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Green F, du Plooy C, Rehman AM, Nhapi RT, Lake MT, Barnett W, Hoffman N, Zar HJ, Donald KA, Stein DJ, Wedderburn CJ. Language outcomes of preschool children who are HIV-exposed uninfected: An analysis of a South African cohort. PLoS One 2024; 19:e0297471. [PMID: 38598467 PMCID: PMC11006185 DOI: 10.1371/journal.pone.0297471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/05/2024] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION There are approximately 16 million children who are HIV-exposed and uninfected (CHEU) worldwide. Studies suggest that CHEU are at risk for developmental impairment in infancy, particularly in language domains. However, there is limited research examining neurocognitive function in CHEU older than 2 years, including important pre-school years. This study aimed to investigate associations between HIV exposure without infection and neurocognitive outcomes and to determine risk factors for neurodevelopment in CHEU at age 3-4 years. METHODS The Drakenstein Child Health Study is a South African population-based birth cohort which enrolled women in pregnancy with ongoing follow up. Neurocognitive outcomes were assessed in children at 3.5 years by trained assessors blinded to HIV status including general cognitive function, language, and memory, measured using the Kaufmann Assessment Battery for Children, Second Edition (KABC-II). Data were compared between CHEU and children who were HIV-unexposed uninfected (CHUU) using multivariable logistic and linear regression, including testing for effect modification; sex-stratified risk factor analyses were performed. RESULTS A total of 497 children were included (97 [20%] CHEU; 400 [80%] CHUU; 50% male), with a mean age of 3.5 years (range 3.4-3.6). Groups had similar birth and household characteristics, although mothers of CHEU were older, on average. Overall, CHEU had lower expressive language scores compared to CHUU on unadjusted and adjusted analyses (effect size: -0.23 [95% CI -0.45, -0.01]). There were no group differences in general cognitive or memory function (p>0.05). On sex-stratified analyses, male CHEU were found to have higher odds of suboptimal cognitive development compared to male CHUU (aOR 2.28 [95% CI 1.06, 4.87], p = 0.034). Several other factors including birthweight, maternal education, maternal ART duration and HIV viral load during pregnancy were associated with cognition, memory, or expressive language outcomes in CHEU, dependent on child sex. INTERPRETATION The findings suggest that perinatal HIV exposure continues to be associated with impaired language development across the preschool years, highlighting the importance of targeting early interventions to optimise language outcomes. Further, the results suggest the importance of demographic, biological and HIV-related variables influencing developmental outcomes in CHEU. The greater risk of suboptimal cognitive development in male CHEU requires investigation around sex-specific mechanisms.
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Affiliation(s)
- Freddy Green
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Christopher du Plooy
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrea M. Rehman
- MRC International Statistics & Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Raymond T. Nhapi
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Marilyn T. Lake
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council (SAMRC), Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Whitney Barnett
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Nadia Hoffman
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
| | - Heather J. Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council (SAMRC), Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Kirsten A. Donald
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Dan J. Stein
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- SAMRC, Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Catherine J. Wedderburn
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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Camacho-Pacheco RT, Hernández-Pineda J, Brito-Pérez Y, Plazola-Camacho N, Coronado-Zarco IA, Arreola-Ramírez G, Bermejo-Haro MY, Najera-Hernández MA, González-Pérez G, Herrera-Salazar A, Olmos-Ortiz A, Soriano-Becerril D, Sandoval-Montes C, Figueroa-Damian R, Rodríguez-Martínez S, Mancilla-Herrera I. Disturbances in the IgG Antibody Profile in HIV-Exposed Uninfected Infants Associated with Maternal Factors. J Immunol Res 2024; 2024:8815767. [PMID: 38375063 PMCID: PMC10876311 DOI: 10.1155/2024/8815767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 01/11/2024] [Accepted: 01/24/2024] [Indexed: 02/21/2024] Open
Abstract
Over the last 20 years, the incidence of vertical HIV transmission has decreased from 25%-42% to less than 1%. Although there are no signs of infection, the health of HIV-exposed uninfected (HEU) infants is notoriously affected during the first months of life, with opportunistic infections being the most common disease. Some studies have reported effects on the vertical transfer of antibodies, but little is known about the subclass distribution of these antibodies. We proposed to evaluate the total IgG concentration and its subclasses in HIV+ mothers and HEU pairs and to determine which maternal factors condition their levels. In this study, plasma from 69 HEU newborns, their mothers, and 71 control pairs was quantified via immunoassays for each IgG isotype. Furthermore, we followed the antibody profile of HEUs throughout the first year of life. We showed that mothers present an antibody profile characterized by high concentrations of IgG1 and IgG3 but reduced IgG2, and HEU infants are born with an IgG subclass profile similar to that of their maternal pair. Interestingly, this passively transferred profile could remain influenced even during their own antibody production in HEU infants, depending on maternal conditions such as CD4+ T-cell counts and maternal antiretroviral treatment. Our findings indicate that HEU infants exhibit an altered IgG subclass profile influenced by maternal factors, potentially contributing to their increased susceptibility to infections.
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Affiliation(s)
- Rodrigo T. Camacho-Pacheco
- Infectology and Immunology Department, National Institute of Perinatology (INPer), Mexico City, Mexico
- Departamento de Inmunología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Ciudad de México, Mexico
- Posgrado en Inmunología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Jessica Hernández-Pineda
- Infectology and Immunology Department, National Institute of Perinatology (INPer), Mexico City, Mexico
| | - Yesenia Brito-Pérez
- Infectology and Immunology Department, National Institute of Perinatology (INPer), Mexico City, Mexico
| | - Noemi Plazola-Camacho
- Infectology and Immunology Department, National Institute of Perinatology (INPer), Mexico City, Mexico
| | | | | | - Mextli Y. Bermejo-Haro
- Infectology and Immunology Department, National Institute of Perinatology (INPer), Mexico City, Mexico
- Departamento de Inmunología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Ciudad de México, Mexico
- Posgrado en Inmunología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City, Mexico
| | - M. Angel Najera-Hernández
- Infectology and Immunology Department, National Institute of Perinatology (INPer), Mexico City, Mexico
| | - Gabriela González-Pérez
- Department of Physiology and Cellular Development, National Institute of Perinatology (INPer), Mexico City, Mexico
| | - Alma Herrera-Salazar
- Unidad de Investigación Multidisciplinaria, Facultad de Estudios Superiores Cuautitlán, UNAM, Cuautitlán Izcalli, Mexico
| | - Andrea Olmos-Ortiz
- Immunobiochemistry Department, National Institute of Perinatology (INPer), Mexico City, Mexico
| | - Diana Soriano-Becerril
- Infectology and Immunology Department, National Institute of Perinatology (INPer), Mexico City, Mexico
| | - Claudia Sandoval-Montes
- Departamento de Inmunología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Ciudad de México, Mexico
| | - Ricardo Figueroa-Damian
- Infectology and Immunology Department, National Institute of Perinatology (INPer), Mexico City, Mexico
| | - Sandra Rodríguez-Martínez
- Departamento de Inmunología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Ciudad de México, Mexico
| | - Ismael Mancilla-Herrera
- Infectology and Immunology Department, National Institute of Perinatology (INPer), Mexico City, Mexico
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Wedderburn CJ, Bondar J, Lake MT, Nhapi R, Barnett W, Nicol MP, Goddard L, Zar HJ. Risk and rates of hospitalisation in young children: A prospective study of a South African birth cohort. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002754. [PMID: 38232126 PMCID: PMC10793893 DOI: 10.1371/journal.pgph.0002754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/04/2023] [Indexed: 01/19/2024]
Abstract
Children in sub-Saharan Africa (SSA) are disproportionately affected by morbidity and mortality. There is also a growing vulnerable population of children who are HIV-exposed uninfected (HEU). Understanding reasons and risk factors for early-life child hospitalisation will help optimise interventions to improve health outcomes. We investigated hospitalisations from birth to two years in a South African birth cohort study. Mother-child pairs in the Drakenstein Child Health Study were followed from birth to two years with active surveillance for hospital admission and investigation of aetiology and outcome. Incidence, duration, cause, and factors associated with child hospitalisation were investigated, and compared between HEU and HIV-unexposed uninfected (HUU) children. Of 1136 children (247 HEU; 889 HUU), 314 (28%) children were hospitalised in 430 episodes despite >98% childhood vaccination coverage. The highest hospitalisation rate was from 0-6 months, decreasing thereafter; 20% (84/430) of hospitalisations occurred in neonates at birth. Amongst hospitalisations subsequent to discharge after birth, 83% (288/346) had an infectious cause; lower respiratory tract infection (LRTI) was the most common cause (49%;169/346) with respiratory syncytial virus (RSV) responsible for 31% of LRTIs; from 0-6 months, RSV-LRTI accounted for 22% (36/164) of all-cause hospitalisations. HIV exposure was associated with increased incidence rates of hospitalisation in infants (IRR 1.63 [95% CI 1.29-2.05]) and longer hospital admission (p = 0.004). Prematurity (HR 2.82 [95% CI 2.28-3.49]), delayed infant vaccinations (HR 1.43 [95% CI 1.12-1.82]), or raised maternal HIV viral load in HEU infants were risk factors for hospitalisation; breastfeeding was protective (HR 0.69 [95% CI 0.53-0.90]). In conclusion, children in SSA experience high rates of hospitalisation in early life. Infectious causes, especially RSV-LRTI, underly most hospital admissions. HEU children are at greater risk of hospitalisation in infancy compared to HUU children. Available strategies such as promoting breastfeeding, timely vaccination, and optimising antenatal maternal HIV care should be strengthened. New interventions to prevent RSV may have additional impact in reducing hospitalisation.
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Affiliation(s)
- Catherine J. Wedderburn
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Julia Bondar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marilyn T. Lake
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Raymond Nhapi
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Whitney Barnett
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, United States of America
| | - Mark P. Nicol
- Marshall Centre, School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Liz Goddard
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Heather J. Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
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Zotova N, Munyaneza A, Murenzi G, Kubwimana G, Adedimeji A, Anastos K, Yotebieng M, Ca-IeDEA CI. Low birth weight among infants and pregnancy outcomes among women living with HIV and HIV-negative women in Rwanda. RESEARCH SQUARE 2023:rs.3.rs-3467879. [PMID: 37961121 PMCID: PMC10635363 DOI: 10.21203/rs.3.rs-3467879/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Introduction In utero exposure to HIV and/or triple antiretroviral therapy (ART) have been shown to be associated with preterm births and low birth weight (LBW), but data from low-resources settings with high burden of HIV remain limited. This study utilized retrospective data to describe pregnancy outcomes among Rwandan women living with HIV (WLHIV) and HIV-negative women and to assess the association of HIV and ART with LBW. Methods This study used data from a large cohort of WLHIV and HIV-negative women in Rwanda for a cross-sectional analysis. Retrospective data were collected from antenatal care (ANC), delivery, and Prevention of Mother to Child Transmission (PMTCT) registries within the Central Africa International Epidemiology Databases to Evaluate AIDS (CA-IeDEA) in Rwanda. Data from women with documented HIV test results and known pregnancy outcomes were included in the analysis. Analyses for predictors of LBW (< 2,500 g) were restricted to singleton live births. Logistic models were used to identify independent predictors and estimate the odd ratios (OR) and 95% confidence intervals (CI) measuring the strength of their association with LBW. Results and discussion Out of 10,608 women with known HIV status and with documented pregnancy outcomes, 9.7% (n = 1,024) were WLHIV. We restricted the sample to 10,483 women who had singleton live births for the analysis of the primary outcome, LBW. Compared with HIV-negative women, WLHIV had higher rates of stillbirth, preterm births, and LBW babies. Multivariable model showed that WLHIV and primigravidae had higher odds of LBW. Lower maternal weight and primigravidae status were associated with greater odds of LBW. Among WLHIV, the use of ART was associated with significantly lower odds of LBW in a bivariate analysis. Even in a sample of relatively healthier uncomplicated pregnancies and women who delivered in low-risk settings, WLHIV still had higher rates of poor pregnancy outcomes and to have LBW infants compared to women without HIV. Lower maternal weight and primigravidae status were independently associated with LBW. Given that supplementary nutrition to malnourished pregnant women is known to decrease the incidence of LBW, providing such supplements to lower-weight WLHIV, especially primigravidae women, might help reduce LBW.
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Affiliation(s)
| | | | - Gad Murenzi
- Research for Development (RD Rwanda) and Rwanda Military Hospital
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Wedderburn CJ, Bondar J, Lake MT, Nhapi R, Barnett W, Nicol MP, Goddard L, Zar HJ. Risk and rates of hospitalisation in young children: a prospective study of a South African birth cohort. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.08.23289961. [PMID: 37398166 PMCID: PMC10312830 DOI: 10.1101/2023.06.08.23289961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Introduction Children in sub-Saharan Africa (SSA) are disproportionately affected by morbidity and mortality; there is also a growing vulnerable population of children who are HIV-exposed uninfected (HEU). Understanding reasons and risk factors for early-life child hospitalisation will help optimise interventions to improve health outcomes. We investigated hospitalisations from birth to two years in a South African birth cohort. Methods Mother-child pairs in the Drakenstein Child Health Study were followed from birth to two years with active surveillance for hospital admission and investigation of aetiology and outcome. Incidence, duration, cause, and factors associated with child hospitalisation were investigated, and compared between HEU and HIV-unexposed uninfected (HUU) children. Results Of 1136 children (247 HEU; 889 HUU), 314 (28%) children were hospitalised in 430 episodes despite >98% childhood vaccination coverage. The highest hospitalisation rate was from 0-6 months, decreasing thereafter; 20% (84/430) of hospitalisations occurred in neonates at birth. Amongst hospitalisations subsequent to discharge after birth, 83% (288/346) had an infectious cause; lower respiratory tract infection (LRTI) was the most common cause (49%;169/346) with respiratory syncytial virus (RSV) responsible for 31% of LRTIs; from 0-6 months, RSV-LRTI accounted for 22% (36/164) of all-cause hospitalisations. HIV exposure was a risk factor for hospitalisation in infants (IRR 1.63 [95% CI 1.29-2.05]) and longer hospital admission (p=0.004). Prematurity (HR 2.82 [95% CI 2.28-3.49]), delayed infant vaccinations (1.43 [1.12-1.82]), or raised maternal HIV viral load in HEU infants were risk factors; breastfeeding was protective (0.69 [0.53-0.90]). Conclusion Children in SSA continue to experience high rates of hospitalisation in early life. Infectious causes, especially RSV-LRTI, underly most hospital admissions. HEU children are at particular risk in infancy. Available strategies such as promoting breastfeeding, timely vaccination, and optimising antenatal maternal HIV care should be strengthened. New interventions to prevent RSV may have a large additional impact in reducing hospitalisation.
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Affiliation(s)
- Catherine J Wedderburn
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, South Africa
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, UK
- Neuroscience Institute, University of Cape Town, South Africa
| | - Julia Bondar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, South Africa
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marilyn T Lake
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, South Africa
| | - Raymond Nhapi
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, South Africa
| | - Whitney Barnett
- Department of Psychology and Human Development, Vanderbilt University
| | - Mark P Nicol
- Marshall Centre, School of Biomedical Sciences, University of Western Australia, Australia
| | - Liz Goddard
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, South Africa
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, South Africa
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Abstract
Prior to widespread availability of antiretroviral therapy (ART) in sub-Saharan Africa, children who were HIV-exposed but uninfected (HEU) had increased mortality, morbidity and undernutrition compared with children who were HIV-unexposed. Scale-up of ART has led to impressive declines in vertical HIV transmission, but over 15 million children are now HEU, 90% of whom live in sub-Saharan Africa. There are ongoing health disparities among children who are HEU, with higher mortality, morbidity and stunting and modest impairments in early child development, which collectively hamper health and human capital in high prevalence countries. The underlying causes are multifactorial and include exposure to HIV, co-infections and a skewed antenatal inflammatory milieu, particularly if mothers start ART once they have advanced disease, as well as socioeconomic risk factors, which may cluster in HIV-affected households. Improving maternal health through early and sustained ART, ensuring optimal breastfeeding, and implementing evidence-based priority interventions for all children in areas of high HIV prevalence, will likely improve outcomes. A more comprehensive intervention package based on the Nurturing Care Framework may have particular benefits for children who are HEU, to close health gaps and ensure that the next generation of HIV-free children survive and thrive, and lead healthy and productive lives.
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du Toit LDV, Prinsloo A, Steel HC, Feucht U, Louw R, Rossouw TM. Immune and Metabolic Alterations in Children with Perinatal HIV Exposure. Viruses 2023; 15:v15020279. [PMID: 36851493 PMCID: PMC9966389 DOI: 10.3390/v15020279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
With the global rollout of mother-to-child prevention programs for women living with HIV, vertical transmission has been all but eliminated in many countries. However, the number of children who are exposed in utero to HIV and antiretroviral therapy (ART) is ever-increasing. These children who are HIV-exposed-but-uninfected (CHEU) are now well recognized as having persistent health disparities compared to children who are HIV-unexposed-and-uninfected (CHUU). Differences reported between these two groups include immune dysfunction and higher levels of inflammation, cognitive and metabolic abnormalities, as well as increased morbidity and mortality in CHEU. The reasons for these disparities remain largely unknown. The present review focuses on a proposed link between immunometabolic aberrations and clinical pathologies observed in the rapidly expanding CHEU population. By drawing attention, firstly, to the significance of the immune and metabolic alterations observed in these children, and secondly, the impact of their healthcare requirements, particularly in low- and middle-income countries, this review aims to sensitize healthcare workers and policymakers about the long-term risks of in utero exposure to HIV and ART.
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Affiliation(s)
- Louise D V du Toit
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
- UP Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria 0001, South Africa
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Pretoria 0001, South Africa
| | - Andrea Prinsloo
- UP Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria 0001, South Africa
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Pretoria 0001, South Africa
- Department of Hematology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Helen C Steel
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Ute Feucht
- UP Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria 0001, South Africa
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Pretoria 0001, South Africa
- Department of Pediatrics, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Roan Louw
- Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom 2520, South Africa
| | - Theresa M Rossouw
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
- UP Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria 0001, South Africa
- Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Pretoria 0001, South Africa
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Nyofane M, Hoffman M, Mulol H, Botha T, Vannevel V, Pattinson R, Feucht U. Early Childhood Growth Parameters in South African Children with Exposure to Maternal HIV Infection and Placental Insufficiency. Viruses 2022; 14:v14122745. [PMID: 36560749 PMCID: PMC9782627 DOI: 10.3390/v14122745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/24/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
Maternal HIV exposure and intrauterine growth restriction (IUGR) due to placental insufficiency both carry major risks to early child growth. We compared the growth outcomes of children aged 18 months who had abnormal umbilical artery resistance indices (UmA-RI), as a marker of placental insufficiency, with a comparator group of children with normal UmA-RI during pregnancy, as mediated by maternal HIV infection. The cross-sectional study included 271 children, grouped into four subgroups based on HIV exposure and history of normal/abnormal UmA-RI, using available pregnancy and birth information. Standard procedures were followed to collect anthropometric data, and z-scores computed as per World Health Organization growth standards. Lower length-for-age z-scores (LAZ) were observed in children who were HIV-exposed-uninfected (CHEU) (-0.71 ± 1.23; p = 0.004) and who had abnormal UmA-RI findings (-0.68 ± 1.53; p < 0.001). CHEU with abnormal UmA-RI had lower LAZ (-1.3 ± 1.3; p < 0.001) and weight-for-age z-scores (WAZ) (-0.64 ± 0.92; p = 0.014) compared to the control group. The prevalence of stunting was 40.0% in CHEU with abnormal UmA-RI and 16.0% in CHEU with normal UmA-RI (p < 0.001; p = 0.016, respectively). In conclusion, maternal HIV exposure and placental insufficiency are independent risk factors for childhood stunting, with this risk potentiated when these two risk factors overlap.
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Affiliation(s)
- Mothusi Nyofane
- Department of Consumer and Food Sciences, University of Pretoria, Pretoria 0002, South Africa
- Department of Nutrition, National University of Lesotho, Maseru 100, Lesotho
- Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Kalafong Provincial Tertiary Hospital, Pretoria 0001, South Africa
- Research Unit for Maternal and Infant Health Care Strategies, South African Medical Research Council, Pretoria 0001, South Africa
- Correspondence: ; Tel.: +266-5775-1718
| | - Marinel Hoffman
- Department of Consumer and Food Sciences, University of Pretoria, Pretoria 0002, South Africa
- Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Kalafong Provincial Tertiary Hospital, Pretoria 0001, South Africa
- Research Unit for Maternal and Infant Health Care Strategies, South African Medical Research Council, Pretoria 0001, South Africa
| | - Helen Mulol
- Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Kalafong Provincial Tertiary Hospital, Pretoria 0001, South Africa
- Research Unit for Maternal and Infant Health Care Strategies, South African Medical Research Council, Pretoria 0001, South Africa
- Department of Paediatrics, University of Pretoria, Pretoria 0002, South Africa
| | - Tanita Botha
- Department of Statistics, University of Pretoria, Pretoria 0002, South Africa
| | - Valerie Vannevel
- Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Kalafong Provincial Tertiary Hospital, Pretoria 0001, South Africa
- Research Unit for Maternal and Infant Health Care Strategies, South African Medical Research Council, Pretoria 0001, South Africa
- Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria 0002, South Africa
| | - Robert Pattinson
- Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Kalafong Provincial Tertiary Hospital, Pretoria 0001, South Africa
- Research Unit for Maternal and Infant Health Care Strategies, South African Medical Research Council, Pretoria 0001, South Africa
- Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria 0002, South Africa
| | - Ute Feucht
- Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Kalafong Provincial Tertiary Hospital, Pretoria 0001, South Africa
- Research Unit for Maternal and Infant Health Care Strategies, South African Medical Research Council, Pretoria 0001, South Africa
- Department of Paediatrics, University of Pretoria, Pretoria 0002, South Africa
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9
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Millar AJW, Cox SG. Surgical implications of HIV infection. Pediatr Surg Int 2022; 39:39. [PMID: 36482099 DOI: 10.1007/s00383-022-05333-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
According to the joint United Nations Programme on HIV/AIDS (UNAIDS), 37.7 million adults and children worldwide were estimated to be living with HIV or acquired immune deficiency syndrome (AIDS) at the end of 2020 [UNAIDS. (2022). http://www.unaids.org . Accessed 30 May 2022]. Most reside in low- and middle-income countries, with approximately 67% in sub-Saharan Africa (SSA). At the end of 2020, the total number of children less than 15 years of age living with HIV infection was 2.6 million, of whom 2.3 million (88%) were living in SSA. Aggressive interventions have reduced the annual number of incident (new) HIV infections among children to around 150,000 [UNAIDS. (2022). http://www.unaids.org . Accessed 30 May 2022]. However, paediatric HIV infection remains a pandemic affecting children predominantly in SSA but is also seen in Asia and sporadically elsewhere particularly in areas of civil strife such as is currently the case in Ukraine [War in Ukraine. (2022). https://www.unaids.org/en/War-Ukraine-special . Accessed Apr 2022]. New HIV infections among children declined by more than half (54%) from 2010 to 2020, due mainly to the increased provision of antiretroviral therapy to pregnant and breastfeeding women living with HIV [UNAIDS. (2022). http://www.unaids.org . Accessed 30 May 2022]. These programmes include early identification of HIV infection in pregnant or breastfeeding women through routine HIV testing, provision of antiretroviral therapy (ART) to all HIV-infected women who are pregnant or breastfeeding, provision of antiretroviral prophylaxis to their newborn infants during the first 6-12 weeks of life, delivery by elective Caesarean section when indicated, promotion of exclusive breastfeeding, early infancy screening for HIV infection, and initiation of ART in infants with HIV infection. HIV-infected children may require surgery either as an emergency to deal with a life-threatening incidental condition unrelated to HIV infection or for a complication of the disease such as tuberculosis or an aggressive soft tissue infection like necrotising fasciitis. Non-emergency surgical procedures may be required to assist in the diagnosis of an HIV-related condition or to correct a routine surgical problem electively. Surgical conditions associated with HIV infection are described under categories of soft tissue or organ-specific infections requiring drainage or debridement; gastrointestinal tract disease and complications; infections in the perineal area; malignancies and HIV-associated vasculitis. Although surgical outcomes are less favourable in HIV-infected children, pre-operative treatment of coinfections, administration of cotrimoxazole prophylaxis, nutritional support and antiretroviral therapy, together with peri-operative antibiotic prophylaxis have resulted in excellent short-term outcomes [World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach, June 201 http://www.apps.who.int/iris/bitstream/10665/85321/1/9789241505727_eng.pdf?ua=1 ; World Health Organization Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV, September 2015. http://www.apps.who.int/iris/bitstream/10665/186275/1/9789241509565_eng.pdf?ua=1;Eley et al. in BMC Infect Dis 2:3, 2002;Karpelowsky et al. in Pediatr Surg Int 28:1007-1014, 2012;].
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Affiliation(s)
- Alastair J W Millar
- Health Sciences Faculty, University of Cape Town and Red Cross War Memorial Children's Hospital, Rondebosch, 7700, Cape Town, South Africa.
| | - Sharon G Cox
- University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Evolution of the Gut Microbiome in HIV-Exposed Uninfected and Unexposed Infants during the First Year of Life. mBio 2022; 13:e0122922. [PMID: 36073815 PMCID: PMC9600264 DOI: 10.1128/mbio.01229-22] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
HIV-exposed uninfected infants (HEU) have abnormal immunologic functions and increased infectious morbidity in the first 6 months of life, which gradually decreases thereafter. The mechanisms underlying HEU immune dysfunctions are unknown. We hypothesized that unique characteristics of the HEU gut microbiota associated with maternal HIV status may underlie the HEU immunologic dysfunctions. We characterized the infant gut, maternal gut, and breast milk microbiomes of mother-infant pairs, including 123 with HEU and 117 with HIV-uninfected infants (HUU), from South Africa. Pan-bacterial 16S rRNA gene sequencing was performed on (i) infant stool at 6, 28, and 62 weeks; (ii) maternal stool at delivery and 62 weeks; and (iii) breast milk at 6 weeks. Infant gut alpha and beta diversities were similar between groups. Microbial composition significantly differed, including 12 genera, 5 families and 1 phylum at 6 weeks; 12 genera and 2 families at 28 weeks; and 2 genera and 2 families at 62 weeks of life. Maternal gut microbiomes significantly differed in beta diversity and microbial composition, and breast milk microbiomes differed in microbial composition only. Infant gut microbiotas extensively overlapped with maternal gut and minimally with breast milk microbiotas. Nevertheless, exclusively breastfed HEU and HUU had less divergent microbiomes than nonexclusively breastfed infants. Feeding pattern and maternal gut microbiome imprint the HEU gut microbiome. Compared to HUU, the HEU gut microbiome prominently differs in early infancy, including increased abundance of taxa previously observed to be present in excess in adults with HIV. The HEU and HUU gut microbiome compositions converge over time, mirroring the kinetics of HEU infectious morbidity risk.
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11
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Jalbert E, Ghosh T, Smith C, Amaral FR, Mussi-Pinhata MM, Weinberg A. Impaired functionality of antigen presenting cells in HIV- exposed uninfected infants in the first six months of life. Front Immunol 2022; 13:960313. [PMID: 36032106 PMCID: PMC9411519 DOI: 10.3389/fimmu.2022.960313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
HIV-exposed uninfected infants (HEU) have increased morbidity and mortality due to infections in the first 6 months of life that tapers down to 2 years of life. The underlying immunologic defects remain undefined. We investigated antigen-presenting cells (APC) by comparing the phenotype of unstimulated APC, responses to toll-like receptor (TLR) stimulation, and ability to activate natural killer (NK) cells in 24 HEU and 64 HIV-unexposed infants (HUU) at 1-2 days of life (birth) and 28 HEU and 45 HUU at 6 months of life. At birth, unstimulated APC showed higher levels of activation and cytokine production in HEU than HUU and stimulation with TLR agonists revealed lower expression of inflammatory cytokines and activation markers, but similar expression of IL10 regulatory cytokine, in APC from HEU compared to HUU. Differences were still present at 6 months of life. From birth to 6 months, APC underwent extensive phenotypic and functional changes in HUU and minimal changes in HEU. TLR stimulation also generated lower NK cell expression of CD69 and/or IFNγ in HEU compared with HUU at birth and 6 months. In vitro experiments showed that NK IFNγ expression depended on APC cytokine secretion in response to TLR stimulation. Ex vivo IL10 supplementation decreased APC-mediated NK cell activation measured by IFNγ expression. We conclude that APC maturation was stunted or delayed in the first 6 months of life in HEU compared with HUU. Deficient inflammatory APC responses and/or the imbalance between inflammatory and regulatory responses in HEU may play an important role in their increased susceptibility to severe infections.
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Affiliation(s)
- Emilie Jalbert
- Department of Pediatrics, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, United States
| | - Tusharkanti Ghosh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, United States
| | - Christiana Smith
- Department of Pediatrics, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, United States
| | - Fabiana R. Amaral
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marisa M. Mussi-Pinhata
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Adriana Weinberg
- Department of Pediatrics, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, United States
- Department of Medicine and Pathology, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, United States
- *Correspondence: Adriana Weinberg,
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12
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Malaba TR, Myer L, Gray C, Newell ML. Cohort profile: Prematurity Immunology in Mothers living with HIV and their infants Study (PIMS). BMJ Open 2021; 11:e047133. [PMID: 34593488 PMCID: PMC8487191 DOI: 10.1136/bmjopen-2020-047133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 08/25/2021] [Indexed: 01/16/2023] Open
Abstract
PURPOSE Prematurity Immunology in Mothers living with HIV and their infants Study (PIMS) is a prospective cohort study in South Africa investigating the association between antiretroviral therapy (ART) use, preterm delivery (PTD) and small-for-gestational age (SGA) live births. PIMS main hypotheses are that ART initiation in pregnancy and ART-induced hypertension are associated with PTD and SGA respectively and that reconstitution of cellular immune responses in women on ART from before pregnancy results in increases in PTD of GA infants. PARTICIPANTS Pregnant women (n=3972) aged ≥18 years regardless of HIV status recruited from 2015 to 2016 into the overall PIMS cohort (2517 HIV-negative, 1455 living with HIV). A nested cohort contained 551 women living with HIV who were ≤24 weeks' GA on ultrasound: 261 initiated ART before pregnancy, 290 initiated during the pregnancy. FINDINGS TO DATE Women in the overall cohort were followed antenatally through to delivery using routine clinical records; further women in the nested cohort were actively followed up until 12 months post partum, with data collected on maternal health (HIV care and ART use, clinical care and intercurrent clinical history). Other procedures conducted on the nested cohort included physical examinations (anthropometry, blood pressure measurement), assessment of fetal growth (ultrasound), maternal and infant phlebotomy for storage of plasma, RNA and peripheral blood mononuclear cells, collection of delivery specimens (placenta and cord blood) and infant 12-month developmental assessment. Preliminary findings have contributed to our understanding of risk factors for adverse birth outcomes, and the relationship between pregnancy immunology, HIV/ART and adverse birth outcomes. FUTURE PLANS Using specimens collected from study participants living with HIV throughout pregnancy and first year of life, the PIMS provides a valuable platform for answering a variety of research questions focused on temporal changes of immunology markers in women whose immune status is altered by HIV infection, and how ART initiated during the pregnancy affects immune responses. The relationship between these immunological changes with adverse birth outcomes as well as possible longer-term impact of exposure to ART in fetal and early life will be explored. Additionally, further active and passive follow-up of mothers and their infants is planned at school-going age and beyond to chart growth, morbidity and development, as well as changes in family circumstances.
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Affiliation(s)
- Thokozile R Malaba
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town Faculty of Health Sciences, Observatory, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town Faculty of Health Sciences, Observatory, South Africa
| | - Clive Gray
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine and Department of Pathology, University of Cape Town Faculty of Health Sciences, Observatory, South Africa
| | - Marie-Louise Newell
- Institute for Developmental Science, University of Southampton Faculty of Medicine, Southampton, UK
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Chudnovets A, Liu J, Narasimhan H, Liu Y, Burd I. Role of Inflammation in Virus Pathogenesis during Pregnancy. J Virol 2020; 95:e01381-19. [PMID: 33115865 PMCID: PMC7944452 DOI: 10.1128/jvi.01381-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Viral infections during pregnancy lead to a spectrum of maternal and fetal outcomes, ranging from asymptomatic disease to more critical conditions presenting with severe maternal morbidity, stillbirth, preterm birth, intrauterine growth restriction, and fetal congenital anomalies, either apparent at birth or later in life. In this article, we review the pathogenesis of several viral infections that are particularly relevant in the context of pregnancy and intrauterine inflammation. Understanding the diverse mechanisms employed by viral pathogens as well as the repertoire of immune responses induced in the mother may help to establish novel therapeutic options to attenuate changes in the maternal-fetal interface and prevent adverse pregnancy outcomes.
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Affiliation(s)
- Anna Chudnovets
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jin Liu
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Harish Narasimhan
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yang Liu
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Irina Burd
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Mackay CA, Smit JS, Khan F, Dessai F, Connolly C, Masekela R. Umbilical cord interleukin-6 predicts outcome in very low birthweight infants in a high HIV-burden setting: a prospective cohort study. Arch Dis Child 2020; 105:932-937. [PMID: 32404441 DOI: 10.1136/archdischild-2019-318665] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/13/2020] [Accepted: 04/04/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES South Africa has a double burden of high neonatal mortality and maternal HIV prevalence. Common to both is a proinflammatory in utero and perinatal milieu. The aim of this study was to determine cytokine profiles in HIV exposed (HE) and HIV unexposed (HU) very low birthweight (VLBW) infants and to determine whether these were associated with predischarge outcomes. DESIGN Single-centre, prospective cohort study conducted from 1 June 2017 to 31 January 2019. PATIENTS Inborn infants with birth weight of <1500 g were enrolled and cord blood was collected for interleukin (IL)-6 and tumour necrosis factor alpha (TNF-α) assays. Participants provided informed consent and ethics approval was obtained. OUTCOME MEASURES The primary outcome was umbilical cord cytokine levels according to maternal HIV status. Secondary outcomes included death and/or serious neonatal infection, necrotising enterocolitis, intraventricular haemorrhage, periventricular leucomalacia, chronic lung disease and haemodynamically significant patent ductus arteriosus before discharge. RESULTS A total of 279 cases were included with 269 cytokine assays performed on 122 HEs and 147 HUs. Median IL-6 levels were 53.0 pg/mL in HEs and 21.0 pg/mL in HUs (p=0.07). Median TNF-α levels were 7.2 pg/mL in HEs and 6.5 pg/mL in HUs (p=0.6). There was significantly more late-onset sepsis in the HE group compared with the HU group (41.2% vs 27.9%) (p=0.03). IL-6 levels were significantly higher for those with any adverse outcome (p=0.006) and death and/or any adverse outcome (p=0.0001). TNF-α levels did not differ according to predischarge outcomes. CONCLUSION There is no significant difference in IL-6 and TNF-α levels in cord blood of HE compared with HU VLBWs. However, IL-6 levels are significantly higher in VLBWs with adverse predischarge outcomes, and VLBW HEs are at increased risk of adverse predischarge outcomes compared with HUs, particularly late-onset sepsis.
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Affiliation(s)
- Cheryl Anne Mackay
- Paediatrics Department, Dora Nginza Hospital, Port Elizabeth, South Africa
| | - James Stephanus Smit
- Paediatrics Department, Dora Nginza Hospital, Port Elizabeth, Eastern Cape, South Africa
| | - Farhaad Khan
- Paediatrics Department, Dora Nginza Hospital, Port Elizabeth, Eastern Cape, South Africa
| | - Fazana Dessai
- University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | | | - Refiloe Masekela
- Paediatrics and Child Health, University of KwaZulu-Natal College of Health Sciences, Durban, South Africa
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Effect of co-trimoxazole prophylaxis on morbidity and mortality of HIV-exposed, HIV-uninfected infants in South Africa: a randomised controlled, non-inferiority trial. LANCET GLOBAL HEALTH 2020; 7:e1717-e1727. [PMID: 31708152 DOI: 10.1016/s2214-109x(19)30422-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/15/2019] [Accepted: 09/19/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND WHO guidelines recommend co-trimoxazole prophylaxis for HIV-exposed, HIV-uninfected infants. These guidelines date back to an era in which HIV testing of infants was impossible and mothers had poor access to antiretroviral treatment. To determine whether this guideline requires revision in the current era of effective prevention of mother-to-child transmission and early infant diagnosis programmes, we aimed to investigate whether receiving no co-trimoxazole prophylaxis is inferior to receiving co-trimoxazole prophylaxis in the resulting incidence of grade 3 or 4 common childhood illnesses or mortality in breastfed HIV-exposed, HIV-uninfected infants. METHODS We investigated our aim in a randomised controlled, non-inferiority trial. We enrolled the HIV-negative infants of mothers living with HIV who were actively involved in transmission prevention programmes in two clinics in Durban, South Africa. Infants were included in the study if they were breastfeeding at the screening and enrolment visits, and their mother was planning to breastfeed for at least 6 months; were a singleton birth and had a birthweight of 2 kg or more; had no clinically observed genetic disorders; and had no serious illnesses and had not received antibiotics or traditional medications (such as herbal remedies). Infants were randomly assigned (1:1) to receive co-trimoxazole or no co-trimoxazole. In the co-trimoxazole group, infants received the drug until all exposure to HIV had ceased (ie, 6 weeks after last exposure to breastmilk) and the infant was confirmed to be uninfected with HIV. The drug was administered by mothers in once-daily regimens of 20 mg trimethoprim and 100 mg sulfamethoxazole orally (age <6 months or bodyweight <5 kg), or 40 mg trimethoprim and 200 mg sulfamethoxazole orally (age >6 months or bodyweight >5 kg). Clinical and laboratory staff always remained masked to group assignment, but mothers and study counsellors were not. Infants and their mothers attended study visits at ages 6 weeks (for enrolment and randomisation), 10 weeks, 14 weeks, and then monthly from 4 to 12 months. Our primary outcome was the incidence of grade 3 or 4 common childhood illnesses (pneumonia or diarrhoea) or mortality in breastfed HIV-exposed, HIV-uninfected infants by age 12 months. A non-inferiority bound of 5% was used. The study is registered with the Pan African Clinical Trials Registry, number PACTR201311000621110, and the South African National Clinical Trials Registry, number DOH-27-0614-4728. FINDINGS We screened 1570 mother-child pairs for study enrolment, from whom (78%) eligible infants were enrolled into the study between Oct 16, 2013, and May 23, 2018. Of the infants enrolled, 611 (50%) were randomly assigned to the co-trimoxazole group and 609 (50%) were randomly assigned to the no co-trimoxazole group. One (<1%) infant in the no co-trimoxazole group was excluded from the analysis of the final outcomes for having received traditional medicine (which only became apparent after randomisation); therefore, 611 (50%) infants in the co-trimoxazole group and 608 (50%) infants in the no co-trimoxazole group were included in the final intention-to-treat analysis. 136 (22%) infants in the co-trimoxazole group and 139 (23%) infants in the no co-trimoxazole group did not complete the 12-month study visit, predominantly because of loss to follow-up (93 [15%] infants in the co-trimoxazole group; 90 [15%] infants in the no co-trimoxazole group). The cumulative probability of the composite primary outcome was 0·114 (95% CI 0·076 to 0·147; 49 events) in the co-trimoxazole group versus 0·0795 (0·044 to 0·115; 39 events) in the no co-trimoxazole group. The risk difference (no co-trimoxazole group minus co-trimoxazole group) was -0·0319 (-0·075 to 0·011), meaning that the risk was around 3 percentage points lower in the no co-trimoxazole group on the additive scale. INTERPRETATION We can conclude that no co-trimoxazole is not inferior to daily co-trimoxazole among breastfed HIV-exposed, HIV-uninfected infants whose mothers are accessing a prevention of mother-to-child transmission programme in an area unaffected by malaria. We therefore believe that WHO should revise the co-trimoxazole guidelines for HIV-exposed, HIV-uninfected infants in areas unaffected by malaria. FUNDING HIV Prevention Research Unit of the South African Medical Research Council and the Family Larsson-Rosenquist Foundation.
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Goetghebuer T, Smolen KK, Adler C, Das J, McBride T, Smits G, Lecomte S, Haelterman E, Barlow P, Piedra PA, van der Klis F, Kollmann TR, Lauffenburger DA, Alter G, Levy J, Marchant A. Initiation of Antiretroviral Therapy Before Pregnancy Reduces the Risk of Infection-related Hospitalization in Human Immunodeficiency Virus-exposed Uninfected Infants Born in a High-income Country. Clin Infect Dis 2020; 68:1193-1203. [PMID: 30215689 DOI: 10.1093/cid/ciy673] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 08/10/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Epidemiological studies conducted in low- and high-income countries showed that infants exposed to maternal human immunodeficiency virus (HIV) have a high risk of severe infections. Immune alterations during fetal life have been proposed as a possible mechanism. METHODS This prospective study assessed the relative risk of hospitalization for infection in HIV-exposed uninfected (HEU) infants as compared to HIV-unexposed (HU) infants born in a high-income country (HIC). Markers of monocyte activation and levels of pathogen-specific antibodies were measured at birth to identify correlates of infant susceptibility. RESULTS There were 27 of 132 HEU infants and 14 of 123 HU infants hospitalized for infection during the first year of life (adjusted hazard ratio [aHR] 2.33, 95% confidence interval [CI] 1.10-4.97). Most of this increased risk was associated with the time of initiation of maternal antiretroviral therapy (ART). As compared to HU infants, the risk of hospitalization for infection of HEU infants was 4-fold higher when mothers initiated ART during pregnancy (aHR 3.84, 95% CI 1.69-8.71) and was not significantly increased when ART was initiated before pregnancy (aHR 1.42, 95% CI 0.58-3.48). The activation of newborn monocytes and the reduced transfer of maternal antibodies were most intense following ART initiation during pregnancy, and predicted the risk of infant hospitalization. CONCLUSIONS These observations indicate that initiation of maternal ART before pregnancy reduces the susceptibility of HEU infants born in a HIC to severe infections, and that this effect could be related to the prevention of immune alterations during fetal life.
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Affiliation(s)
| | - Kinga K Smolen
- Institute for Medical Immunology, Université libre de Bruxelles, Charleroi, Belgium
| | | | - Jishnu Das
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts.,Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Trevor McBride
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - Gaby Smits
- National Institute of Health and the Environment, Bilthoven, The Netherlands
| | - Sandra Lecomte
- Institute for Medical Immunology, Université libre de Bruxelles, Charleroi, Belgium
| | | | - Patricia Barlow
- Department of Obstetrics and Gynecology, Hôpital Saint-Pierre, Brussels, Belgium
| | - Pedro A Piedra
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Fiona van der Klis
- National Institute of Health and the Environment, Bilthoven, The Netherlands
| | - Tobias R Kollmann
- Division of Infectious Diseases, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Douglas A Lauffenburger
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Galit Alter
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts
| | - Jack Levy
- Department of Pediatrics, Hôpital Saint-Pierre, Brussels
| | - Arnaud Marchant
- Institute for Medical Immunology, Université libre de Bruxelles, Charleroi, Belgium
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Arsić Arsenijevic V, Vyzantiadis TA, Mares M, Otasevic S, Tragiannidis A, Janic D. Diagnosis of Pneumocystis jirovecii Pneumonia in Pediatric Patients in Serbia, Greece, and Romania. Current Status and Challenges for Collaboration. J Fungi (Basel) 2020; 6:jof6020049. [PMID: 32316676 PMCID: PMC7345889 DOI: 10.3390/jof6020049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/27/2022] Open
Abstract
Pneumocystis jirovecii can cause fatal Pneumocystis pneumonia (PcP). Many children have been exposed to the fungus and are colonized in early age, while some individuals at high risk for fungal infections may develop PcP, a disease that is difficult to diagnose. Insufficient laboratory availability, lack of knowledge, and local epidemiology gaps make the problem more serious. Traditionally, the diagnosis is based on microscopic visualization of Pneumocystis in respiratory specimens. The molecular diagnosis is important but not widely used. The aim of this study was to collect initial indicative data from Serbia, Greece, and Romania concerning pediatric patients with suspected PcP in order to: find the key underlying diseases, determine current clinical and laboratory practices, and try to propose an integrative future molecular perspective based on regional collaboration. Data were collected by the search of literature and the use of an online questionnaire, filled by relevant scientists specialized in the field. All three countries presented similar clinical practices in terms of PcP prophylaxis and clinical suspicion. In Serbia and Greece the hematology/oncology diseases are the main risks, while in Romania HIV infection is an additional risk. Molecular diagnosis is available only in Greece. PcP seems to be under-diagnosed and regional collaboration in the field of laboratory diagnosis with an emphasis on molecular approaches may help to cover the gaps and improve the practices.
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Affiliation(s)
- Valentina Arsić Arsenijevic
- National Reference Laboratory for Medical Mycology, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Correspondence: ; Tel.: +381-63-327-564
| | - Timoleon-Achilleas Vyzantiadis
- First Department of Microbiology, School of Medicine, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Mihai Mares
- Laboratory of Antimicrobial Chemotherapy, Ion Ionescu de la Brad University, 700490 Iasi, Romania;
| | - Suzana Otasevic
- Department of Microbiology & Public Health Institute Clinical Center of Nis, Faculty of Medicine, University of Nis, 18000 Nis, Serbia;
| | - Athanasios Tragiannidis
- Haematology Oncology Unit, Second Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Dragana Janic
- Institute for Oncology and Radiology of Serbia, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
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Wedderburn CJ, Evans C, Yeung S, Gibb DM, Donald KA, Prendergast AJ. Growth and Neurodevelopment of HIV-Exposed Uninfected Children: a Conceptual Framework. Curr HIV/AIDS Rep 2019; 16:501-513. [PMID: 31732866 PMCID: PMC6920255 DOI: 10.1007/s11904-019-00459-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW The population of HIV-exposed uninfected (HEU) children is expanding rapidly, and over one million HEU infants are born each year globally. Several recent studies have reported that HEU children, particularly in low- and middle-income countries, are at risk of poor outcomes, including impaired growth and neurodevelopment. However, the reasons for poor clinical outcomes amongst HEU children remain unclear. RECENT FINDINGS We summarise the findings from recent large studies that have characterised growth and neurodevelopment in HEU children, identified risk factors and explored underlying mechanistic pathways. We propose a conceptual framework to explain how exposure to HIV and antiretroviral therapy (ART) may lead to adverse growth and neurodevelopment in uninfected children, and review the available evidence and research gaps. We propose that HEU children are affected both indirectly, through the augmentation of universal risk factors underlying poor growth and neurodevelopment, and directly through HIV/ART-specific pathways, which ultimately may converge through a series of common pathogenic mechanisms. In the era of universal ART, a better understanding of these pathways is crucial to inform future prevention and intervention strategies.
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Affiliation(s)
- Catherine J Wedderburn
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Ceri Evans
- Blizard Institute, Queen Mary University of London, London, UK.
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.
| | - Shunmay Yeung
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit, University College London, London, UK
| | - Kirsten A Donald
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London, UK
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
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19
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Siawaya ACM, Mveang-Nzoghe A, Mpega CNM, Leboueny M, Ndjindji OM, Ndong AM, Essone PN, Siawaya JFD. Increased platelets count in HIV-1 uninfected infants born from HIV-1 infected mothers. Hematol Rep 2019; 11:7056. [PMID: 31583065 PMCID: PMC6775485 DOI: 10.4081/hr.2019.7056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 06/06/2017] [Indexed: 12/03/2022] Open
Abstract
HIV-exposed uninfected infants (HEU) represent a growing population in developing countries including Gabon. Several studies have shown the vulnerability of these infants toward infectious diseases. The aim of the study was to contribute to the global effort to understand how HIVexposure or anti retroviral therapy affects infants’ blood elements. We assessed HEU infants’ complete blood count using a blood analyzer instrument. Our investigations showed that among the observed clinically relevant hematological abnormalities events, thrombocytosis was the most prevalent clinically relevant hematological abnormality associated with HEU infants’. We showed that HEU infants had significantly higher platelets count than HUinfants. Therefore, higher level of platelets seems to characterize HEU infants when compared to HU infants.
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Affiliation(s)
| | - Amandine Mveang-Nzoghe
- Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique, Libreville, Gabon
| | - Chérone Nancy Mbani Mpega
- Département de Chimie, Faculté des Sciences, Université des Sciences et Techniques de Masuku, Franceville, Gabon
| | - Marielle Leboueny
- Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique, Libreville, Gabon
| | - Ofilia Mvoundza Ndjindji
- Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique, Libreville, Gabon
| | - Armel Mintsa Ndong
- Unité de Virologie, Laboratoire National de Santé Publique, Libreville, Gabon
| | - Paulin N Essone
- Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique, Libreville, Gabon.,Division of Immunology, Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Science, University of Cape Town, South Africa
| | - Joel Fleury Djoba Siawaya
- Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique, Libreville, Gabon
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20
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Cassidy AR, Williams PL, Leidner J, Mayondi G, Ajibola G, Makhema J, Holding PA, Powis KM, Batlang O, Petlo C, Shapiro R, Kammerer B, Lockman S. In Utero Efavirenz Exposure and Neurodevelopmental Outcomes in HIV-exposed Uninfected Children in Botswana. Pediatr Infect Dis J 2019; 38:828-834. [PMID: 30985518 PMCID: PMC6629483 DOI: 10.1097/inf.0000000000002332] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Minimal data exist related to neurodevelopment after in utero exposure to Efavirenz (EFV). We sought to compare neurodevelopmental outcomes in HIV-exposed/uninfected (HEU) children with in utero exposure to EFV-based triple antiretroviral treatment (ART) versus non-EFV-based ART, and to examine whether timing of initial EFV exposure is associated with neurodevelopment deficits. METHODS Women living with HIV who had received EFV-based ART during pregnancy and whose HEU newborn participated in a prior study were reconsented for their HEU toddler to undergo neurodevelopmental testing at 24 months old. We administered the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III), Developmental Milestones Checklist (DMC) and Profile of Social Emotional Development (PSED). We compared outcomes to previously-collected data from a cohort of 24-month-old HEU children with in utero exposure to non-EFV-based ART. Adjusted general linear models were used to compare mean outcomes. RESULTS Our analysis included 493 HEU children (126 EFV-exposed, 367 EFV-unexposed). Adjusted mean scores for the EFV-exposed group were worse than the EFV-unexposed group on BSID-III Receptive Language (adjusted means = 21.5 vs. 22.5, P = 0.05), DMC Locomotor (30.7 vs. 32.0, P < 0.01) and Fine Motor scales (17.8 vs. 19.2, P < 0.01); and PSED (11.7 vs. 9.9, P = 0.02); but better on the DMC Language scale (17.6 vs. 16.5, P = 0.01). Earlier (vs. later) EFV exposure was associated with worse scores on the BSID-III Receptive Language scale (20.7 vs. 22.2, P = 0.02). CONCLUSIONS HEU children exposed in utero to EFV-based ART may be at higher risk for neurodevelopmental and social-emotional deficits than HEU children exposed to non-EFV-based ART.
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Affiliation(s)
- Adam R. Cassidy
- Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | - Gloria Mayondi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Kathleen M. Powis
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Massachusetts General Hospital, Boston, MA, USA
| | - Oganne Batlang
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Chipo Petlo
- Ministry of Health and Wellness, Gaborone, Botswana
| | - Roger Shapiro
- Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Betsy Kammerer
- Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Shahin Lockman
- Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA, USA
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21
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Chen JC, Zhang Y, Rongkavilit C, Wang B, Huang XM, Nong Z, Liu J, Zeng D, McGrath E. Growth of HIV-Exposed Infants in Southwest China: A Comparative Study. Glob Pediatr Health 2019; 6:2333794X19854964. [PMID: 31236432 PMCID: PMC6572890 DOI: 10.1177/2333794x19854964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/02/2019] [Accepted: 05/10/2019] [Indexed: 11/25/2022] Open
Abstract
Objectives. Prevention of mother-to-child HIV transmission has been globally successful leading to a decline in HIV-infected infants. Thus, the number of HIV-exposed, but uninfected, infants is increasing. As growth is an important indicator of child health, this study aimed to evaluate growth parameters of HIV-exposed Chinese infants. Methods. A prospective study was conducted among HIV-exposed (HIV-infected and uninfected) infants born during 2007 to 2015 in Liuzhou, China. Their weight and length were assessed longitudinally from birth to 18 months of age and compared with HIV-unexposed, uninfected (HUU) infants from the same region. Results. There were 467 HIV-exposed infants. Four percent of infants were HIV-infected. The mean weight-for-age (WAZ) and length-for-age (LAZ) z scores of HIV-infected infants were significantly lower than those of HIV-exposed but uninfected (HEU) infants during 9 to 18 months and 12 to 18 months of age, respectively. Additionally, the mean WAZ and LAZ scores of HIV-infected infants were significantly lower than HUU infants during the first 12 months and 18 months of life, respectively. The mean WAZ and LAZ scores of HEU infants were significantly lower than HUU infants during the first 12 months and 6 months of life, respectively. HEU infants also had a lower mean weight-for-length z score than HUU infants during the first 6 months. Conclusion. We demonstrated poor growth among HIV-exposed Chinese infants, including HIV-uninfected, compared with HUU infants. The results emphasize the need for nutritional monitoring and interventions for HIV-exposed infants regardless of HIV infection status. Research is needed on long-term growth trajectories and factors affecting growth of HIV-exposed infants in China.
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Affiliation(s)
- Ji-Chang Chen
- Liuzhou Maternal and Child Healthcare Hospital, Liuzhou, China
| | - Yu Zhang
- Liuzhou Maternal and Child Healthcare Hospital, Liuzhou, China
| | | | - Bo Wang
- University of Massachusetts System, Boston, MA, USA
| | - Xue-Mei Huang
- Liuzhou Maternal and Child Healthcare Hospital, Liuzhou, China
| | - Zheng Nong
- Liuzhou Maternal and Child Healthcare Hospital, Liuzhou, China
| | - Jing Liu
- Liuzhou Maternal and Child Healthcare Hospital, Liuzhou, China
| | - Dingyuan Zeng
- Liuzhou Maternal and Child Healthcare Hospital, Liuzhou, China
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22
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Martinez DR, Fong Y, Li SH, Yang F, Jennewein MF, Weiner JA, Harrell EA, Mangold JF, Goswami R, Seage GR, Alter G, Ackerman ME, Peng X, Fouda GG, Permar SR. Fc Characteristics Mediate Selective Placental Transfer of IgG in HIV-Infected Women. Cell 2019; 178:190-201.e11. [PMID: 31204101 DOI: 10.1016/j.cell.2019.05.046] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/11/2019] [Accepted: 05/22/2019] [Indexed: 10/26/2022]
Abstract
The placental transfer of maternal IgG is critical for infant protection against infectious pathogens. However, factors that modulate the placental transfer of IgG remain largely undefined. HIV-infected women have impaired placental IgG transfer, presenting a unique "disruption model" to define factors that modulate placental IgG transfer. We measured the placental transfer efficiency of maternal HIV and pathogen-specific IgG in US and Malawian HIV-infected mothers and their HIV-exposed uninfected and infected infants. We examined the role of maternal HIV disease progression, infant factors, placental Fc receptor expression, IgG subclass, and glycan signatures and their association with placental IgG transfer efficiency. Maternal IgG characteristics, such as binding to placentally expressed Fc receptors FcγRIIa and FcγRIIIa, and Fc region glycan profiles were associated with placental IgG transfer efficiency. Our findings suggest that Fc region characteristics modulate the selective placental transfer of IgG, with implications for maternal vaccine design and infant health.
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Affiliation(s)
- David R Martinez
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC 27710, USA; Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710, USA
| | - Youyi Fong
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Shuk Hang Li
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710, USA
| | - Fang Yang
- Department of Molecular Biomedical Sciences, North Carolina State University College of Veterinary Medicine, Raleigh, NC 27607, USA
| | - Madeleine F Jennewein
- Ragon Institute of the Massachusetts General Hospital, MIT and Harvard, Cambridge, MA 02139, USA
| | - Joshua A Weiner
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755, USA
| | - Erin A Harrell
- Department of Molecular Biomedical Sciences, North Carolina State University College of Veterinary Medicine, Raleigh, NC 27607, USA
| | - Jesse F Mangold
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710, USA
| | - Ria Goswami
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710, USA
| | - George R Seage
- Department of Epidemiology, Harvard T.H. School of Public Health, Boston, MA 02115, USA
| | - Galit Alter
- Ragon Institute of the Massachusetts General Hospital, MIT and Harvard, Cambridge, MA 02139, USA
| | | | - Xinxia Peng
- Department of Molecular Biomedical Sciences, North Carolina State University College of Veterinary Medicine, Raleigh, NC 27607, USA; Bioinformatics Graduate Program, North Carolina State University, Raleigh, NC 27607, USA; Bioinformatics Research Center, North Carolina State University, Raleigh, NC 27607, USA
| | - Genevieve G Fouda
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710, USA; Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA.
| | - Sallie R Permar
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC 27710, USA; Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710, USA; Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA.
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23
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Jalbert E, Williamson KM, Kroehl ME, Johnson MJ, Cutland C, Madhi SA, Nunes MC, Weinberg A. HIV-Exposed Uninfected Infants Have Increased Regulatory T Cells That Correlate With Decreased T Cell Function. Front Immunol 2019; 10:595. [PMID: 30972079 PMCID: PMC6445326 DOI: 10.3389/fimmu.2019.00595] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 03/05/2019] [Indexed: 01/03/2023] Open
Abstract
Background: HIV-exposed uninfected infants (HEU) are at higher risk of severe infections, hospitalizations and death compared with HIV-unexposed uninfected infants (HUU), but the immune deficit underlying it is not known. To address this gap, we investigated T cell functionality and its relationship to phenotypic profiles of T cells and antigen presenting cells (APC) in HEU and HUU. Methods: Blood mononuclear cells from 55 HEU and 16 HUU were stimulated with Staphylococcal Enterotoxin B (SEB) or mock for 72 h, and tested by flow cytometry for proliferation and expression of Th1, Th2, and regulatory (Treg) markers. In parallel, cells were phenotypically assessed for differentiation profiles of Treg, conventional T cell (Tconv) and APC in unstimulated cells. Results: HEU had lower CD4+ functional responses to SEB/mock and similar CD8+ responses compared with HUU. In the phenotypic T cell panel, HEU showed higher proportions of CD4+ and CD8+ Treg expressing IL10, FOXP3, and CD25; higher effector Tconv and Treg; and lower naïve and CD4+TGFβ+ Treg compared with HUU. In the phenotypic APC panel, HEU showed higher proportions of CD1c+ cDC2, CD123+ pDC, CD16+ inflammatory monocytes and cDC and higher expression of CD103 on CD1c-CD123-CD16-cDC1 compared with HUU. Regression analyses adjusted for HIV exposure and multiple comparisons showed that higher CD8+IL10+ and CD8+FOXP3+ Treg in unstimulated cells were associated with lower CD8+ T cell functional responses to SEB/mock. Functionality was not affected by Tconv differentiation, but higher APC activation in aggregate was associated with higher CD8+IL10+ Treg responses to SEB. Conclusions: T cell functionality was decreased in HEU compared with HUU. High CD8+ Treg proportions were the most important predictors of decreased T cell functionality in HEU and HUU.
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Affiliation(s)
- Emilie Jalbert
- University of Colorado Denver Anschutz Medical Center, Aurora, CO, United States
| | - Kayla M Williamson
- University of Colorado Denver Anschutz Medical Center, Aurora, CO, United States
| | - Miranda E Kroehl
- University of Colorado Denver Anschutz Medical Center, Aurora, CO, United States
| | - Michael J Johnson
- University of Colorado Denver Anschutz Medical Center, Aurora, CO, United States
| | - Clare Cutland
- University of Witwatersrand, Johannesburg, South Africa
| | | | - Marta C Nunes
- University of Witwatersrand, Johannesburg, South Africa
| | - Adriana Weinberg
- University of Colorado Denver Anschutz Medical Center, Aurora, CO, United States
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24
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Dzanibe S, Jaspan HB, Zulu MZ, Kiravu A, Gray CM. Impact of maternal HIV exposure, feeding status, and microbiome on infant cellular immunity. J Leukoc Biol 2019; 105:281-289. [PMID: 30577072 PMCID: PMC6923687 DOI: 10.1002/jlb.mr0318-120r] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/17/2018] [Accepted: 12/05/2018] [Indexed: 01/02/2023] Open
Abstract
At least one-third of infants born in sub-Saharan Africa have been exposed to the effects of maternal HIV infection and antiretroviral treatment. Intrauterine HIV exposure is associated with increased rates of morbidity and mortality in children. Although the mechanisms responsible for poor infant health with HIV-1 exposure are likely to be multifactorial, we posit that the maternal environment during gestation and in the perinatal period results in altered infant immunity and is possibly the strongest contributing factor responsible for the disproportionally high infectious events among HIV-exposed infants who remain HIV uninfected. This review provides a synthesis of studies reporting the impact of intrauterine HIV exposure, feeding practices, and microbiota on immune ontogeny in the first year of life in HIV-exposed uninfected infants.
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Affiliation(s)
- Sonwabile Dzanibe
- Division of Immunology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Heather B. Jaspan
- Division of Immunology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Seattle Children’s Research Institute and Departments of Paediatrics and Global Health, University of Washington, Seattle, WA, USA
| | - Michael Z. Zulu
- Division of Immunology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Agano Kiravu
- Division of Immunology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Clive M. Gray
- Division of Immunology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
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25
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Nuttall JJC. Current antimicrobial management of community-acquired pneumonia in HIV-infected children. Expert Opin Pharmacother 2019; 20:595-608. [PMID: 30664362 DOI: 10.1080/14656566.2018.1561864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Community-acquired pneumonia is a leading cause of morbidity and mortality amongst HIV-infected infants and children. Polymicrobial infection is common and, due to the difficulties in confirming the etiology of pneumonia, empiric broad-spectrum antimicrobial therapy is frequently used. AREAS COVERED The author based this article on literature identified from PubMed. The author's search terms included: pneumonia, community-acquired pneumonia, HIV, children. The articles reviewed included original studies, recent review articles and current guidelines on the management of pneumonia in HIV-infected children. The microbiological etiology and the empiric and pathogen-specific antimicrobial therapy of community-acquired pneumonia in HIV-infected and HIV-exposed infants and children are also discussed. EXPERT OPINION There are many changing epidemiological factors impacting antimicrobial management of community-acquired pneumonia in the context of HIV infection in infants and children. These include vaccination strategies, antimicrobial prophylaxis, emerging drug-resistant pathogens, and recognition of the importance of viruses and tuberculosis in the etiology of community-acquired pneumonia. Further research is needed on optimal amtimicrobial management strategies in HIV-exposed uninfected children, and HIV-infected children receiving antiretroviral therapy.
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Affiliation(s)
- James J C Nuttall
- a Department of Paediatrics and Child Health, Faculty of Health Sciences , University of Cape Town and Red Cross War Memorial Children's Hospital , Cape Town , South Africa
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26
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Yeganeh N, Watts DH, Xu J, Kerin T, Joao EC, Pilotto JH, Theron G, Gray G, Santos B, Fonseca R, Kreitchmann R, Pinto J, Mussi-Pinhata MM, Veloso V, Camarca M, Mofenson L, Moye J, Nielsen-Saines K. Infectious Morbidity, Mortality and Nutrition in HIV-exposed, Uninfected, Formula-fed Infants: Results From the HPTN 040/PACTG 1043 Trial. Pediatr Infect Dis J 2018; 37:1271-1278. [PMID: 29750766 PMCID: PMC6226320 DOI: 10.1097/inf.0000000000002082] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV-exposed uninfected (HEU) infants are a growing population with potentially poor health outcomes. We evaluated morbidity and mortality in HEU formula-fed infants enrolled in the NICHD HPTN 040/PACTG 1043 trial. METHODS Infectious morbidity, mortality and undernutrition were evaluated within a cohort of 1000 HEU infants enrolled between April 2004 and April 2010 in Brazil (n = 766) and South Africa (n = 234) as part of the NICHD/HPTN 040 trial of 3 different antiretroviral regimens to decrease intrapartum HIV vertical transmission. RESULTS Twenty-three percent of infants had at least 1 infectious serious adverse effect. Infants born to mothers with <12 years of education [adjusted odds ratio (AOR), 2.6; 95% confidence interval [CI], 1.2-5.9), with maternal viral load of >1,000,000 copies/mL at delivery (AOR, 9.9; 95% CI, 1.6-63.1) were more likely to have infectious serious adverse effects. At 6 months, the infant mortality rate per 1000 live births overall was 22 ± 2.6, 9.1 ± 1.8 in Brazil and 64.1 ± 3 in South Africa. Undernutrition and stunting peaked at 1 month of age with 18% having a weight-for-age Z score ≤-2, and 22% with height for Z score ≤-2. The likelihood of infant mortality was greater among infants born in South Africa compared with Brazil (AOR, 6.2; 95% CI, 2.5-15.8), high maternal viral load (AOR, 1.7; 95% CI, 1.01-2.9) and birth weight-for-age Z score ≤-2 (AOR, 5.2; 95% CI, 1.8-14.8). CONCLUSIONS There were high rates of undernutrition, stunting and infectious serious adverse effect in this study's formula-fed HEU population. Suppressing maternal HIV viral load during the peripartum period may be a modifiable risk factor to decrease infant mortality.
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Affiliation(s)
- Nava Yeganeh
- David Geffen UCLA School of Medicine, Los Angeles, CA
| | - D. Heather Watts
- Office of the Global AIDS Coordinator and Health Diplomacy, U.S. Dept. of State, Washington D.C
| | | | - Tara Kerin
- David Geffen UCLA School of Medicine, Los Angeles, CA
| | - Esau C. Joao
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | - Jose Henrique Pilotto
- Hospital Geral de Nova Iguaçu, Nova Iguaçu and Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, (Fiocruz), Rio de Janeiro, Brazil, Perinatal HIV Research Unit
| | - Gerhard Theron
- Stellenbosch University/Tygerberg Hospital, Cape Town, South Africa
| | - Glenda Gray
- University of Witwatersrand/Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | | | | | | | - Jorge Pinto
- Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Valdilea Veloso
- Laboratório de Pesquisa Clínica em DST e AIDS - Instituto de Pesquisa Clínica Evandro Chagas - Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, Brazil
| | | | - Lynne Mofenson
- Elisabeth Glaser Pediatric AIDS Foundation, Washington DC
| | - Jack Moye
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Breastfeeding mitigates the effects of maternal HIV on infant infectious morbidity in the Option B+ era. AIDS 2018; 32:2383-2391. [PMID: 30134300 DOI: 10.1097/qad.0000000000001974] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The effects of in-utero HIV-exposure on infectious morbidity and mortality in settings with universal maternal treatment and high breastfeeding rates are unclear. Further, the benefits of exclusive feeding options have not been assessed in the Option B+ era. We investigated these in two African settings with high breastfeeding uptake and good HIV treatment infrastructure during the first year of life. METHODS Cox regression with time-changing variables in a birth cohort of 749 HIV-exposed uninfected and HIV-unexposed uninfected infants from Cape Town, South Africa and Jos, Nigeria. RESULTS There was no difference in infectious morbidity incidence between HIV-exposed uninfected and HIV-unexposed uninfected infants (hazard ratio 1.01; 95% CI 0.78-1.32) after adjusting for confounding variables. Formula-fed infants had significantly higher infectious morbidity incidence when compared with exclusively breastfed infants (hazard ratio 1.64; 95% CI 1.03-2.63) and mixed-breastfed infants (hazard ratio 1.42; 95% CI 1.00-2.02) after adjusting for potential confounding variables. There was no significant difference in mortality among HIV-exposed infants and HIV-unexposed infants during the first year of life in this cohort (2.04 versus 0.94%, P = 0.38). Notably, exclusive breastfeeding for only 4 months had protective effects on morbidity up to 1 year. CONCLUSION In settings with universal antiretroviral coverage and high breastfeeding rates, breastfeeding mitigates the effects of in-utero HIV exposure among infants during the first year of life. These findings support previous recommendations for exclusive breastfeeding among HIV-infected women and highlight the role that breastfeeding plays on the health of infants in settings where exclusive breastfeeding is not always feasible or where replacement feeding is recommended.
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28
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Maloupazoa Siawaya AC, Mvoundza Ndjindji O, Kuissi Kamgaing E, Mveang-Nzoghe A, Mbani Mpega CN, Leboueny M, Kengue Boussougou R, Mintsa Ndong A, Essone PN, Djoba Siawaya JF. Altered Toll-Like Receptor-4 Response to Lipopolysaccharides in Infants Exposed to HIV-1 and Its Preventive Therapy. Front Immunol 2018; 9:222. [PMID: 29491865 PMCID: PMC5817973 DOI: 10.3389/fimmu.2018.00222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/26/2018] [Indexed: 11/13/2022] Open
Abstract
Pathogen sensing and recognition through pattern recognition receptors, and subsequent production of pro-inflammatory cytokines, is the cornerstone of the innate immune system. Despite the fact that HIV-exposed uninfected (HEU) infants are prone to serious bacterial infections, no study has focused on the functionality of their bacteria recognition system. This is the first study to investigate baseline levels of three critically important immune response molecules in this population: complement component (C)-3, toll-like receptor (TLR)-4, and C-reactive protein (CRP). We enrolled 16 HEU and 6 HIV-unexposed (HU) infants. TLR4 function was investigated by stimulating whole blood with increasing concentrations of TLR4-agonist ultrapure lipopolysaccharides. TLR4/TLR4-agonist dose response were assessed by measuring IL-6 secretion. Complement C3 and CRP were measured by photo spectrometry. Data showed no significant differences in baseline concentration of CRP between HEU and HU infants. Complement C3 was significantly higher in HEU infants than HU infants. TLR4 anergy was observed in 7 of 12 HEU infants, whereas the rest of HEU infants (n = 4) and the control HU infants tested (n = 3) showed responsive TLR4. None of the HEU infants investigated in this study had severe infections in the year after their birth. In conclusion, TLR4 anergy can occur in HEU infants without necessarily translating to increased vulnerability to infectious diseases.
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Affiliation(s)
- Anicet Christel Maloupazoa Siawaya
- Centre Hospitalier Universitaire Mère-Enfant Fondation Jeanne Ebori (CHUMEFJE), Libreville, Gabon.,Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique à Libreville (LNSP), Libreville, Gabon
| | - Ofilia Mvoundza Ndjindji
- Centre Hospitalier Universitaire Mère-Enfant Fondation Jeanne Ebori (CHUMEFJE), Libreville, Gabon.,Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique à Libreville (LNSP), Libreville, Gabon
| | - Eliane Kuissi Kamgaing
- Département de Pédiatrie, Université des Sciences de la Santé d'Owendo (USS), Owendo, Gabon.,Service de Néonatologie, Centre Hospitalier Universitaire de Libreville (CHUL), Libreville, Gabon
| | - Amandine Mveang-Nzoghe
- Centre Hospitalier Universitaire Mère-Enfant Fondation Jeanne Ebori (CHUMEFJE), Libreville, Gabon.,Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique à Libreville (LNSP), Libreville, Gabon
| | - Chérone Nancy Mbani Mpega
- Département de Chimie, Faculté des Sciences, Université des sciences et techniques de Masuku, Franceville, Gabon
| | - Marielle Leboueny
- Centre Hospitalier Universitaire Mère-Enfant Fondation Jeanne Ebori (CHUMEFJE), Libreville, Gabon.,Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique à Libreville (LNSP), Libreville, Gabon
| | | | - Armel Mintsa Ndong
- Unité de Virologie, Laboratoire National de Santé Publique à Libreville (LNSP), Libreville, Gabon
| | - Paulin N Essone
- Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique à Libreville (LNSP), Libreville, Gabon.,Centre de Recherche Médicales de Lambaréné, Lambaréné, Gabon.,Institut für Tropenmedizin, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Joel Fleury Djoba Siawaya
- Centre Hospitalier Universitaire Mère-Enfant Fondation Jeanne Ebori (CHUMEFJE), Libreville, Gabon.,Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique à Libreville (LNSP), Libreville, Gabon
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Abstract
PURPOSE OF REVIEW Emerging research on the pediatric microbiome implicates the importance of the microbiome on the development of the immune system, nervous system, and growth. Changes to the microbiome during infancy are associated with the development of chronic illnesses such as asthma and inflammatory bowel disease. Additionally, the microbiome provides protection against certain pathogens, affects vaccine responses, and alters drug metabolism. This review highlights what is known about the microbiome, the establishment of a healthy microbiome and the significance that changes to the microbiome composition have on growth and health of children and adolescents. RECENT FINDINGS Vaginal delivery, breastfeeding, maternal health, and nutrition help shape a healthy microbiome. Caesarian delivery, formula feeding, and antibiotic use perturb the microbiome and are associated with the development of type II diabetes, asthma, allergic diseases, and obesity later in life. Specific interventions using pre and probiotics in multiple settings are under investigation with limited success. SUMMARY A better understanding of the microbiome and the interaction with the immune system may help guide interventions to alter the microbiome toward a state of lifelong health.
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Sun C, Dlamini PS, Maimbolwa MC, Changala Lukwesa Mukonka C, Nyamakura R, Omoni G, Seboni N, Larson E. Success Stories: Overcoming Barriers to Research in Southern and Eastern African Countries. Clin Nurs Res 2017; 26:399-418. [PMID: 28707552 DOI: 10.1177/1054773817718935] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is an ever-growing need for clinically focused, culturally relevant research on which nurses can base their practice. However, there may not be a concurrent rise in efforts to strengthen infrastructure needed to promote research in developing and low-income countries. In such cases, nurse researchers must find innovative ways to address and overcome barriers to research. This article presents five exemplars of nurses conducting high-quality nursing research in resource-poor settings in southern and eastern Africa. Furthermore, it suggests strategies to address these barriers, such as piggybacking on larger studies, interdisciplinary collaboration, and partnership with influential stakeholders. These tactics may be used to increase research productivity elsewhere.
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Affiliation(s)
- Carolyn Sun
- 1 Columbia University School of Nursing, New York, NY, USA
| | | | | | | | | | | | | | - Elaine Larson
- 1 Columbia University School of Nursing, New York, NY, USA
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Miyamoto M, Gouvêa AFTB, Ono E, Succi RCM, Pahwa S, Moraes-Pinto MID. Immune development in HIV-exposed uninfected children born to HIV-infected women. Rev Inst Med Trop Sao Paulo 2017; 59:e30. [PMID: 28591258 PMCID: PMC5459537 DOI: 10.1590/s1678-9946201759030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 02/22/2017] [Indexed: 01/15/2023] Open
Abstract
Immunological and clinical findings suggestive of some immune dysfunction have been reported among HIV-exposed uninfected (HEU) children and adolescents. Whether these defects are persistent or transitory is still unknown. HEU pediatric population at birth, 12 months, 6-12 years were evaluated in comparison to healthy age-matched HIV-unexposed controls. Plasma levels of LPS, sCD14, cytokines, lymphocyte immunophenotyping and T-cell receptor excision circles (TREC) were assessed. HEU and controls had similar LPS levels, which remained low from birth to 6-12 years; for plasma sCD14, IL-2, IL-6, IL-7, IL-10, IL-12p70, IL-13, IL-17, IFN-γ, TNF-α, G-CSF, GM-CSF and MCP-1, which increased from birth to 12 months and then decreased at 6-12 years; and for TREC/106 PBMC at birth in HEU and controls. By contrast, plasma MIP-1β levels were lower in HEU than in controls (p=0.009) at 12 months, and IL-4 levels were higher in HEU than controls (p=0.04) at 6-12 years. Immune activation was higher in HEU at 12 months and at 6-12 years than controls based on frequencies of CD38+HLA-DR+CD8+T cells (p=0.05) and of CD38+HLA-DR+CD4+T cells (p=0.006). Resting memory and activated mature B cells increased from birth to 6-12 years in both groups. The development of the immune system in vertically HEU individuals is comparable to the general population in most parameters, but subtle or transient differences exist. Their role in influencing clinical incidences in HEU is unknown.
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Affiliation(s)
- Maristela Miyamoto
- Universidade Federal de São Paulo, Departamento de Pediatria, São Paulo, São Paulo, Brazil
| | - Aída F T B Gouvêa
- Universidade Federal de São Paulo, Departamento de Pediatria, São Paulo, São Paulo, Brazil
| | - Erika Ono
- Universidade Federal de São Paulo, Departamento de Pediatria, São Paulo, São Paulo, Brazil
| | - Regina Célia M Succi
- Universidade Federal de São Paulo, Departamento de Pediatria, São Paulo, São Paulo, Brazil
| | - Savita Pahwa
- University of Miami, Department of Medicine, Miami, USA
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32
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Nankabirwa V, Tumwine JK, Namugga O, Tylleskär T, Ndeezi G, Robberstad B, Netea MG, Sommerfelt H. Early versus late BCG vaccination in HIV-1-exposed infants in Uganda: study protocol for a randomized controlled trial. Trials 2017; 18:152. [PMID: 28359325 PMCID: PMC5374628 DOI: 10.1186/s13063-017-1881-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/07/2017] [Indexed: 12/21/2022] Open
Abstract
Background Bacillus Calmette-Guérin (BCG) vaccination may have nonspecific effects, i.e., effects on childhood morbidity and mortality that go beyond its effect on the risk of childhood tuberculosis (TB). Though the available scientific literature is mostly from observational studies, and is fraught with controversy, BCG vaccination at birth may protect infants in high-mortality populations against serious infections other than TB. Yet, other studies indicate that giving BCG later in infancy may modify immune responses to non-TB antigens and potentially enhance immunity, potentially also against tuberculosis (TB). It is unclear whether BCG vaccination very early in life offers adequate protection against TB and other infections among HIV-1-exposed children because even those who remain uninfected with HIV-1 show signs of impaired immunocompetence early in infancy. This study will compare BCG vaccination at birth with BCG vaccination at 14 weeks of age in HIV-1-exposed infants. Methods This is an individually randomized controlled trial in 2200 HIV-1-exposed infants. The intervention is BCG vaccination within 24 h of birth while the comparator is BCG given at 14 weeks of age. The study co-primary outcomes are severe illness in the first 14 weeks of life, and production of tumor necrosis factor, interleukin (IL)-1β, IL-6 and interferon-γ in response to mycobacterial and nonmycobacterial antigens. The study is being conducted in three health centers in Uganda. Discussion A well-timed BCG vaccination could have important nonspecific effects in HIV-1-exposed infants. This trial could inform the development of appropriate timing of BCG vaccination for HIV-1-exposed infants. Trial registration ClinicalTrials.gov, identifier: NCT02606526. Registered on 12 November 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1881-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Victoria Nankabirwa
- Department of Epidemiology and Biostatics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda. .,Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, .
| | - James K Tumwine
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Olive Namugga
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen
| | - Thorkild Tylleskär
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen
| | - Grace Ndeezi
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Bjarne Robberstad
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Halvor Sommerfelt
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen.,Global Women and Children's Health, Norwegian Institute of Public Health, Oslo, Norway
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33
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Excess respiratory viral infections and low antibody responses among HIV-exposed, uninfected infants. AIDS 2017; 31:669-679. [PMID: 28060016 DOI: 10.1097/qad.0000000000001393] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE HIV-exposed uninfected (HEUs) infants have frequent severe infection, hospitalization, and death. We performed a serologic investigation to determine the role of common childhood respiratory pathogens in the excess incidence of infections in HEUs. DESIGN Prospective cohort study of mother-infant pairs. METHODS Among 247 HEUs and 88 HIV-unexposed uninfected (HUU) infant-mother pairs, we measured maternal antibodies to respiratory syncytial virus (RSV) and pneumococcus (PNC 1, 5, 6B, 14); infant antibodies to RSV, influenza A (flu), parainfluenza viruses (1, 2, 3), and PNC 1, 5, 6B, and 14 were measured at 0 and 6 months, and antitetanus antibodies at 6 months. RESULTS HIV-infected mothers had higher RSV and lower PNC antibody concentrations at delivery than uninfected mothers. Transplacental transfer of maternal antibodies, particularly for RSV, was lower in HEUs compared with HUUs. At birth, HEUs had higher concentrations of anti-RSV antibodies than HUUs, but lower antibodies to the other respiratory agents. At 6 months, HEUs had significantly higher proportions of seroconversions and higher antibody concentrations against parainfluenza viruses 1, 2, and 3. There were no significant differences in seroconversions to flu and RSV, but antibody concentrations to RSV were six-fold lower in HEUs versus HUUs at 6 months. Antibody responses to at least two doses of tetanus vaccine were also six-fold lower in HEUs compared with HUUs. CONCLUSION Six-month-old HEUs had a higher incidence of respiratory viral infections than HUUs. In addition to the low passive protection from maternal antibodies, low antibody responses of HEUs may contribute to increased morbidity and mortality.
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Maloupazoa Siawaya AC, Mveang-Nzoghe A, Mvoundza Ndjindji O, Mintsa Ndong A, Essone PN, Djoba Siawaya JF. Cases of Impaired Oxidative Burst in HIV-Exposed Uninfected Infants' Neutrophils-A Pilot Study. Front Immunol 2017; 8:262. [PMID: 28337206 PMCID: PMC5343014 DOI: 10.3389/fimmu.2017.00262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 02/23/2017] [Indexed: 11/16/2022] Open
Abstract
An increased risk of serious bacterial infections in HIV-exposed uninfected (HEU) infants has been demonstrated. Although neutrophils are essential for the protection of infants against bacterial infections, no study has investigated their profile in HEU infants to date. In this study, we assessed the function of neutrophils in HEU infants using the nitroblue tetrazolium reduction test. Among 25 HEU infants, 9 (36%) showed a reduced ability of their neutrophils to produce reactive oxygen species upon stimulation with bacteria. No alteration of total neutrophil counts was noted in the blood of HEU infants indicating that the alteration observed in the 36% of HEU infants may only be functional. Conclusively, impaired neutrophil function could be a factor of vulnerability in HEU infants.
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Affiliation(s)
| | - Amandine Mveang-Nzoghe
- Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique , Libreville , Gabon
| | - Ofilia Mvoundza Ndjindji
- Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique , Libreville , Gabon
| | - Armel Mintsa Ndong
- Unité de Virologie, Laboratoire National de Santé Publique , Libreville , Gabon
| | - Paulin N Essone
- Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique, Libreville, Gabon; Faculty of Health Sciences, Institute of Infectious Diseases and Molecular Medicine (IDM), Division of Immunology and South African Medical Research Council (SAMRC) Immunology of Infectious Diseases, University of Cape Town, Cape Town, South Africa
| | - Joel Fleury Djoba Siawaya
- Unités de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique , Libreville , Gabon
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35
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Rabie H, Goussard P. Tuberculosis and pneumonia in HIV-infected children: an overview. Pneumonia (Nathan) 2016; 8:19. [PMID: 28702298 PMCID: PMC5471701 DOI: 10.1186/s41479-016-0021-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/03/2016] [Indexed: 02/07/2023] Open
Abstract
Pneumonia remains the most common cause of hospitalization and the most important cause of death in young children. In high human immunodeficiency virus (HIV)-burden settings, HIV-infected children carry a high burden of lower respiratory tract infection from common respiratory viruses, bacteria and Mycobacterium tuberculosis. In addition, Pneumocystis jirovecii and cytomegalovirus are important opportunistic pathogens. As the vertical transmission risk of HIV decreases and access to antiretroviral therapy increases, the epidemiology of these infections is changing, but HIV-infected infants and children still carry a disproportionate burden of these infections. There is also increasing recognition of the impact of in utero exposure to HIV on the general health of exposed but uninfected infants. The reasons for this increased risk are not limited to socioeconomic status or adverse environmental conditions—there is emerging evidence that these HIV-exposed but uninfected infants may have particular immune deficits that could increase their vulnerability to respiratory pathogens. We discuss the impact of tuberculosis and other lower respiratory tract infections on the health of HIV-infected infants and children.
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Affiliation(s)
- Helena Rabie
- Department of Pediatrics and Child Health, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa.,Childrens Infectious Diseases Clinical Research Unit (KidCRU), University of Stellenbosch, Cape Town, South Africa.,Division of Infectious Diseases, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000 South Africa
| | - Pierre Goussard
- Department of Pediatrics and Child Health, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa
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Dauby N, Chamekh M, Melin P, Slogrove AL, Goetghebuer T. Increased Risk of Group B Streptococcus Invasive Infection in HIV-Exposed but Uninfected Infants: A Review of the Evidence and Possible Mechanisms. Front Immunol 2016; 7:505. [PMID: 27899925 PMCID: PMC5110531 DOI: 10.3389/fimmu.2016.00505] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 10/27/2016] [Indexed: 12/20/2022] Open
Abstract
Group B Streptococcus (GBS) is a major cause of neonatal sepsis and mortality worldwide. Studies from both developed and developing countries have shown that HIV-exposed but uninfected (HEU) infants are at increased risk of infectious morbidity, as compared to HIV-unexposed uninfected infants (HUU). A higher susceptibility to GBS infections has been reported in HEU infants, particularly late-onset diseases and more severe manifestations of GBS diseases. We review here the possible explanations for increased susceptibility to GBS infection. Maternal GBS colonization during pregnancy is a major risk factor for early-onset GBS invasive disease, but colonization rates are not higher in HIV-infected compared to HIV-uninfected pregnant women, while selective colonization with more virulent strains in HIV-infected women is suggested in some studies. Lower serotype-specific GBS maternal antibody transfer and quantitative and qualitative defects of innate immune responses in HEU infants may play a role in the increased risk of GBS invasive disease. The impact of maternal antiretroviral treatment and its consequences on immune activation in HEU newborns are important to study. Maternal immunization presents a promising intervention to reduce GBS burden in the growing HEU population.
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Affiliation(s)
- Nicolas Dauby
- Department of Infectious Diseases, CHU Saint-Pierre, Brussels, Belgium; Institute for Medical Immunology, Université Libre de Bruxelles (ULB), Gosselies, Belgium
| | - Mustapha Chamekh
- Institute for Medical Immunology, Université Libre de Bruxelles (ULB) , Gosselies , Belgium
| | - Pierrette Melin
- Department of Clinical Microbiology, National Reference Centre for Group B Streptococci, CHU Sart-Tilman, Université de Liège (ULg) , Liège , Belgium
| | - Amy L Slogrove
- Department of Paediatrics and Child Health, Division of Paediatric Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa; Centre for Infectious Disease and Epidemiologic Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tessa Goetghebuer
- Department of Paediatrics, CHU Saint-Pierre, Brussels, Belgium; Université Libre de Bruxelles (ULB), Brussels, Belgium
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Maternal HIV infection alters the immune balance in the mother and fetus; implications for pregnancy outcome and infant health. Curr Opin HIV AIDS 2016; 11:138-45. [PMID: 26679415 DOI: 10.1097/coh.0000000000000239] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW With the rapid roll-out of combination antiretroviral therapy to prevent mother-to-child transmission of HIV, there is an annual increase in the number of uninfected infants born to HIV-infected women. Although the introduction of combination antiretroviral therapy has vastly improved pregnancy outcome and the health of infants born to HIV-infected women, concerns remain regarding the impact the maternal HIV infection on the pregnancy outcome and the health of HIV-exposed uninfected infants. RECENT FINDINGS Maternal HIV infection is associated with negative pregnancy outcomes such as low birth weight. In addition, an increased susceptibility to infections is reported in HIV-exposed uninfected infants compared with infants born to uninfected women. Studies have shown that HIV-exposure affects the maternal/fetal unit, with increase of proinflammatory cytokine produced by placental cells, as well as altered infant immune responses. These changes could provide the underlying conditions for negative pregnancy outcomes and facilitate mother-to-child transmission of HIV in the infant. Further studies are required to understand the underlying mechanisms and investigate whether these altered infant immune responses persist and have clinical consequences beyond childhood. SUMMARY HIV infection in pregnant women is associated with altered immune responses in HIV-infected women and their offspring with clinical consequences for pregnancy outcome and the HIV-exposed uninfected infant. Further studies are required to address the origin and long-term consequences of prenatal HIV-exposure and subsequent immune activation for infant health.
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38
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Ruck C, Reikie BA, Marchant A, Kollmann TR, Kakkar F. Linking Susceptibility to Infectious Diseases to Immune System Abnormalities among HIV-Exposed Uninfected Infants. Front Immunol 2016; 7:310. [PMID: 27594857 PMCID: PMC4990535 DOI: 10.3389/fimmu.2016.00310] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/02/2016] [Indexed: 12/22/2022] Open
Abstract
HIV-exposed uninfected (HEU) infants experience increased overall mortality from infectious causes when compared to HIV-unexposed uninfected (HU) infants. This is the case in both the resource-rich and resource-limited settings. Here, we explore the concept that specific types of infectious diseases that are more common among HEU infants could provide clues as to the potential underlying immunological abnormalities. The most commonly reported infections in HEU vs. HU infants are caused by encapsulated bacteria, suggesting the existence of a less effective humoral (antibody, complement) immune response. Decreased transplacental transfer of protective maternal antibodies has consistently been observed among HEU newborns, suggesting that this may indeed be one of the key drivers of their susceptibility to infections with encapsulated bacteria. Reassuringly, HEU humoral response to vaccination appears to be well conserved. While there appears to be an increase in overall incidence of acute viral infections, no specific pattern of acute viral infections has emerged; and although there is evidence of increased chronic viral infection from perinatal transmission of hepatitis C and cytomegalovirus, no data exist to suggest an increase in adverse outcomes. Thus, no firm conclusions about antiviral effector mechanisms can be drawn. However, the most unusual of reported infections among the HEU have been opportunistic infections, suggesting the possibility of underlying defects in CD4 helper T cells and overall immune regulatory function. This may relate to the observation that the immunological profile of HEUs indicates a more activated T cell profile as well as a more inflammatory innate immune response. However, both of these observations appear transient, marked in early infancy, but no longer evident later in life. The causes of these early-life changes in immune profiles are likely multifactorial and may be related to in utero exposure to HIV, but also to increased environmental exposure to pathogens from sicker household contacts, in utero and postnatal antiretroviral drug exposure, and, in certain circumstances, differences in mode of feeding. The relative importance of each of these factors will be important to delineate in an attempt to identify those HEU at highest risk of adverse outcomes for targeted interventions.
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Affiliation(s)
- Candice Ruck
- Department of Pediatrics, BC Women's and Children's Hospital, University of British Columbia , Vancouver, BC , Canada
| | - Brian A Reikie
- Department of Surgery, University of Manitoba , Winnipeg, MB , Canada
| | - Arnaud Marchant
- Institute for Medical Immunology, Université Libre de Bruxelles , Charleroi , Belgium
| | - Tobias R Kollmann
- Department of Pediatrics, BC Women's and Children's Hospital, University of British Columbia , Vancouver, BC , Canada
| | - Fatima Kakkar
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal , Montréal, QC , Canada
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40
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Coutsoudis A, Daniels B, Moodley-Govender E, Ngomane N, Zako L, Spooner E, Kiepiela P, Reddy S, Kuhn L, Ramjee G. Randomised controlled trial testing the effect of cotrimoxazole prophylaxis on morbidity and mortality outcomes in breastfed HIV-exposed uninfected infants: study protocol. BMJ Open 2016; 6:e010656. [PMID: 27406638 PMCID: PMC4947798 DOI: 10.1136/bmjopen-2015-010656] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION No randomised controlled trial (RCT) has examined the efficacy of cotrimoxazole (CTX) prophylaxis in HIV-exposed uninfected (HEU) infants during the breastfeeding period, in this new era of effective prevention of mother-to-child transmission (PMTCT) prophylaxis. The efficacy of CTX prophylaxis has presently been demonstrated only in HIV-infected children. The absence of proven benefits in HEU breastfed infants associated with infectious diseases justifies an RCT as proposed. Herewith lies the rationale for conducting the proposed study. METHODS A partially blinded RCT is proposed to evaluate the efficacy of CTX prophylaxis administered from 6 weeks of age to HEU infants receiving a PMTCT regimen. A non-inferiority design will be used, randomising 1298 infants to receive CTX or not to receive CTX. Participants will be reviewed at the following time points: 6 weeks (enrolment and randomisation), 10 weeks, 14 weeks, 4 months and monthly thereafter until 12 months of age. They will be evaluated for anthropometric growth, interval illness, CTX adherence, signs and symptoms of study drug toxicity, concomitant medication use, breastfeeding status and HIV infection status. The study will compare the incidence of grade 3 and grade 4 common childhood illnesses (focusing on pneumonia and diarrhoea) and all-cause mortality until 12 months of age. In a subset of participants, we will compare grade 3 and grade 4 haemoglobin and alanine aminotransferase results as well as investigate gut integrity. ETHICS AND DISSEMINATION The study has ethical approval from the University of KwaZulu-Natal Biomedical Research Ethics Committee (BFC212/13). TRIAL REGISTRATION NUMBERS PACTR201311000621110 and DOH-27-0614-4728; Pre-results.
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Affiliation(s)
- Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Brodie Daniels
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Eshia Moodley-Govender
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | | | - Linda Zako
- eThekwini Health Unit, eThekwini Municipality, Durban, South Africa
| | - Elizabeth Spooner
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Photini Kiepiela
- HIV Prevention Research Unit, Medical Research Council of South Africa, Durban, South Africa
| | - Shabashini Reddy
- HIV Prevention Research Unit, Medical Research Council of South Africa, Durban, South Africa
| | - Louise Kuhn
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Gita Ramjee
- HIV Prevention Research Unit, Medical Research Council of South Africa, Durban, South Africa
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Altfeld M, Bunders MJ. Impact of HIV-1 infection on the feto-maternal crosstalk and consequences for pregnancy outcome and infant health. Semin Immunopathol 2016; 38:727-738. [PMID: 27392971 DOI: 10.1007/s00281-016-0578-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/16/2016] [Indexed: 12/21/2022]
Abstract
Adaptation of the maternal immune system to establish maternal/fetal equilibrium is required for a successful pregnancy. Viral infections, including HIV-1 infection, can alter this maternal/fetal equilibrium, with significant consequences for pregnancy outcome, including miscarriages, impaired fetal growth, and premature delivery. Furthermore, maternal HIV-1 infection has been shown to have a long-term impact on the developing fetal immune system also when the infant is not infected with the virus. In this review, we discuss the consequences of maternal HIV-1 infection and antiretroviral therapy on pregnancy outcome and the health of the uninfected HIV-1-exposed infant.
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Affiliation(s)
- Marcus Altfeld
- Department of Virus Immunology, Heinrich-Pette Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
| | - Madeleine J Bunders
- Department of Virus Immunology, Heinrich-Pette Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany. .,Department of Experimental Immunology, University of Amsterdam (UvA), Academic Medical Center (AMC), Amsterdam, The Netherlands. .,Emma Childrens Hospital,UvA, AMC, Amsterdam, The Netherlands.
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Rossouw ME, Cornell M, Cotton MF, Esser MM. Feeding practices and nutritional status of HIV-exposed and HIV-unexposed infants in the Western Cape. South Afr J HIV Med 2016; 17:398. [PMID: 29568600 PMCID: PMC5843154 DOI: 10.4102/sajhivmed.v17i1.398] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 11/13/2015] [Indexed: 11/01/2022] Open
Abstract
Background Optimal infant- and young child-feeding practices are crucial for nutritional status, growth, development, health and, ultimately, survival. Human breast milk is optimal nutrition for all infants. Complementary food introduced at the correct age is part of optimal feeding practices. In South Africa, widespread access to antiretrovirals and a programme to prevent mother-to-child transmission of HIV have reduced HIV infection in infants and increased the number of HIV-exposed uninfected (HEU) infants. However, little is known about the feeding practices and nutritional status of HEU and HIV-unexposed (HU) infants. Objective To assess the feeding practices and nutritional status of HIV-exposed and HIV-unexposed (HU) infants in the Western Cape. Design Prospective substudy on feeding practices nested in a pilot study investigating the innate immune abnormalities in HEU infants compared to HU infants. The main study commenced at week 2 of life with the nutrition component added from 6 months. Information on children's dietary intake was obtained at each visit from the caregiver, mainly the mother. Head circumference, weight and length were recorded at each visit. Data were obtained from 6-, 12- and 18-month visits. World Health Organization feeding practice indicators and nutrition indicators were utilised. Setting Tygerberg Academic Hospital, Western Cape. Mothers were recruited from the postnatal wards. Subjects Forty-seven mother-infant pairs, 25 HEU and 22 HU infants, participated in this nutritional substudy. Eight (17%) infants, one HU and seven HEU, were lost to follow-up over the next 12 months. The HEU children were mainly Xhosa (76%) and HU were mainly mixed race (77%). Results The participants were from poor socio-economic backgrounds. In both groups, adherence to breastfeeding recommendations was low with suboptimal dietary diversity. We noted a high rate of sugar- and salt-containing snacks given from a young age. The HU group had poorer anthropometric and nutritional indicators not explained by nutritional factors alone. However, alcohol and tobacco use was much higher amongst the HU mothers. Conclusion Adherence to breastfeeding recommendations was low. Ethnicity and cultural milieu may have influenced feeding choices and growth. Further research is needed to understand possible reasons for the poorer nutritional and anthropometric indicators in the HU group.
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Affiliation(s)
- Magdel E Rossouw
- Department of Paediatrics and Child Health, Family Clinical Research Unit, Stellenbosch University, Tygerberg Campus, South Africa
| | - Morna Cornell
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Mark F Cotton
- Department of Paediatrics and Child Health, Family Clinical Research Unit, Stellenbosch University, Tygerberg Campus, South Africa
| | - Monika M Esser
- Department of Pathology, National Health Laboratory Service Immunology Unit (NHLS), Stellenbosch University, Tygerberg Campus, South Africa
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Evans C, Jones CE, Prendergast AJ. HIV-exposed, uninfected infants: new global challenges in the era of paediatric HIV elimination. THE LANCET. INFECTIOUS DISEASES 2016; 16:e92-e107. [PMID: 27049574 DOI: 10.1016/s1473-3099(16)00055-4] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 01/01/2016] [Accepted: 01/21/2016] [Indexed: 10/22/2022]
Abstract
The number of infants infected with HIV is declining with the rise in interventions for the elimination of paediatric HIV infection, but the number of uninfected infants exposed to HIV through their HIV-infected mothers is increasing. Interest in the health outcomes of HIV-exposed, uninfected infants has grown in the past decade, with several studies suggesting that these infants have increased mortality rates, increased infectious morbidity, and impaired growth compared with HIV-unexposed infants. However, heterogeneous results might reflect the inherent challenges in studies of HIV-exposed, uninfected infants, which need large populations with appropriate, contemporaneous comparison groups and repeated HIV testing throughout the period of breastfeeding. We review the effects of HIV exposure on mortality, morbidity, and growth, discuss the immunological abnormalities identified so far, and provide an overview of interventions that could be effective in this susceptible population. As the number of infants infected with HIV declines, the health needs of HIV-exposed, uninfected infants should be prioritised further, to ensure that post-2015 Sustainable Development Goals are achieved.
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Affiliation(s)
- Ceri Evans
- Blizard Institute, Queen Mary University of London, London, UK; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Christine E Jones
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London, UK; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Kelly MS, Wirth KE, Steenhoff AP, Cunningham CK, Arscott-Mills T, Boiditswe SC, Patel MZ, Shah SS, Finalle R, Makone I, Feemster KA. Treatment Failures and Excess Mortality Among HIV-Exposed, Uninfected Children With Pneumonia. J Pediatric Infect Dis Soc 2015; 4:e117-26. [PMID: 26582879 PMCID: PMC4681380 DOI: 10.1093/jpids/piu092] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 08/26/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-exposed, uninfected (HIV-EU) children are at increased risk of infectious illnesses and mortality compared with children of HIV-negative mothers (HIV-unexposed). However, treatment outcomes for lower respiratory tract infections among HIV-EU children remain poorly defined. METHODS We conducted a hospital-based, prospective cohort study of N = 238 children aged 1-23 months with pneumonia, defined by the World Health Organization. Children were recruited within 6 hours of presentation to a tertiary hospital in Botswana. The primary outcome--treatment failure at 48 hours--was assessed by an investigator blinded to HIV exposure status. RESULTS Median age was 6.0 months; 55% were male. One hundred fifty-three (64%) children were HIV-unexposed, 64 (27%) were HIV-EU, and 20 (8%) were HIV-infected; the HIV exposure status of 1 child could not be established. Treatment failure at 48 hours occurred in 79 (33%) children, including in 36 (24%) HIV-unexposed, 30 (47%) HIV-EU, and 12 (60%) HIV-infected children. In multivariable analyses, HIV-EU children were more likely to fail treatment at 48 hours (risk ratio [RR]: 1.83, 95% confidence interval [CI]: 1.27-2.64, P = .001) and had higher in-hospital mortality (RR: 4.31, 95% CI: 1.44-12.87, P = .01) than HIV-unexposed children. Differences in outcomes by HIV exposure status were observed only among children under 6 months of age. HIV-EU children more frequently received treatment with a third-generation cephalosporin, but this did not reduce the risk of treatment failure in this group. CONCLUSIONS HIV-EU children with pneumonia have higher rates of treatment failure and in-hospital mortality than HIV-unexposed children during the first 6 months of life. Treatment with a third-generation cephalosporins did not improve outcomes among HIV-EU children.
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Affiliation(s)
- Matthew S. Kelly
- Botswana–UPenn Partnership, Gaborone, Botswana
- Divisions of Global Health
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Kathleen E. Wirth
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Andrew P. Steenhoff
- Botswana–UPenn Partnership, Gaborone, Botswana
- Divisions of Global Health
- Infectious Diseases, The Children's Hospital of Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Coleen K. Cunningham
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Tonya Arscott-Mills
- Botswana–UPenn Partnership, Gaborone, Botswana
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, Ohio
| | - Rodney Finalle
- Divisions of Global Health
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Kristen A. Feemster
- Divisions of Global Health
- Infectious Diseases, The Children's Hospital of Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Cytomegalovirus IgG Level and Avidity in Breastfeeding Infants of HIV-Infected Mothers in Malawi. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2015; 22:1222-6. [PMID: 26424831 DOI: 10.1128/cvi.00460-15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 09/27/2015] [Indexed: 12/27/2022]
Abstract
Cytomegalovirus (CMV) infection is common among infants of HIV-infected mothers in resource-limited settings. We examined the prevalence and timing of infant CMV infection during the first year of life using IgG antibody and avidity among HIV-exposed infants in Malawi and correlated the results with the presence of detectable CMV DNA in the blood. The Breastfeeding, Antiretrovirals and Nutrition (BAN) study randomized 2,369 mothers and their infants to maternal antiretrovirals, infant nevirapine, or neither for 28 weeks of breastfeeding, followed by weaning. Stored plasma specimens were tested for CMV IgG and antibody avidity from a random subset of infants who had been previously tested with blood CMV PCR and had available specimens at birth and at 24 and 48 weeks of age. Ninety-four of 127 infants (74.0%) tested at 24 weeks of age had CMV IgG of low or intermediate avidity, signifying primary CMV infections. An additional 22 infants (17.3%) had IgG of high avidity; 19 of them had CMV DNA detected in their blood, indicating infant infections. Taken together, these results show that the estimated prevalence of CMV infection at 24 weeks was 88.9%. By 48 weeks of age, 81.3% of infants had anti-CMV IgG; most of them (70.9%) had IgG of high avidity. The CMV serology and avidity testing, combined with the PCR results, confirmed a high rate of primary CMV infection by 6 months of life among breastfeeding infants of HIV-infected mothers. The CMV PCR in blood detected most, but not all, infant CMV infections.
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Adler C, Haelterman E, Barlow P, Marchant A, Levy J, Goetghebuer T. Severe Infections in HIV-Exposed Uninfected Infants Born in a European Country. PLoS One 2015; 10:e0135375. [PMID: 26284528 PMCID: PMC4540431 DOI: 10.1371/journal.pone.0135375] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 07/21/2015] [Indexed: 11/24/2022] Open
Abstract
Background Several studies indicate that HIV-exposed uninfected (HEU) children have a high infectious morbidity. We previously reported an increased incidence of group B streptococcus (GBS) infections in HEU infants born in Belgium. Methods This study was undertaken to evaluate the incidence and risk factors of all cause severe infections in HEU infants born in Belgium between 1985 and 2006, including the pre-antiretroviral (ARV) prophylaxis era (1985 to 1994). The medical charts of 537 HEU infants followed in a single center were reviewed. Results The incidence rate of severe infections during the first year of life was 16.8/100 HEU infant-years. The rates of invasive S. pneumoniae (0.62/100 infant-years) and GBS infections (1.05/100 infant-years) were, respectively, 4 and 13-fold higher in HEU infants than in the general infant population. Preterm birth was a risk factor for severe infections in the neonatal period (aOR = 21.34, 95%CI:7.12–63.93) and post-neonatal period (aHR = 3.00, 95%CI:1.53–5.88). As compared to the pre-ARV prophylaxis era, infants born in the ARV prophylaxis era (i.e., after April 1994) had a greater risk of severe infections (aHR = 2.93; 95%CI:1.07–8.05). This risk excess was present in those who received ARV prophylaxis (aHR 2.01, 95%CI 0.72–5.65) and also in those born in the ARV prophylaxis era who did not benefit from ARV prophylaxis as a result of poor access to antenatal care or lack of compliance (aHR 3.06, 95%CI 0.88–10.66). Conclusions In HEU infants born in an industrialized country, preterm birth and being born during the ARV prophylaxis era were risk factors of severe infections throughout the first year of life. These observations have important implications for the clinical management of HIV-infected mothers and their infants.
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Affiliation(s)
- Catherine Adler
- Pediatric Department, St Pierre University Hospital, Brussels, Belgium
| | | | - Patricia Barlow
- Obstetrical Department, St Pierre University Hospital, Brussels, Belgium
| | - Arnaud Marchant
- Institute for Medical Immunology, Université Libre de Bruxelles (ULB), Gosselies, Belgium
| | - Jack Levy
- Pediatric Department, St Pierre University Hospital, Brussels, Belgium
- * E-mail:
| | - Tessa Goetghebuer
- Pediatric Department, St Pierre University Hospital, Brussels, Belgium
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Van Niekerk E, Nel DG, Blaauw R, Kirsten GF. Probiotics Reduce Necrotizing Enterocolitis Severity in HIV-exposed Premature Infants. J Trop Pediatr 2015; 61:155-64. [PMID: 25724213 DOI: 10.1093/tropej/fmv004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To assess the effect of probiotics on the incidence of necrotizing enterocolitis (NEC) in premature infants born to human immunodeficiency virus (HIV)-positive and HIV-negative women. PATIENTS AND METHODS HIV-exposed and HIV-unexposed premature infants were randomized to either the probiotic or the placebo group. The probiotic consisted of 1 × 10(9) colony-forming units, Lactobacillus rhamnosus GG and Bifidobacterium infantis per day. RESULTS In total, 74 HIV-exposed and 110 HIV-unexposed infants were enrolled and randomized. The incidence of death [4 (5.4%) vs. 7 (6%); p = 0.79] and NEC [4 (5%) vs. 5 (5%); p = 0.76] did not differ significantly between the HIV-exposed and HIV-unexposed groups. A significant difference was found for total NEC incidence between the study and control groups [3 (3%) vs. 6 (6%); p = 0.029]. The incidence of NEC in the HIV-exposed group differed significantly [Bells I 2 (5%) vs. Bells III 2 (5%); p = 0.045). CONCLUSION Probiotic supplementation reduced the incidence of NEC in the premature very low birth weight infants; however, results failed to show a lower incidence of NEC in HIV-exposed premature infants. A reduction in the severity of disease was found in the HIV-exposed study group.
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Affiliation(s)
- Evette Van Niekerk
- Division Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Daniel G Nel
- Department of Statistics and Actuarial Science, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Reneé Blaauw
- Division Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Gert F Kirsten
- Division of Neonatology, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
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Chang TS, Wiener J, Dollard SC, Amin MM, Ellington S, Chasela C, Kayira D, Tegha G, Kamwendo D, Jamieson DJ, van der Horst C, Kourtis AP. Effect of cytomegalovirus infection on breastfeeding transmission of HIV and on the health of infants born to HIV-infected mothers. AIDS 2015; 29:831-6. [PMID: 25985405 PMCID: PMC4493887 DOI: 10.1097/qad.0000000000000617] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection can be acquired in utero or postnatally through horizontal transmission and breastfeeding. The effect of postnatal CMV infection on postnatal HIV transmission is unknown. METHODS The Breastfeeding, Antiretrovirals and Nutrition study, conducted in Malawi, randomized 2369 mothers and their infants to three antiretroviral prophylaxis arms - mother (triple regimen), infant (nevirapine), or neither - for 28 weeks of breastfeeding, followed by weaning. Stored plasma and peripheral blood mononuclear cell specimens were available for 492 infants at 24 weeks and were tested with CMV PCR. Available samples from infants who were CMV PCR-positive at 24 weeks were also tested at birth (N = 242), and from infants PCR-negative at 24 weeks were tested at 48 weeks (N = 96). Cox proportional-hazards models were used to determine if CMV infection was associated with infant morbidity, mortality, or postnatal HIV acquisition. RESULTS At 24 weeks of age, CMV DNA was detected in 345/492 infants (70.1%); the estimated congenital CMV infection rate was 2.3%, and the estimated rate of CMV infection at 48 weeks was 78.5%. CMV infection at 24 weeks was associated with subsequent HIV acquisition through breastfeeding or infant death between 24 and 48 weeks of age (hazard ratio 4.27, P = 0.05). CONCLUSION Most breastfed infants of HIV-infected mothers in this resource-limited setting are infected with CMV by 24 weeks of age. Early CMV infection may be a risk factor for subsequent infant HIV infection through breastfeeding, pointing to the need for comprehensive approaches in order to achieve elimination of breastfeeding transmission of HIV.
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Affiliation(s)
| | - Jeffrey Wiener
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sheila C. Dollard
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Minal M. Amin
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sascha Ellington
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | | | | | | | - Athena P. Kourtis
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Pfeifer K, Kalra V, Adebowale A, Juthani-Mehta M, Soo-Shin M. Apical Pneumocystis jiroveci as an AIDS defining illness: A case report illustrating a change in the paradigm. J Radiol Case Rep 2014; 8:15-24. [PMID: 25926907 DOI: 10.3941/jrcr.v8i11.1772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pneumocystis jiroveci pneumonia is a common acquired immune deficiency syndrome defining illness. Pneumocystis jiroveci pneumonia is classically described as having symmetrical bilateral perihilar ground-glass opacities on chest radiographs. We present an "atypical" case of Pneumocystis jiroveci pneumonia presenting as symmetric biapical cystic spaces with relative sparing of the remainder of the lungs in a 22 year-old male, previously undiagnosed with acquired immune deficiency syndrome. Our case illustrates that formerly unusual presentations of Pneumocystis jiroveci pneumonia are becoming more common as acquired immune deficiency syndrome defining illnesses as more patients are being imaged with further imaging such as high resolution computed tomography.
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Affiliation(s)
- Kyle Pfeifer
- Department of Radiology, Yale New Haven hospital, New Haven, CT, USA
| | - Vivek Kalra
- Department of Radiology, Yale New Haven hospital, New Haven, CT, USA
| | | | | | - Myung Soo-Shin
- Department of Radiology, Yale New Haven hospital, New Haven, CT, USA
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Fetal exposure to HIV-1 alters chemokine receptor expression by CD4+T cells and increases susceptibility to HIV-1. Sci Rep 2014; 4:6690. [PMID: 25341640 PMCID: PMC4208038 DOI: 10.1038/srep06690] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 09/23/2014] [Indexed: 01/02/2023] Open
Abstract
Absolute numbers of lymphocytes are decreased in uninfected infants born to HIV-1-infected women (HIV-1-exposed). Although the exact mechanism is unknown, fetal exposure to maternal HIV-1-infection could prime the immune system and affect T cell trafficking. We compared the expression of chemokine receptors on cord blood CD4+ T cells from HIV-1-exposed children and healthy controls. At baseline CD4+ T cells had a largely naïve phenotype. However, stimulation with cytokines resulted in an upregulation of inflammatory response-related chemokine receptors on CD4+ T cells, with HIV-1-exposed infants having a significantly higher frequency of CD4+ T cells expressing, in particularly Th2 associated chemokine receptors (CCR3 p < 0.01, CCR8 p = 0.03). Numbers of naive CCR7+ CD4+ T cells were reduced (p = 0.01) in HIV-1-exposed infants. We further assessed whether the inflammatory phenotype was associated with susceptibility to HIV-1 and detected higher levels of p24 upon in in vitro infection of stimulated CD4+ T cells of HIV-1-exposed infants. In summary, fetal exposure to HIV-1 primes the immune system in the infant leading to an enhanced immune activation and altered T cell homing, with potential ramifications regarding T cell responses and the acquisition of HIV-1 as an infant.
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