Skin disease among human immunodeficiency virus-infected adolescents in Zimbabwe: a strong indicator of underlying HIV infection

Prevalence and Pattern of Paediatric dermatoses among children in Aminu Kano teaching Hospital Kano, Nigeria

INTRODUCTION

Skin disorders are common among children, most especially the infections and infestations as the immunity is not fully developed during childhood. Skin disorders are among common causes of morbidity in developing countries of Sub-Saharan Africa.Skin disorders are major cause of concern among children. This study aimed to document the prevalence of skin diseases among children who attended the paediatric outpatient clinic of the Aminu Kano Teaching Hospital (AKTH) Kano, Nigeria.

METHODS

It was a cross-sectional study. The study population included children aged between 6 weeks and 14years from the study area who attend Paediatric Out Patient Department (POPD) clinics recruited consecutively. Data obtained from the patients included age, gender, clinical features, socio-economic class and diagnosis.

RESULT

Two hundred and twenty-three children aged 6weeks to 14years were enrolled into the study. The mean age of the children was 84.42+ 40.12. There were 110 males (49.3%) and 113 females (50.7%) with Male to female ratio 1:1.1. Fifty-five children (24.7%) had skin disorders. There were 14 specific diagnosis made. The leading categories were infections accounting for 18.3% of the skin disorders (p < 0.001). Seborrheic dermatitis was the commonest specific diagnosis found among 3.1% of the children.

CONCLUSION

Prevalence of skin disorders among children attending POPD of Aminiu Kano Teaching Hospital is 24.7%. Infections and infestations were the commonest category of skin disorders found.

Mucocutaneous diseases in the combined antiretroviral therapy era: prevalence and spectrum in HIV seropositive children and adolescents in Durban, South Africa

BACKGROUND

Mucocutaneous diseases (MCD) have been commonly described among human immunodeficiency virus (HIV) infected patients before the combined antiretroviral therapy (cART) era. There is limited data on the frequency and type of MCD in the cART era in African children and adolescents. This study aimed to describe the prevalence and spectrum of MCD in South African children and adolescents seropositive for HIV on cART.

METHODS

A cross-sectional study of 310 participants aged 0-19 years attending a public sector ART clinic at King Edward VIII Hospital, Durban, South Africa, was conducted. Demographic, clinical, and laboratory information was obtained from the participants and hospital records. Participants were examined. Data were collated and analyzed with SPSS version 23.

RESULTS

MCD were observed in 77.4% of HIV-infected children. The prevalence was higher among males and adolescents above 16 years old (83.9%). Infectious skin disorders (44.7%) were less common than noninfectious dermatoses (55.3%). More common disorders encountered included generalized pruritus (32.6%), fungal infections (20.9%), and inflammatory (20.4%) and pigmentary (20.4%) skin disorders. Tinea capitis and pedis were the most prevalent fungal infections, while oral candidiasis (0.2%) was the least. Inflammatory skin disorders and dyschromia appeared to be more common than in the pre-cART era.

CONCLUSIONS

While MCD are still common in HIV-infected children and adolescents in the cART era, the pattern and types of disorders have changed to a predominance of non-infectious dermatoses.

Chronic itch in African Americans: an unmet need

Chronic pruritus carries a significant burden of disease and is associated with a negative impact on quality of life. African Americans are disproportionately burdened by chronic pruritic disorders, including but not limited to atopic dermatitis, prurigo nodularis, inflammatory scalp dermatoses, pathologic scarring, and HIV-related dermatoses. Racial differences in skin structure and function may contribute to the pathogenesis of itch in African Americans. Itch perception and response to treatment in African Americans remain understudied and not well understood. As such, there is a large unmet need with regard to the knowledge and management of pruritus in African Americans. This review highlights notable differences in the epidemiology, pathophysiology, genetic predisposition, clinical presentation, and response to treatment for select pruritic skin conditions. By addressing itch as an unmet need in African Americans, we hope to improve patient outcomes and lessen disparities in dermatologic care.

Mucocutaneous Manifestations in HIV-Infected Patients and Their Relationship to CD4 Lymphocyte Counts

BACKGROUND

More than 90% of human immunodeficiency virus- (HIV-) infected patients show at least one mucocutaneous manifestation during the course of their disease. The frequency, pattern, and associated factors of these complications vary among different populations.

OBJECTIVE

This study was planned to evaluate the frequency of cutaneous presentations in HIV-infected patients and their association with the count of CD4 cells.

METHODS

A cross-sectional study was conducted on eighty-four HIV-positive patients, who attended the Behavior Consultation Center of Arak University of Medical Sciences. All subjects had a complete physical examination by an expert dermatologist. Further diagnostic procedures were performed, if necessary. Counts of CD4 were determined using flow cytometry.

RESULTS

From 84 patients who enrolled in this study, 95.2% manifested at least one type of mucocutaneous lesions. The most common presentation was xerosis, followed by seborrheic dermatitis, herpes simplex, and oral candidiasis. Oral candidiasis and furuncle were significantly associated with decrease in CD4 cell counts.

CONCLUSIONS

Cutaneous manifestations are common in HIV-positive patients, some of which (oral candidiasis and furuncle) could be applicable as useful clinical indicators to predict the immune status of the patients. Therefore, regular skin examinations are recommended as routine HIV-infected patients' healthcare programs.

Prevalence of pruritic papular eruption among HIV patients: A cross-sectional study

Introduction:

Pruritic papular eruption (PPE) remains as one of the most common cutaneous manifestations in HIV-infected patients. Proper knowledge about understanding the risk factors associated with this disease may help to decrease the prevalence of PPE.

Objective:

The present study was conducted to determine the prevalence of PPE in HIV-infected patients and to correlate between the severity of PPE and individual CD4 count.

Materials and Methods:

This was a cross-sectional study, conducted in Palakkad Antiretroviral Therapy Centre, Kerala, between March 2017 and April 2017. A total of 100 HIV patients with evidence of multiple itchy skin lesions of 1-month duration were included in the study. Severity of lesion was evaluated using an objective “rash severity scale” for PPE. Data were coded and analyzed.

Results:

Prevalence of PPE was 11.35% in our study. The mean age of the study population was 41.17 ± 12. Male-to-female ratio was 1:2. In our study, 97% of the patients were giving history of mosquito bite. Most of the patients (40%) had moderate type of PPE. In our study, majority (86%) had a CD4 count of more than 200, and the incidence of PPE was more frequently seen in patients with CD4 count more than 200 cells which was statistically significant.

Conclusion:

PPEs are unique dermatosis, which is having a devastating impact on the quality of life, stigmatizing them in their communities. Thus, recognizing those lesions helps in allowing better treatment of this distressing condition.

Mucocutaneous manifestations of human immunodeficiency virus (HIV) infection in children in relation to the degree of immunosuppression

BACKGROUND

Human immunodeficiency virus (HIV) infection in children is becoming a common occurrence. Worldwide, limited studies have been done on the mucocutaneous manifestations in HIV-positive children. The aim of our study was to analyze the spectrum of mucocutaneous manifestations of pediatric HIV infection and correlate to degree of immunosuppression.

MATERIAL AND METHODS

One hundred and sixty-five children under 18 years with HIV, who presented to the departments of dermatology and pediatrics, were examined for mucocutaneous manifestations. Patients were classified into four groups of immunodeficiency such as normal, mild, advanced, and severe, based on NACO guidelines of immunosuppression. The most recent CD4 count (within 6 months of study period) was considered.

RESULTS

One hundred and sixty-five patients were examined, and skin manifestations were seen in 100 (61%) of them.The highest incidence of mucocutaneous manifestations was in 6-10 age group. Papular pruritic eruptions (PPE) (16%) was the most common condition, with highest prevalence in severe CD4 category (38%). Molluscum contagiosum (MC) (10%) was the most common infectious condition, with highest prevalence in advanced CD4 category (14%). Severe cutaneous adverse reactions (SCAR) caused by nevirapine were seen in three children. The percentage of skin manifestations was highest in the advanced (107%) and severe (100%) CD4 category. There was no significant difference in manifestations between those who were on antiretroviral therapy (ART) and those not.

CONCLUSION

The percentage of skin manifestations increased with degree of CD4 depletion. PPE was found to be the hallmark of severe immunosuppression. However, opportunistic infections did not correlate with severity of immunodeficiency.

Patterns of common skin infections among children living with HIV/AIDS in Hawassa City, Ethiopia: a cross sectional study

Objectives

Skin disorders are the most common health problems seen among HIV positive patients. It presents with a variety of manifestations which can cause significant morbidity. This study was aimed to assess the prevalence of common skin problems among children living with HIV/AIDS at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia, 2017/2018. Hospital based cross-sectional study was conducted among 125 children living with HIV/AIDS who were recruited through simple random sampling techniques from February to April 2017. Pre-tested, structured questionnaires were used to collect the data.

Result

Among a total of 125 study participants, 72 (57.6%) of the children were males and 97 (77.6%) were in the age range of 10–14 years. 90 (72%) of participants had different kinds of skin problems. Among those who had one kind of common skin infection, 53 (42.4%) were males. Viral skin infections that accounts 48 (53.3%), were the leading cause of skin infections followed by 43 (47.8%), 33(36.7%) and 22 (24.7%) fungal infections, inflammatory and bacterial skin infections respectively. Among all children who were taking ART, only 2.4% of the children had skin related side effects.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3991-4) contains supplementary material, which is available to authorized users.

Understanding the experience and manifestation of depression in adolescents living with HIV in Harare, Zimbabwe

BACKGROUND

Studies have found that adolescents living with HIV are at risk of depression, which in turn affects adherence to medication. This study explored the experience and manifestation of depression in adolescents living with HIV in Zimbabwe in order to inform intervention development.

METHODS

We conducted a body mapping exercise with 21 HIV positive 15-19 years olds who had been diagnosed with major depressive disorder. Participants created a painted map of their body to assist them in expressing their somatic and emotional experiences in qualitative interviews. The interviews were transcribed and thematically coded using NVivo 10.

RESULTS

Participants attributed their experiences of depression to their relationships and interactions with significant people in their lives, primarily family members and peers. A sense of being different from others was common among participants, both due to their HIV status and the impact HIV has had on their life circumstances. Participants described a longing to be important or to matter to the people in their lives. A sense of isolation and rejection was common, as well as grief and loss, including ambiguous and anticipated loss. Participants' idioms of distress included 'thinking deeply' ('kufungisisa'), 'pain', darkness, 'stress' or a lack of hope and ambiguity for the future. Suicidal ideation was described, including slow suicide through poor adherence. Supportive factors were also relational, including the importance of supportive relatives and peers, clinic staff and psychosocial support programmes.

CONCLUSIONS

An understanding of HIV positive adolescents' own narratives around depression can inform the development and integration of appropriate mental health interventions within HIV care and treatment programmes. Study findings suggest that family and peer-led interventions are potentially useful in the prevention and management of depression in adolescents living with HIV.

Clinical outcomes in children and adolescents initiating antiretroviral therapy in decentralized healthcare settings in Zimbabwe

INTRODUCTION

Decentralized HIV care for adults does not appear to compromise clinical outcomes. HIV care for children poses additional clinical and social complexities. We conducted a prospective cohort study to investigate clinical outcomes in children aged 6-15 years who registered for HIV care at seven primary healthcare clinics (PHCs) in Harare, Zimbabwe.

METHODS

Participants were recruited between January 2013 and December 2014 and followed for 18 months. Rates of and reasons for mortality, hospitalization and unscheduled PHC attendances were ascertained. Cox proportional modelling was used to determine the hazard of death, unscheduled attendances and hospitalization.

RESULTS

We recruited 385 participants, median age 11 years (IQR: 9-13) and 52% were female. The median CD4 count was 375 cells/mm3 (IQR: 215-599) and 77% commenced ART over the study period, with 64% of those who had viral load measured achieving an HIV viral load <400 copies/ml. At 18 months, 4% of those who started ART vs. 24% of those who remained ART-naïve were lost-to-follow-up (p < 0.001). Hospitalization and mortality rates were low (8.14/100 person-years (pyrs) and 2.86/100 pyrs, respectively). There was a high rate of unscheduled PHC attendances (34.94/100 pyrs), but only 7% resulted in hospitalization. Respiratory disease was the major cause of hospitalization, unscheduled attendances and death. CD4 count <350cells/mm3 was a risk factor for hospitalization (aHR 3.6 (95%CI 1.6-8.2)).

CONCLUSIONS

Despite only 64% of participants achieving virological suppression, clinical outcomes were good and high rates of retention in care were observed. This demonstrates that in an era moving towards differentiated care in addition to implementation of universal treatment, decentralized HIV care for children is achievable. Interventions to improve adherence in this age-group are urgently needed.

Chronic Morbidity Among Older Children and Adolescents at Diagnosis of HIV Infection

BACKGROUND

Substantial numbers of children with HIV present to health care services in older childhood and adolescence, previously undiagnosed. These "slow-progressors" may experience considerable chronic ill health, which is not well characterized. We investigated the prevalence of chronic morbidity among children aged 6-15 years at diagnosis of HIV infection.

METHODS

A cross-sectional study was performed at 7 primary care clinics in Harare, Zimbabwe. Children aged 6-15 years who tested HIV positive following provider-initiated HIV testing and counseling were recruited. A detailed clinical history and standardized clinical examination was undertaken. The association between chronic disease and CD4 count was investigated using multivariate logistic regression.

RESULTS

Of the 385 participants recruited [52% female, median age 11 years (interquartile range 8-13)], 95% were perinatally HIV infected. The median CD4 count was 375 (interquartile range 215-599) cells per cubic millimeter. Although 78% had previous contact with health care services, HIV testing had not been performed. There was a high burden of chronic morbidity: 23% were stunted, 21% had pubertal delay, 25% had chronic skin disease, 54% had a chronic cough of more than 1 month-duration, 28% had abnormal lung function, and 12% reported hearing impairment. There was no association between CD4 count of <500 cells per cubic millimeter or <350 cells per cubic millimeter with WHO stage or these chronic conditions.

CONCLUSIONS

In children with slow-progressing HIV, there is a substantial burden of chronic morbidity even when CD4 count is relatively preserved. Timely HIV testing and prompt antiretroviral therapy initiation are urgently needed to prevent development of chronic complications.

Treatment of Dermatological Conditions Associated with HIV/AIDS: The Scarcity of Guidance on a Global Scale

Background. Skin diseases associated with Human Immunodeficiency Virus (HIV) infection are associated with significant morbidity and mortality. In resource-limited settings, nondermatologists and lay health care providers on the front line of HIV care provide much of the treatment for these conditions. Objective. To evaluate guidelines for treatment of HIV-related skin conditions and assess their accessibility, comprehensiveness, and quality of evidence employed. Methods. A review was undertaken of all national and society guidelines which included treatment information on the ten highest burden HIV-related skin conditions. The search strategy included gray and peer-reviewed literature. Results. Of 430 potential guidelines, 86 met inclusion criteria, and only 2 were written specifically to address HIV-related skin diseases as a whole. Treatment information for HIV-related skin conditions was embedded within guidelines written for other purposes, primarily HIV/AIDs treatment guidelines (49%). Development of guidelines relied either partially or completely on expert opinion (62%). Only 16% of guidelines used gradation of evidence quality and these were primarily from high-income countries (p = 0.001). Limitations. Due to the nature of gray literature, not all guidelines may have been identified. Conclusion. This review highlights the need for evidence-based summary guidelines that address treatment for HIV-related skin conditions in an accessible format.

Clinical, Virologic, Immunologic Outcomes and Emerging HIV Drug Resistance Patterns in Children and Adolescents in Public ART Care in Zimbabwe

OBJECTIVE

To determine immunologic, virologic outcomes and drug resistance among children and adolescents receiving care during routine programmatic implementation in a low-income country.

METHODS

A cross-sectional evaluation with collection of clinical and laboratory data for children (0-<10 years) and adolescents (10-19 years) attending a public ART program in Harare providing care for pediatric patients since 2004, was conducted. Longitudinal data for each participant was obtained from the clinic based medical record.

RESULTS

Data from 599 children and adolescents was evaluated. The participants presented to care with low CD4 cell count and CD4%, median baseline CD4% was lower in adolescents compared with children (11.0% vs. 15.0%, p<0.0001). The median age at ART initiation was 8.0 years (IQR 3.0, 12.0); median time on ART was 2.9 years (IQR 1.7, 4.5). On ART, median CD4% improved for all age groups but remained below 25%. Older age (≥ 5 years) at ART initiation was associated with severe stunting (HAZ <-2: 53.3% vs. 28.4%, p<0.0001). Virologic failure rate was 30.6% and associated with age at ART initiation. In children, nevirapine based ART regimen was associated with a 3-fold increased risk of failure (AOR: 3.5; 95% CI: 1.3, 9.1, p = 0.0180). Children (<10 y) on ART for ≥4 years had higher failure rates than those on ART for <4 years (39.6% vs. 23.9%, p = 0.0239). In those initiating ART as adolescents, each additional year in age above 10 years at the time of ART initiation (AOR 0.4 95%CI: 0.1, 0.9, p = 0.0324), and each additional year on ART (AOR 0.4, 95%CI 0.2, 0.9, p = 0.0379) were associated with decreased risk of virologic failure. Drug resistance was evident in 67.6% of sequenced virus isolates.

CONCLUSIONS

During routine programmatic implementation of HIV care for children and adolescents, delayed age at ART initiation has long-term implications on immunologic recovery, growth and virologic outcomes.

Allergic diseases in subjects under 18 years living with HIV

Background

In recent decades there has been an increase in the prevalence of allergic disease. Manifestations of these diseases have allegedly been observed in people living with Human Immunodeficiency Virus (HIV), however, few studies have been directed at patients under 18 years old. In this context, the aim of this study is to estimate the prevalence of allergic disease in patients under 18 years old, living with HIV, and to investigate the relationship between clinico-immunological characteristics of the HIV infection and atopy.

Methods

This is a cross-sectional epidemiological study involving patients under 18 years of age who were followed up by specialized HIV services in the Southern Region of the State of Santa Catarina, Brazil, from February to October 2012. Data collection tools included a questionnaire established by the International Study of Asthma and Allergy in Childhood (ISAAC), socio-demographic data, as well as laboratory test results obtained from the medical records. Blood samples were taken to measure total serum Immunoglobulin E (IgE) levels and a Radioallergosorbent Test (RAST) for the main aeroallergens. Analysis was performed using Student’s t test, chi-squared, Fisher’s exact and Mann–Whitney tests, wherever indicated, with p < 0.05 value considered significant.

Results

29 individuals were evaluated. The prevalence of symptoms of allergic disease was 65.5% (95% CI 56.1-74.8), the most frequent being rhinitis 44.8% (95% CI 35.0-54.5), followed by asthma 37.9% (95% CI 28.3-47.4) and eczema 27.6% (95% CI 18.8-36.3). RAST was positive in 20.7% of the individuals. There was no significant difference in terms of total serum IgE between individuals with and without symptoms of allergic disease. Nevertheless, a high frequency of raised levels of total serum IgE (40.7%) and an association between raised IgE and clinical staging of disease were observed. A further association between CD8+ cell count and prevalence of symptomatic allergic disease (p = 0.014) was observed.

Conclusion

There was a high prevalence of reported allergic disease, as well as a high frequency of raised levels of total serum IgE. The association between CD8+ cell count and the prevalence of symptomatic allergic disease corroborates studies that demonstrated the role of such cells in the development of allergic disease.

Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges

Worldwide, more than three million children are infected with HIV, 90% of whom live in sub-Saharan Africa. As the HIV epidemic matures and antiretroviral treatment is scaled up, children with HIV are reaching adolescence in large numbers. The growing population of adolescents with perinatally acquired HIV infection living within this region presents not only unprecedented challenges but also opportunities to learn about the pathogenesis of HIV infection. In this Review, we discuss the changing epidemiology of paediatric HIV and the particular features of HIV infection in adolescents in sub-Saharan Africa. Longstanding HIV infection acquired when the immune system is not developed results in distinctive chronic clinical complications that cause severe morbidity. As well as dealing with chronic illness, HIV-infected adolescents have to confront psychosocial issues, maintain adherence to drugs, and learn to negotiate sexual relationships, while undergoing rapid physical and psychological development. Context-specific strategies for early identification of HIV infection in children and prompt linkage to care need to be developed. Clinical HIV care should integrate age-appropriate sexual and reproductive health and psychological, educational, and social services. Health-care workers will need to be trained to recognise and manage the needs of these young people so that the increasing numbers of children surviving to adolescence can access quality care beyond specialist services at low-level health-care facilities.

Antiretroviral treatment, management challenges and outcomes in perinatally HIV-infected adolescents

Three decades into the HIV/AIDS epidemic there is a growing cohort of perinatally HIV-infected adolescents globally. Their survival into adolescence and beyond represent one of the major successes in the battle against the disease that has claimed the lives of millions of children. This population is diverse and there are unique issues related to antiretroviral treatment and management. Drawing from the literature and experience, this paper discusses several broad areas related to antiretroviral management, including: 1) diverse presentation of HIV, (2) use of combination antiretroviral therapy including in the setting of co-morbidities and rapid growth and development, (3) challenges of cART, including nonadherence, resistance, and management of the highly treatment-experienced adolescent patient, (4) additional unique concerns and management issues related to PHIV-infected adolescents, including the consequences of longterm inflammation, risk of transmission, and transitions to adult care. In each section, the experience in both resource-rich and limited settings are discussed with the aim of highlighting the differences and importantly the similarities, to share lessons learnt and provide insight into the multi-faceted approaches that may be needed to address the challenges faced by this unique and resilient population.

Burden of HIV among primary school children and feasibility of primary school-linked HIV testing in Harare, Zimbabwe: a mixed methods study

Population-based surveys in Southern Africa suggest a substantial burden of undiagnosed HIV-infected long-term survivors of mother-to-child transmission. We conducted an HIV prevalence survey of primary school pupils in Harare, Zimbabwe, and evaluated school-linked HIV counselling and testing (HCT) for pupils, their families and schoolteachers. Population-weighted cluster sampling was used to select six primary schools. Randomly selected class-grade pupils underwent anonymous HIV testing, with concurrent school-linked family HCT offered during the survey. Focus group discussions and interviews were conducted with pupils, parents/ guardians, counsellors, and schoolteachers. About 4386 (73%) pupils provided specimens for anonymous HIV testing. Median age was 9 years (IQR 8–11), and 54% were female. HIV prevalence was 2.7% (95% CI: 2.2–3.1) with no difference by gender. HIV infection was significantly associated with orphanhood, stunting, wasting, and being one or more class grades behind in school due to illness (p <0.001). After adjusting for covariates, orphanhood and stunting remained significantly associated with being HIV positive (p <0.001). Uptake of diagnostic HIV testing by pupils was low with only 47/4386 (1%) pupils undergoing HCT. The HIV prevalence among children under 15 years who underwent HIV testing was 6.8%. The main barrier to HIV testing was parents’ fear of their children experiencing stigma and of unmasking their own HIV status should the child test HIV positive. Most guardians believed that a child's HIV-positive result should not be disclosed and the child could take HIV treatment without knowing the reason. Increased recognition of the high burden of undiagnosed HIV infection in children is needed. Despite awareness of the benefits of HIV testing, HIV-related stigma still dominates parents/guardians' psychological landscape. There is need for comprehensive information and support for families to engage with HIV testing services.

Disability and HIV: What drives this relationship in Eastern and Southern Africa?

The Eastern and Southern Africa (ESA) region is the epicentre of the global HIV epidemic and also home to a large number of people with disabilities. Both HIV and Disability are significant public health issues. While they are generally viewed as distinct and unrelated phenomena data seems to suggest that they are particularly closely intertwined in ESA. For the first time in history, by using the same disability indicator consistently, the publication of the World Report on Disability in 2011 has allowed for the comparison of disability data between countries, and across regions. This has the potential to shed some light on the relationship between disability and socio-economic markers and other health conditions in a way that was not possible previously. In the absence of disability and HIV-specific population-based surveys, this paper uses global socio-economic and HIV datasets and compares them to data contained in the most recent World Report on Disability. The analysis suggests that disability prevalence may be related to HIV-prevalence in ESA (Pearson 0.87). It identifies research and policy gaps and seeks to shed light on the relationship between the two phenomena. It concludes that, more than any other region in the world, ESA needs to ensure better data collection on disability and the inclusion of disability throughout its HIV programmes in order to provide a comprehensive and appropriate response to the epidemic.

Common skin conditions in children with HIV/AIDS

The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data inform us that approximately 2.3 million children were infected with HIV at the end of 2009. The greatest burden of this infection is thrust squarely on the most impoverished healthcare systems in the world. Sub-Saharan Africa is home to at least 68% of the global total of HIV infection of 22.5 million. Although a scale up of antiretrovirals has been one of the UNAIDS priorities, and access to services to prevent mother-to-child transmission has increased, an estimated 370,000 children were newly infected in 2009. Hence, infected mothers continue giving birth to HIV-infected children who require appropriate healthcare to diagnose and treat their underlying immunodeficiency and related disorders. Skin lesions are common in these children as they present with infections common in the general population, albeit more severe. Those lesions that are markers of HIV or AIDS are important signs heralding an improving or declining immune system and the success of antiretrovirals. Cutaneous manifestations of HIV/AIDS can be classified broadly as infections and infestations, inflammatory conditions, tumors, and antiretroviral related. This manuscript discusses the more common skin conditions seen in children infected with HIV so as to improve the diagnosis and therapy administered by healthcare professionals especially in sub-Saharan Africa.

Acquired epidermodysplasia verruciformis due to multiple and unusual HPV infection among vertically-infected, HIV-positive adolescents in Zimbabwe

BACKGROUND

We have previously described the presentation of epidermodysplasia verruciformis (EV)-like eruptions in almost a quarter of hospitalized adolescents with vertically-acquired human immunodeficiency virus (HIV) infection in Harare, Zimbabwe, a region with a high prevalence of HIV infection.

METHODS

We performed a clinical case note review and skin biopsy from affected sites in 4 HIV-infected adolescents with EV-like lesions in Harare. Biopsies were processed for histology and for human papillomavirus (HPV) typing.

RESULTS

All patients had long-standing skin lesions that pre-dated the diagnosis of HIV by several years. The histology of skin biopsies from all patients was consistent with EV. In each biopsy, EV-associated β-HPV type 5 was identified (additionally, type 19 was found in 1 biopsy). Cutaneous wart-associated HPV types 1 and 2 were detected in all biopsies, together with genital lesion-associated HPV types 6, 16, and 52, (as well as ≥3 other genital lesion-associated HPV types). Despite immune reconstitution with combination antiretroviral therapy (cART), there was no improvement in EV-like lesions in any patient.

CONCLUSIONS

EV is a disfiguring and potentially stigmatizing condition among this patient group and is difficult to treat; cART appears to have no impact on the progression of skin disease. Among adolescents with longstanding HIV-induced immunosuppression and with high levels of sun exposure, close dermatological surveillance for potential skin malignancy is required.

Pruritic papular eruptions as presenting illness of HIV

Mucocutaneous manifestations can be the first markers of HIV. We are reporting the case of an adolescent girl who presented with chronic, recurrent, intensely pruritic papular lichenified eruptions over extremities, face and trunk, which were exudative and crusted at places. She had delayed milestones with growth failure and no pubertal features. She did not have any risk factors to be suspected for HIV. The lesions were refractory to treatment, so she was tested for HIV and she came out to be HIV positive. This case reports pruritic papular eruptions as presenting illness of HIV.

Supporting adolescent orphan girls to stay in school as HIV risk prevention: evidence from a randomized controlled trial in Zimbabwe

OBJECTIVES

Using a randomized controlled trial in rural eastern Zimbabwe, we tested whether comprehensive support to keep orphan adolescent girls in school could reduce HIV risk.

METHODS

All orphan girls in grade 6 in 25 primary schools were invited to participate in the study in fall 2007 (n = 329). Primary schools were randomized to condition. All primary schools received a universal daily feeding program; intervention participants received fees, uniforms, and a school-based helper to monitor attendance and resolve problems. We conducted annual surveys and collected additional information on school dropout, marriage, and pregnancy rates. We analyzed data using generalized estimating equations over 3 time points, controlling for school and age at baseline.

RESULTS

The intervention reduced school dropout by 82% and marriage by 63% after 2 years. Compared with control participants, the intervention group reported greater school bonding, better future expectations, more equitable gender attitudes, and more concerns about the consequences of sex.

CONCLUSIONS

We found promising evidence that comprehensive school support may reduce HIV risk for orphan girls. Further study, including assessment of dose response, cost benefit, and HIV and herpes simplex virus 2 biomarker measurement, is warranted.

Pruritic papular eruptions as presenting illness of HIV

Mucocutaneous manifestations can be the first markers of HIV. We are reporting the case of an adolescent girl who presented with chronic, recurrent, intensely pruritic papular lichenified eruptions over extremities, face and trunk, which were exudative and crusted at places. She had delayed milestones with growth failure and no pubertal features. She did not have any risk factors to be suspected for HIV. The lesions were refractory to treatment, so she was tested for HIV and she came out to be HIV positive. This case reports pruritic papular eruptions as presenting illness of HIV.

Chest radiography patterns in 75 adolescents with vertically-acquired human immunodeficiency virus (HIV) infection

Aim

To evaluate lung disease on chest radiography (CR), the relative frequency of CR abnormalities, and their clinical correlates in adolescents with vertically-acquired human immunodeficiency virus (HIV) infection.

Materials and methods

CRs of 75 patients [59 inpatients (33 males; mean age 13.7 ± 2.3 years) and 16 outpatients (eight males; mean age 14.1 ± 2.1 years)] were retrospectively reviewed by three independent observers. The overall extent of disease (to the nearest 5%), its distribution, and the proportional extents (totalling 100%) of different radiographic patterns (including ring/tramline opacities and consolidation) were quantified. CR features and clinical data were compared.

Results

CRs were abnormal in 51/75 (68%) with “extensive” disease in 38/51 (74%). Ring/tramline opacities and consolidation predominated (i.e., proportional extent >50%) in 26 and 21 patients, respectively. Consolidation was significantly more common in patients hospitalized primarily for a respiratory illness than patients hospitalized for a non-respiratory illness or in outpatients (p < 0.005, χ² for trend); by contrast, ring/tramline opacities did not differ in prevalence across the groups. On stepwise logistic regression, predominant consolidation was associated with progressive dyspnoea [odds ratio (OR) 5.60; 95% confidence intervals (CI): 1.60, 20.1; p < 0.01] and was associated with a primary respiratory cause for hospital admission (OR: 22.0; CI: 2.7, 181.1; p < 0.005). Ring/tramline opacities were equally prevalent in patients with and without chronic symptoms and in those admitted to hospital with respiratory and non-respiratory illness.

Conclusion

In HIV-infected adolescents, evaluated in secondary practice, CR abnormalities are prevalent. The presence of ring/tramline opacities, believed to reflect chronic airway disease, is not linked chronic respiratory symptoms.