Pneumocystis carinii pneumonia prophylaxis and early clinical manifestations of severe perinatal human immunodeficiency virus type 1 infection. Northern California Pediatric HIV Consortium

The effectiveness of state and national policy on the implementation of perinatal HIV prevention interventions

OBJECTIVES

The 1994 and 1995 US Public Health Service Guidelines regarding HIV testing and treatment for pregnant women and the resulting 1995 California law mandating an HIV test and treatment offer to every pregnant woman aim to reduce perinatal HIV transmission. However, the effectiveness of such policies after implementation is often unclear. We analyzed the association between these policies and offers of HIV tests and treatment to HIV-infected women in California.

METHODS

Data from active, population-based surveillance of 496 HIV-infected women and their infants, collected from 1987 to 2002, were analyzed to compare rates of offers of HIV tests and treatment before and after 1996.

RESULTS

We found significant increases in offers of HIV tests (P<.001) and offers of treatment (P<.001) when we compared women who delivered between 1987 and 1995 with those who delivered between 1996 and 2002. Receipt of prenatal care was the major predictor of both test and treatment offer. A significant shift in reported HIV risk factors was also evident between the 2 groups.

CONCLUSIONS

Our findings of increased offers of HIV tests and treatment to HIV-infected pregnant women suggest that the national guidelines and the 1996 California law improved health care for these women, which may lessen the risk of perinatal HIV transmission.

Estimating the number of vertically HIV-infected children eligible for antiretroviral treatment in resource-limited settings

BACKGROUND

With the gradual roll-out of antiretroviral therapy (ART) to delay progression of HIV disease in children in programmes across sub-Saharan Africa and resource-limited settings elsewhere, reliable information on the number of vertically infected children eligible for such treatment is urgently required.

METHODS

We present a model to estimate the number of vertically HIV-infected children by age who have progressed to moderate to severe disease (MSD) and as such are eligible for ART on the basis of clinical disease, allowing for: antenatal HIV prevalence, use of interventions to prevent mother-to-child transmission (PMTCT), infant feeding policies and availability of co-trimoxazole to prevent opportunistic infections that may hasten the onset of serious disease. The model assumptions were informed by published evidence and expert opinion; rates of progression to serious disease were inferred from mortality of infected and uninfected children of HIV-infected mothers; and mortality among children treated with ART was based on a study of treated children in Abidjan. To allow widespread use the model has been developed using the Excel spreadsheet software.

RESULTS

With South Africa as a hypothetical example, published antenatal prevalence and demographic data, and assuming PMTCT coverage with single dose nevirapine of 11%, all exposed and infected children receive co-trimoxazole, and various infant feeding policy scenarios, estimated numbers of children eligible for ART are presented.

CONCLUSIONS

This model is easy to implement and flexible and can be used in ART programmes at national and local level.

Disease Progression Among HIV-Infected Children Who Receive Perinatal Zidovudine Prophylaxis

BACKGROUND

Studies of perinatal HIV infection have reported mixed results regarding the prognosis of HIV-infected infants exposed to perinatal zidovudine prophylaxis (PZP).

METHODS

We have followed a population-based cohort of children with perinatal HIV infection to evaluate whether early HIV disease progression was more common among those who received PZP and whether subsequent antiretroviral therapy (ART) was less effective in preventing early disease progression.

RESULTS

We identified 73 children with perinatal HIV infection born between 1994 and 2001 with at least 3 years of follow-up and with information concerning PZP administration. Children who received PZP started subsequent ART at an earlier age than those who did not receive PZP (median age at starting treatment: 2 months for PZP vs. 6 months for no PZP; P = 0.0002). PZP was associated with decreased early HIV progression: 21% (7 of 33) of children who received PZP progressed to a category C diagnosis by 3 years compared with 45% (18 of 40) of children who did not receive PZP (P = 0.047). Children who did not receive PZP progressed to a category C diagnosis at a younger age than children who received PZP (median: 4 vs. 11 months; P = 0.061). ART was as effective in preventing early HIV progression in children who received PZP as in children who did not receive PZP.

CONCLUSIONS

In our population-based cohort of perinatally HIV-infected children, those who received PZP started ART at a significantly earlier age than those who did not receive PZP and also demonstrated decreased HIV disease progression by the age of 3 years.

Changes in deaths reported with human immunodeficiency virus infection among United States children less than thirteen years old, 1987 through 1999

BACKGROUND

With implementation of highly active antiretroviral therapy during 1995 through 1999, deaths reported in adults with HIV infection decreased 67%, and the proportions of those accompanied by various opportunistic infections decreased, whereas their proportions with possibly unrelated conditions (e.g. diseases of liver, kidneys and heart) increased.

OBJECTIVE

To examine changes among deaths of children with HIV infection.

METHODS

We analyzed multiple-cause death certificate data with any mention of HIV infection for all US deaths at ages <13 years from 1987 through 1999. We examined changes in the numbers and rates of deaths and the proportions reported with various diseases.

RESULTS

The annual number of children who died with HIV infection increased from 274 in 1987 to 511 in 1994 and then decreased by 81% to 97 in 1999. The median age at death increased from 1 year in 1987 to 5 years in 1999. During the periods 1987 through 1991 (1652 deaths), 1992 through 1995 (1906 deaths) and 1996 through 1999 (762 deaths), the proportion of deaths with pneumocystosis decreased from 19.0% to 9.9% and 7.5%, respectively. In a comparison of 1992 through 1995 with 1996 through 1999, no significant change occurred in the proportions of deaths with nontuberculous mycobacteriosis (5.6% to 6.0%), cytomegalovirus disease (3.2% to 4.4%), heart disease (10.8% to 11.7%), kidney disease (5.0%), liver disease (3.9% to 4.1%) or wasting/cachexia (4.0% to 5.0%).

CONCLUSIONS

Deaths with HIV infection among children have decreased substantially, probably because of both highly active antiretroviral therapy and prevention of perinatal HIV transmission. The decrease after 1995 was greater proportionally among children than among adults, but fewer changes in disease proportions occurred among children.

Evaluating a new strategy for prophylaxis to prevent Pneumocystis carinii pneumonia in HIV-exposed infants in Thailand. Bangkok Collaborative Perinatal HIV Transmission Study Group

OBJECTIVE

To evaluate a strategy for prophylaxis against Pneumocystis carinii pneumonia (PCP) for infants in Thailand.

METHODS

HIV-infected women were offered trimethoprim-sulfamethoxazole for PCP prophylaxis for their children at 1-2 months of age. When the children reached 6 months of age, investigators simulated a decision to continue or stop prophylaxis on the basis of clinical criteria, and compared their decisions with results of polymerase chain reaction (PCR) testing for HIV. We calculated the proportions of children who received and completed prophylaxis, and compared the rates of pneumonia and death from pneumonia with rates from an earlier prospective cohort.

RESULTS

Of 395 eligible infants, 383 (97%) started prophylaxis. By 6 months of age, 10 (2.6%) were lost to follow-up, three (0.8%) were non-adherent, seven (2%) had stopped because of adverse events, four (1%) had died, and 359 (94%) still received prophylaxis. At 6 months of age, 30 (70%) of 43 HIV-infected children and 16 (5%) of 316 uninfected children met the clinical criteria to continue prophylaxis. The incidence of pneumonia at 1 to 6 months of age was 22% (15/68) in the earlier cohort, and 13% (6/46) in the recent cohort [relative risk (RR) 0.6, 95% confidence interval (CI) 0.3-1.4; P= 0.22]; mortality rates were 9% and 4%, respectively (RR 0.5; 95% CI 0.1-2.3; P = 0.47).

CONCLUSION

This PCP prophylaxis strategy appeared to be acceptable and safe, may have reduced morbidity and mortality from pneumonia, and should be considered in developing countries where early laboratory diagnosis of perinatal HIV infection is unavailable.

Opportunistic infections and other clinical manifestations of HIV disease in children

As the decade draws to a close, physicians can be cautiously optimistic about the prevention and treatment of opportunistic infections in children with HIV disease. As more children receive therapy with powerful antiretroviral regimens, fewer are likely to be at risk for opportunistic pathogens. The widespread use of protease inhibitor combination therapies has already resulted in a dramatic decrease in morbidity and mortality in the population of HIV-infected adults. The same effect has been seen at pediatric care centers throughout the United States. Clinicians caring for HIV-infected children are now considering the safety of discontinuing prophylactic therapies for children with sustained immunologic improvement on antiretroviral therapy. For children who remain at risk, prophylactic regimens for PCP and MAC have been shown to decrease the risk for these infections. Preventive regimens for several other opportunistic infections are also available. The understanding of the pathogenesis of HIV and many of the opportunistic pathogens has led to the development of a variety of efficacious therapies for these infections. Despite these advances, physicians can anticipate that HIV-infected children will continue to develop opportunistic infections and other related complications. Some children fail to respond to antiretroviral therapies, whereas others are unable to tolerate the complex medication regimens. Prophylactic therapies are not 100% protective and, despite improved treatments, few opportunistic infections are cured. Most require lifelong maintenance therapy in the absence of immune reconstitution. Drug interactions, complex dosing schedules, adverse side effects, and high costs further limit the efficacy of these therapies. The prophylaxis, diagnosis, and treatment of opportunistic infections are likely to remain integral components of HIV care for the near and distant future.

Mortality after the first year of life among human immunodeficiency virus type 1-infected and uninfected children

BACKGROUND

HIV-infected and uninfected children who survived their first year of life were prospectively followed in Malawi to assess levels of mortality and related risk factors during the second and third years of life.

METHODS

Children with known HIV status from an earlier perinatal intervention trial were enrolled. These children [HIV-infected (Group A); HIV-uninfected but born to HIV-seropositive mothers (Group B); and children born to HIV-seronegative mothers (Group C)] were followed every 3 months until age 36 months. Mortality data were collected at each visit. Immunologic data (CD4+ percent) were collected at or immediately after enrollment.

RESULTS

Overall 702 children were enrolled and 83 children died during follow-up. The mortality rate per 1000 person years of observation was 339.3 among Group A children, 46.3 among Group B children and 35.7 among Group C children. Among HIV-infected children the cumulative proportion surviving to age 24 months was 70% and those surviving to age 36 months was 55%. By age 32 months none of the severely immunosuppressed (CD4% < 15%) children had survived. The mortality differentials between HIV-infected and uninfected children persisted after adjusting for several risk factors. The major causes of death among infected children (n = 52) were wasting and respiratory conditions.

CONCLUSIONS

Although all HIV-infected children had received childhood immunizations, mortality was high. Management of these children should include aggressive antimicrobial treatment, and evaluation of prophylactic regimens should be considered.