Primary HIV-1 infection in African children infected through breastfeeding

Utility of clinical parameters to identify HIV infection in infants below ten weeks of age in South Africa: a prospective cohort study

BACKGROUND

As HIV-infected infants have high mortality, the World Health Organization now recommends initiating antiretroviral therapy as early as possible in the first year of life. However, in many settings, laboratory diagnosis of HIV in infants is not readily available. We aimed to develop a clinical algorithm for HIV presumptive diagnosis in infants < 10 weeks old using screening data from the Children with HIV Early Antiretroviral therapy (CHER) study in South Africa.HIV-infected and HIV-uninfected exposed infants < 10 weeks of age were identified through Vertical Transmission Prevention programs. Clinical and laboratory data were systematically recorded, groups were compared using Kruskal-Wallis, analysis of variance (ANOVA), and Fisher's exact tests. Receiver Operating Characteristic (ROC) curves were compiled using combinations of clinical findings.

RESULTS

417 HIV-infected and 125 HIV-exposed, uninfected infants, median age 46 days (IQR 38-55), were included. The median CD4 percentage in HIV-infected infants was 34 (IQR 28-41)%. HIV-infected infants had lower weight-for-age, more lymphadenopathy, oral thrush, and hepatomegaly than exposed uninfected infants (Adjusted Odds Ratio 0.51, 8.8, 5.6 and 23.5 respectively; p < 0.001 for all). Sensitivity of individual signs was low (< 20%) but specificity high (98-100%). If any one of oral thrush, hepatomegaly, splenomegaly, lymphadenopathy, diaper dermatitis, weight < 50(th) centile are present, sensitivity for HIV infection amongst HIV-exposed infants was 86%. These algorithms performed similarly when used to predict severe immune suppression.

CONCLUSIONS

A combination of physical findings is helpful in identifying infants most likely to be HIV-infected. This may inform management algorithms and provide guidance for focused laboratory testing in some settings, and should be further validated in these settings and elsewhere.

Primary HIV-1 infection among infants in sub-Saharan Africa: HPTN 024

OBJECTIVES

Our objectives were to assess clinical signs and diagnoses associated with primary HIV-1 infection among infants.

METHODS

We analyzed data from a clinical trial (HIV Prevention Trials Network Protocol 024) in sub-Saharan Africa. Study visits were conducted at birth, at 4-6 weeks, and at 3, 6, 9, and 12 months. The study population comprised live born, singleton, first-born infants of HIV-1-infected women with negative HIV-1 RNA assays who were still breastfeeding at 4-6 weeks.

RESULTS

Of 1317 HIV-1-exposed infants, 84 became HIV-1 infected after 4-6 weeks and 1233 remained uninfected. There were 102 primary and 5650 nonprimary infection visits. The most common signs were cough and diarrhea, and the most common diagnoses were malaria and pneumonia. Primary infection was associated with significantly increased odds of diarrhea [odds ratio (OR) = 2.4], pneumonia (OR = 3.5), otitis media (OR = 3.1), and oral thrush (OR = 2.9). For the clinical signs and diagnoses evaluated, sensitivity was low (1%-16.7%) and specificity was high (88.2%-99%). Positive predictive values ranged from 0.1%-1.4%. Negative predictive values ranged from 28.0%-51.1%.

CONCLUSIONS

Certain clinical signs and diagnoses, although more common during primary HIV-1 infection, had low sensitivity and high specificity. Efforts to expand access to laboratory assays for the diagnosis of primary HIV-1 infection among infants of HIV-1-infected women should be emphasized.

The rhesus macaque pediatric SIV infection model - a valuable tool in understanding infant HIV-1 pathogenesis and for designing pediatric HIV-1 prevention strategies

Worldwide, the AIDS pandemic continues almost relentlessly. Women are now representing the fastest growing group of newly infected HIV-1 infected patients. The risk of mother-to-child-transmission (MTCT) of HIV-1 increases proportionally as many of these women are of childbearing age. The screening of pregnant women, the early diagnosis of HIV-1 infection, and the administration of antiretroviral therapy (ART) have helped to reduce MTCT significantly. However, this holds true only for developed countries. In many resource-poor countries, access to ART is limited, and breastfeeding, a major route of HIV-1 transmission, is essential to protect the infant from other infectious diseases preponderant in those geographic regions. HIV-1 infected children, in contrast to adult patients, have higher levels of virus replication that decline only slowly, and a subset progresses to AIDS within the first two years. Thus, it is imperative to understand pediatric HIV-1 pathogenesis to design effective prevention strategies and/or a successful pediatric HIV-1 vaccine. The review summarizes how MTCT of HIV-1 in humans can be modeled in the infant macaque model of SIV infection. Importantly, the infant macaque model of SIV infection provides the opportunity to study early virus-host interactions in multiple anatomic compartments. Furthermore, the review underlines the importance of evaluating SIV/HIV immune responses in the context of the normal developmental changes the immune system undergoes in the newborn. Thus, the pediatric SIV infection model provides a unique resource for preclinical studies of novel intervention therapies and vaccine strategies to stop MTCT of HIV-1.

Acute HIV infection among Kenyan infants

BACKGROUND

Clinical signs and symptoms of acute human immunodeficiency virus (HIV) infection in infants are not well characterized.

METHODS

Serial clinical assessments and HIV PCR assays were conducted in a cohort of children born to HIV-seropositive mothers from birth to 2 years of age. Acute HIV infection visits were defined as those up to 3 months prior to and including the visit at which HIV DNA was first detected. Noninfection visits included all visits at which the child had test results negative for HIV, including the last visit at which a test result negative for HIV DNA was obtained in children who later acquired HIV infection. Differences in the prevalence of symptoms at acute infection versus noninfection visits were determined overall and were stratified by age at infection (<2 months vs. >or=2 months). HIV RNA was measured serially in infected infants and was compared between infants with and infants without symptoms of acute HIV infection.

RESULTS

There were 125 acute infection visits (among 56 infants) and 3491 noninfection visits (among 306 infants). Acute HIV infection was associated with rash (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-2.8), failure to thrive (OR, 1.9; 95% CI, 1.0-3.5), and lymphadenopathy (OR, 2.5; 95% CI, 1.4-4.8). Acute HIV infection was associated with lymphadenopathy (OR, 2.6; 95% CI, 1.3-5.0) in infants <2 months of age and with pneumonia (OR, 3.2; 95% CI, 1.1-9.3) and dehydration (OR, 6.0; 95% CI, 1.9-18.5) in infants >or=2 months of age. Infant peak viral load and mortality were not associated with symptoms of acute HIV infection. However, infants with symptoms had higher viral levels later in the course of infection than did those without symptoms (P=.05).

CONCLUSIONS

Infants may manifest symptoms early during the course of HIV infection, and symptoms of acute HIV infection may correlate with poor viral control. Rash, failure to thrive, lymphadenopathy, pneumonia, and dehydration may signify acute HIV infection in infants.

Potential of a simplified p24 assay for early diagnosis of infant human immunodeficiency virus type 1 infection in Haiti

With global efforts to scale up the prevention of mother-to-child transmission services and pediatric antiretroviral therapy, there is an urgent need to introduce a simple, low-cost infant human immunodeficiency virus test in the field. We postulated that the p24 antigen capture enzyme-linked immunosorbent assay could be simplified by eliminating signal amplification without compromising diagnostic accuracy.

Acute human immunodeficiency virus infection in a breast-fed infant in New York City

Acute human immunodeficiency virus (HIV) infection in a breast-fed infant is a rare diagnosis in developed countries. We present a six-month old girl with postnatally acquired HIV infection complicated by Pneumocystis jéroveci pneumonia, cytomegalovirus pneumonitis and encephalopathy. Her mother had tested negative for HIV during pregnancy. Children infected by mothers during an acute seroconversion may have more rapid disease progression.

Retroviral rebound syndrome after treatment discontinuation in a 15 year old girl with HIV attracted through mother-to-child transmission: case report

A case of a 15 year old girl with retroviral rebound syndrome after discontinuation of highly active antiretroviral treatment (HAART) due to side effects is presented. The patient was transmitted with HIV at birth by her mother. She had recovered from severe AIDS after HAART was initiated five years earlier. This is the first case reported in the literature of retroviral rebound syndrome in a vertically transmitted HIV-infected patient.

Vaccines to prevent transmission of HIV-1 via breastmilk: scientific and logistical priorities

Mother-to-child transmission (MTCT) of HIV-1 is the major mode of paediatric infection. The rapidly increasing incidence of MTCT worldwide has resulted in an urgent need for preventive strategies. Antiretroviral regimens can prevent intrapartum HIV transmission; however, these regimens do not prevent HIV transmission through breastfeeding. Furthermore, children who escape MTCT are again at risk of infection when they become sexually active as adolescents. An infant vaccine regimen, begun at birth, would hence be a more attractive strategy and might also provide the basis for lifetime protection. Unique features of MTCT and paediatric HIV disease could be helpful in understanding correlates of immune protection and could facilitate rapid assessment of vaccine efficacy. Thus, there is compelling rationale to develop safe, effective HIV vaccines for use in infants and children. Here, we discuss the scientific and logistical challenges for the development of paediatric HIV vaccines; available vaccines and completed or planned paediatric vaccine trials are also discussed.