoe area were screened for neutralization.

RESULTS

A total of 6.5% of donor samples gave moderate neutralization of XMRV, but not control pseudotypes. However, further testing by Western blot revealed no evidence of antibodies against MLVs in any of these samples. Furthermore, no evidence of infectious virus or viral nucleic acid was observed.

CONCLUSION

A microneutralization assay was developed for detection of XMRV and can be applied in a high-throughput format for large-scale studies. Although a proportion of blood donors demonstrated the ability to block XMRV envelope-mediated infection, we found no evidence that this inhibition was mediated by specific antibodies elicited by exposure to XMRV or MLV. It is likely that this moderate neutralization is mediated through another, nonspecific mechanism.

Diagnosis of HIV-1 infection in infants using dried blood spots in Tamil Nadu, South India

INTRODUCTION

Diagnosis of HIV infection in infants is difficult due to the presence of maternal antibodies; only nucleic acid assays are very helpful in early detection. Filter papers are especially useful for blood collection in resource-poor settings with limited access to diagnostic facilities. MATERIALS #ENTITYSTARTX00026;

METHODS

DBS samples were collected from the infants born to HIV seropositive mothers who had received single dose nevirapine at onset of labor. The samples were directly spotted onto the Whatman 903 cards from heel, big toe or finger prick depending on the age of the infants. A total of 766 infant samples were collected on dried blood spots (DBS) and transported to the Department of Experimental Medicine (DEM), Chennai, for testing from different government hospitals of rural and urban parts of Tamil Nadu, South India. According to National AIDS Control Organization's (NACO) protocol DNA was extracted from all these DBS and PCR was performed using the Roche kit version 1.5.

RESULTS

Fifteen infants were found to be HIV positive and 751 were HIV negative; all these 15 positive infants and 49 negative infants who were in the age group between 10 and 18 months were repeated with another DBS and compared with whole blood. The DBS results were concordant with the whole blood method and the sensitivity and specificity were 100%.

Early infant HIV-1 diagnosis programs in resource-limited settings: opportunities for improved outcomes and more cost-effective interventions

Early infant diagnosis (EID) of HIV-1 infection confers substantial benefits to HIV-infected and HIV-uninfected infants, to their families, and to programs providing prevention of mother-to-child transmission (PMTCT) services, but has been challenging to implement in resource-limited settings. In order to correctly inform parents/caregivers of infant infection status and link HIV-infected infants to care and treatment, a 'cascade' of events must successfully occur. A frequently cited barrier to expansion of EID programs is the cost of the required laboratory assays. However, substantial implementation barriers, as well as personnel and infrastructure requirements, exist at each step in the cascade. In this update, we review challenges to uptake at each step in the EID cascade, highlighting that even with the highest reported levels of uptake, nearly half of HIV-infected infants may not complete the cascade successfully. We next synthesize the available literature about the costs and cost effectiveness of EID programs; identify areas for future research; and place these findings within the context of the benefits and challenges to EID implementation in resource-limited settings.

Improving mothers' access to PMTCT programs in West Africa: a public health perspective

Despite technical means and apparent political will, the percentage of pregnant women involved in preventing mother-to-child transmission (PMTCT) interventions is not increasing as fast as public health authorities would expect. This is even more striking when compared to the scaling up of access to antiretroviral treatment. It seems important to analyze the successes and failures of the programs and the "scaling-up" of PMTCT programs. This is a major issue for women at two levels: women are very concerned about the health of their children, and they are the ones who implement prevention in collaboration with health services. A review of achievements and failures described from a public health perspective may lead to greater understanding of the social aspects involved in PMTCT program achievements and failures. This paper is based on the combination of a literature review and empirical evidence collected during 15 years of PMTCT implementation, childcare research and treatment programs in West Africa. The analysis aims to identify the social issues that explain the gap between PMTCT program aims and achievements in order to encourage research in the social sciences regarding relationships between mothers and the care system. We find it is possible to build programs at the national level that have a high degree of acceptance of testing and intervention, with a progressive decline in HIV infection among children. However, many obstacles remain, highlighting the necessity to broaden access to HIV screening, develop mass campaigns on testing for couples and improve HIV care and training for caregivers. Because HIV-infected pregnant women are experiencing great psychological distress, healthcare providers must use an approach that is as friendly as possible.

Low-cost HIV-1 diagnosis and quantification in dried blood spots by real time PCR

Background

Rapid and cost-effective methods for HIV-1 diagnosis and viral load monitoring would greatly enhance the clinical management of HIV-1 infected adults and children in limited-resource settings. Recent recommendations to treat perinatally infected infants within the first year of life are feasible only if early diagnosis is routinely available. Dried blood spots (DBS) on filter paper are an easy and convenient way to collect and transport blood samples. A rapid and cost effective method to diagnose and quantify HIV-1 from DBS is urgently needed to facilitate early diagnosis of HIV-1 infection and monitoring of antiretroviral therapy.

Methods and Findings

We have developed a real-time LightCycler (rtLC) PCR assay to detect and quantify HIV-1 from DBS. HIV-1 RNA extracted from DBS was amplified in a one-step, single-tube system using primers specific for long-terminal repeat sequences that are conserved across all HIV-1 clades. SYBR Green dye was used to quantify PCR amplicons and HIV-1 RNA copy numbers were determined from a standard curve generated using serially diluted known copies of HIV-1 RNA. This assay detected samples across clades, has a dynamic range of 5 log₁₀, and %CV <8% up to 4 log₁₀ dilution. Plasma HIV-1 RNA copy numbers obtained using this method correlated well with the Roche Ultrasensitive (r = 0.91) and branched DNA (r = 0.89) assays. The lower limit of detection (95%) was estimated to be 136 copies. The rtLC DBS assay was 2.5 fold rapid as well as 40-fold cheaper when compared to commercial assays. Adaptation of the assay into other real-time systems demonstrated similar performance.

Conclusions

The accuracy, reliability, genotype inclusivity and affordability, along with the small volumes of blood required for the assay suggest that the rtLC DBS assay will be useful for early diagnosis and monitoring of pediatric HIV-1 infection in resource-limited settings.

CD4+/CD8+ T cell ratio for diagnosis of HIV-1 infection in infants: Women and Infants Transmission Study

OBJECTIVE

In this study, we tested the hypothesis that the CD4(+)/CD8(+) T cell ratio could predict HIV infection status in HIV-exposed infants.

METHODS

CD4(+)/CD8(+) T cell ratios were determined from data for live-born singleton infants who had been prospectively enrolled in the Women and Infants Transmission Study. Data for 2208 infants with known HIV infection status (179 HIV-infected and 2029 uninfected infants) were analyzed.

RESULTS

Receiver operating characteristic curves indicated that the CD4(+)/CD8(+) T cell ratio performed better than the proportion of CD4(+) T cells for diagnosis of HIV infection as early as 2 months of age, and this relationship was unaffected by adjustment for maternal race/ethnicity, infant birth weight, gestational age, and gender. At 4 months of age, 90% specificity for HIV diagnosis was associated with 60% sensitivity. For ease of use, graphical estimates based on cubic splines for the time-dependent parameters in a Box-Cox transformation (L), the median (M), and the coefficient of variation (S) were used to create LMS centile curves to show the sensitivity and specificity of CD4(+)/CD8(+) T cell ratios in HIV-infected and uninfected infants until 12 months of age. At 6 months of age, a simplified equation that incorporated sequential CD4(+)/CD8(+) T cell ratios and hematocrit values resulted in improved receiver operating characteristic curves, with 94% positive predictive value and 98% negative predictive value. The positive and negative predictive values remained above 90% in simulated infant populations over a wide range of HIV infection prevalence values.

CONCLUSIONS

In the absence of virological diagnosis, a presumptive diagnosis of HIV infection status can be made on the basis of CD4(+)/CD8(+) T cell ratios in HIV-1-exposed infants after 2 months of age; sensitivity and specificity can be improved at 6 months by using a discriminant analysis equation.

Negative life events: risk to health-related quality of life in children and youth with HIV infection

Children and youth with perinatally acquired HIV infection are living longer because of improved drug therapies, but they may be at risk for poor health-related quality of life (HRQOL) outcomes because of nondisease factors. Families affected by HIV disease are more likely to experience major negative life events (NLEs). The effects of NLEs, shown to impact HRQOL in children with other chronic illnesses, have not been evaluated in children with HIV infection. The primary objective of this study was to determine if NLEs occurring in the previous 12 months were associated with increased risk for poorer outcomes in three measures of HRQOL (health perception, behavior problems, and symptom distress) in a cohort of children and youth with HIV infection. The authors conducted a cross-sectional analysis of data determined in 1999 from 1,018 children and youth 5 to 21 years of age enrolled in a longitudinal follow-up study. Multivariate logistic regressions estimated the odds for worse HRQOL outcomes. Children and youth with one or more NLEs had significantly lower health perceptions, more behavior problems, and greater symptom distress than children with no reported NLEs. The occurrence of NLEs may present a significant nondisease risk for diminished HRQOL among children and youth challenged by HIV disease. Nursing efforts to support these younger patients and their families sustaining major family disruption caused by NLEs may improve overall health outcomes in this vulnerable population.

Pediatric HIV infection: diagnostic laboratory methods

The diagnosis of HIV-1 infection in infants and children continues to present challenges. Currently available virologic assays are sensitive and specific and allow early detection of perinatally acquired HIV infection. Identification soon after birth allows for the rapid initiation of antiretroviral therapy and preservation of the infant's immune system. Serologic diagnostic methods, including HIV-ELISA, Western blot, and immunofluorescence Assay can be used to make the diagnosis of HIV infection in infants older than 18 months of age, children, and adolescents. Recently developed rapid tests allow for testing outside clinical sites, provide results in a short period of time, and allow for prompt initiation of effective prophylaxis in cases of exposure particularly maternal to child transmission. We discuss here the diagnostic management of HIV-exposed infants and HIV-infected children.

Pediatric HIV infection: immune and viral evaluation

Advances in laboratory methods have driven improvements in the management and treatment of HIV infection. The methods to accurately and rapidly diagnose HIV infection in infants and children have been outlined in the previous article. In this review, the laboratory evaluation of infected children is described and methods to monitor progression of disease and response to therapy outlined.

Perinatally Acquired HIV-1 Infection: Prevention and Evaluation of HIV-Exposed Infants

Perinatal transmission of human immunodeficiency virus type 1 (HIV-1) is the primary cause of pediatric HIV infections. In recent years, perinatal HIV-1 transmission rates in the United States have declined markedly because of several factors that include enhanced voluntary counseling and HIV-1 testing (VCT) for pregnant women, widespread use of antiretroviral prophylaxis or combination antiretroviral therapy, avoidance of breastfeeding, and elective cesarean delivery. However, perinatal transmission of HIV-1 still occurs, and 300 to 400 infected infants are born annually, primarily because of missed prevention opportunities. The pediatrician plays a vital role in the prevention of perinatal transmission of HIV-1 by identifying newborns born to infected mothers who were not tested during pregnancy, administering antiretroviral prophylaxis, and ensuring follow-up to confirm or exclude the diagnosis of HIV-1 infection in early infancy. This article reviews recent advances in the prevention of perinatal transmission of HIV-1, discusses evaluation and treatment of infants exposed to HIV-1, and highlights certain unique features of HIV-1 infections in infants, with a focus on early diagnosis, clinical manifestations, treatment, and prognosis.

A 5-week-old HIV-1–exposed girl with failure to thrive and diffuse nodular pulmonary infiltrates

A 5-week-old female infant with vertical HIV-1 exposure, progressive cough, and failure to thrive was given a diagnosis of bilateral diffuse nodular lung lesions. The child was without fever, leukocytosis, anemia, peripheral adenopathy, or hepatosplenomegaly, and the results of repeated blood tests for HIV-1 DNA were negative. A needle biopsy of the lungs revealed granulomatous inflammation and giant cells, with fungal organisms suggestive of Aspergillus species. A nitroblue tetrazolium dye test performed on the patient's blood specimen demonstrated absence of dye reduction, suggesting a diagnosis of chronic granulomatous disease. Further analysis revealed that the child had a deficiency of the p47(phox) component of the nicotinamide adenine dinucleotide phosphate oxidase system. Thus this child with vertical HIV-1 exposure and diffuse pulmonary nodules actually had an autosomal recessive form of chronic granulomatous disease. This case study clearly demonstrates that children with suspected HIV-1 infection might also need evaluation for primary immunodeficiency and that the clinical immunology laboratory is a powerful adjunct in coming to a correct diagnosis.

Oral lesions and dental caries status in perinatally HIV-infected children in Northern Thailand

To describe the prevalence of oral lesions and dental caries status in perinatally HIV-infected children.

DESIGN

A cross-sectional study.

SETTING

Paediatric HIV outpatient department at the Nakornping Provincial Hospital, Chiang Mai, Thailand.

PATIENTS AND METHODS

Forty children with perinatal HIV infection, from early infancy to 12 years of age, were included in the study. These children were examined for oral lesions and dental caries. A number of children receiving antifungal and antiretroviral (ART) therapy were recorded.

RESULTS

The mean DMFT and DMFS scores were both 2.1 (SD = 2.3). The dft and dfs scores were 4.1 (SD = 5.0) and 10.9 (SD = 14.8), respectively. A total of 57.5% of the children had one or more oral lesions. Oral candidiasis and hairy leukoplakia were the most common oral lesions. Only 12.5% of children had received ART. A total of 22.5% of the children had a history of receiving antifungal therapy.

CONCLUSIONS

Oral lesions and dental caries were relatively high in this study. Consequently, treatment and prevention for oral lesions and dental caries are inevitably required for children with HIV infection in Northern Thailand. Furthermore, ART should be made available for all HIV-infected children to decrease the prevalence of HIV-associated oral lesions.

HIV-1 infection and AIDS

Since the initial descriptions of AIDS in the late 1970s, much has been learned about the biology of HIV-1 and the cells it infects. Much has also been learned about mother-to-infant viral transmission and the natural history of HIV-1 infection. Key studies led to strategies for interrupting mother-to-infant transmission, resulting in a significant decline in neonatal HIV-1 infection. More proficient diagnostic techniques made early diagnosis of HIV-1-infected neonates and infants possible during asymptomatic or mildly symptomatic disease stages. Major advances in treatment led to the control of viral replication and thereby altered the course of disease progression. HIV-1/AIDS-associated neurologic disorders declined in parallel. In countries where these therapies are readily available, a dramatic decline in the number of infants born HIV-1 infected has been realized as has a markedly improved survival rate of those infected. Many questions remain, however. The long-term effects of prenatal exposure to antiretroviral agents are not yet known and continue to be studied. Just exactly how HAART therapy may affect early signs of pediatric HIV-1/AIDS-associated CNS disease, should they develop, is unclear. As new anti-retroviral agents are developed and new combination drug regimens are instituted, the potential for neurologic complications, toxicities, and adverse drug interactions (e.g., with antiepileptic drugs (AEDS)) exists and needs to be identified and monitored.

The impact of expected HIV transmission rates on the effectiveness and cost of ruling out HIV infection in infants

OBJECTIVE

To quantify the costs and effectiveness of different strategies for ruling out HIV infection in infants born to HIV-infected mothers in the United States.

METHODS

The authors assessed 4 different testing strategies that incorporated serial HIV DNA polymerase chain reaction (PCR) testing with or without enzyme-linked immunosorbent assay (ELISA) antibody testing. Testing costs, false reassurance rates, and incremental cost-effectiveness ratios were compared for the 4 strategies.

RESULTS

In HIV-exposed infants, HIV DNA PCR testing at birth, 1 month, and 4 months of age results in a false reassurance rate of 21 per million (at a 2% transmission rate). Adding an ELISA test lowers the false reassurance rate to 0.052 per million at a cost of $570,000 per additional case detected; adding another PCR lowers the false reassurance rate to 1.49 per million at a cost of $720,000 per additional case detected compared with the 3-PCR strategy. At a high transmission rate (20%), there would be substantially more erroneously negative results (false reassurance rate is 256 per million with PCR testing at birth, 1 month, and 4 months) and consequently more favorable cost-effectiveness ratios with additional testing: $47,000 per additional case detected by adding 1 ELISA test and $59,000 per additional case detected by adding another PCR test.

CONCLUSIONS

False-negative HIV results after serial testing in exposed infants are rare, and the incremental cost-effectiveness ratios of additional tests are substantial at low transmission rates. However, the false reassurance rate increases considerably with a 3-PCR strategy and additional testing becomes more cost-effective at greater transmission rates; therefore, additional testing may be warranted in infants at greater risk of infection.

Health care industries' perspective of viral load assays: the VERSANT HIV-1 RNA 3.0 assay

This article will compare the VERSANT HIV-1 RNA 3.0 (bDNA 3.0) assay with other HIV-1 viral load assays, particularly the AMPLICOR HIV-1 MONITOR (Amplicor 1.5), the industry standard. The discussion will cover the history of viral load assay development and challenges to the field. It will finish with a description of the evolving markets for viral load assays in the developing world and the impact of variations in the different assays on their ability to reach those markets and patient populations.

Prevention of perinatal HIV infection

In the 20 years since the first description of the clinical manifestations of HIV infection, more than 32 million people have been infected worldwide. In untreated HIV-infected pregnant women, the risk of maternal-child transmission varies from 16 to 40%. In developed countries, utilizing combinations of available medications and elective cesarean sections, it is possible to lower the transmission rates to less than 2 to 4%. Effective programs use universal screening of pregnant women, perinatal antiretroviral therapy, and, at times, delivery via elective cesarean section. In resource-poor areas, major barriers remain to the control of maternal-child transmission.

Borna disease virus and human disease

The biology of Borna disease virus (BDV) strongly supports the likelihood of human infection with BDV or a variant of BDV. Thus far, the evidence supporting BDV infection in humans has initiated much controversy among basic and clinical scientists; only time and additional research will support or refute the hypothesis of human BDV infection. Until an assay of acceptable specificity and sensitivity has been developed, validated, and used to document human BDV infection, scientists cannot reasonably begin to associate BDV infection with specific disease syndromes. Clinical studies seeking causal associations between BDV infection and specific diseases must ensure the proper identification of the BDV infection status of patients and control subjects by using a validated, highly sensitive, and highly specific assay (or series of assays). For clinical studies, a highly sensitive "screening" test followed by a highly specific confirmatory test will be of significant benefit. Although it is possible to formulate hypotheses about the clinical outcomes of human BDV infection based on animal model work, to date no human disease has been causally linked to human BDV infection. Scientists all over the world are actively pursuing these issues, and with continuing advances in clinical and basic BDV research, the answers cannot be far away.