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

Incidence of World Health Organization stage 3 and 4 events, tuberculosis and mortality in untreated, HIV-infected children enrolling in care before 1 year of age: an IeDEA (International Epidemiologic Databases To Evaluate AIDS) East Africa regional analysis

BACKGROUND

Few studies have reported CD4%- and age-stratified rates of World Health Organization Stage 3 (WHO3) events, World Health Organization Stage 4 (WHO4) events, tuberculosis (TB) and mortality in HIV-infected infants before initiation of antiretroviral therapy.

METHODS

HIV-infected children enrolled before 1 year of age in the International Epidemiologic Databases to Evaluate AIDS East Africa region (October 1, 2002, to November, 2008) were included. We estimated incidence rates of earliest clinical event (WHO3, WHO4 and TB), before antiretroviral therapy initiation per local guidelines, stratified by current age (< or ≥6 months) and current CD4% (<15%, 15-24%, ≥25%). CD4%-stratified mortality rates were estimated separately for children who did not experience a clinical event ("background" mortality) and for children who experienced an event, including "acute" mortality (≤30 days post event) and "later" mortality (>30 days post event).

RESULTS

Among 847 children (median enrollment age: 4.8 months; median pre-antiretroviral therapy follow up: 10.8 months; 603 (71%) with ≥1 CD4% recorded), event rates were comparable for those aged <6 and ≥6 months. Current CD4% was associated with risk of WHO4 events for children <6 months of age and with all evaluated events for children ≥6 months old (P < 0.05). "Background" mortality was 3.7-8.4/100 person-years (PY). "Acute" mortality (≤30 days post event) was 33.8/100 PY (after TB) and 41.1/100 PY (after WHO3 or WHO4). "Later" mortality (>30 days post event) ranged by CD4% from 4.7 to 29.1/100 PY.

CONCLUSIONS

In treatment-naïve, HIV-infected infants, WHO3, WHO4 and TB events were common before and after 6 months of age and led to substantial increases in mortality. Early infant HIV diagnosis and treatment are critically important, regardless of CD4%.

Nonvirologic algorithms for predicting HIV infection among HIV-exposed infants younger than 12 weeks of age

BACKGROUND

Early initiation of antiretroviral therapy has been shown to reduce mortality among perinatally HIV-infected infants, but availability of virologic testing remains limited in many settings.

METHODS

We collected cross-sectional data from mother-infant pairs in three primary care clinics in Lusaka, Zambia, to develop predictive models for HIV infection among infants younger than 12 weeks of age. We evaluated algorithm performance for all possible combinations of selected characteristics using an iterative approach. In primary analysis, we identified the model with the highest combined sensitivity and specificity.

RESULTS

Between July 2009 and May 2011, 822 eligible HIV-infected mothers and their HIV-exposed infants were enrolled; of these, 44 (5.4%) infants had HIV diagnosed. We evaluated 382,155,260 different characteristic combinations for predicting infant HIV infection. The algorithm with the highest combined sensitivity and specificity required 5 of the following 7 characteristic thresholds: infant CD8 percentage >22; infant CD4 percentage ≤44; infant weight-for-age Z score ≤0; infant CD4 ≤1600 cells/µL; infant CD8 >2200 cells/µL; maternal CD4 ≤600 cells/µL; and mother not currently using antiretroviral therapy for HIV treatment. This combination had a sensitivity of 90.3%, specificity of 78.4%, positive predictive value of 22.4%, negative predictive value of 99.2% and area under the curve of 0.844.

CONCLUSION

Predicting HIV infection in HIV-exposed infants in this age group is difficult using clinical and immunologic characteristics. Expansion of polymerase chain reaction capacity in resource-limited settings remains urgently needed.

The needs for HIV treatment and care of children, adolescents, pregnant women and older people in low-income and middle-income countries

OBJECTIVE

Success in diagnosing and treating HIV-infected adults has, where HIV care and treatment is available, turned HIV into a chronic, rather than life-limiting disease. Progress meeting the needs of HIV-infected children, perinatally and horizontally infected adolescents, pregnant women and older people has lagged behind. We review the special needs and barriers to scaling up care and antiretroviral therapy (ART) coverage in these populations.

DESIGN AND METHODS

A literature review combined with personal views and operational experience specifically from countries covered by the Evidence for Action programme.

RESULTS

Challenges include logistics of diagnosis and treatment in pregnancy, difficulties in early infant diagnosis, availability of appropriate paediatric formulations, management of adolescents, and comorbidities in older people.

CONCLUSION

Priorities for development need to focus upon the simplification of HIV care to allow provision for all ages at the primary healthcare level. Specific priorities include focused use of virological testing in infants, ongoing development of dispersible and scored fixed-dose ART combinations suitable for use across ages, development of 'adolescent-friendly' HIV services catering for perinatally and horizontally infected adolescents to improve adherence and reduce onward transmissions, simplification of referral pathways to ensure all pregnant women are tested for HIV and commenced on ART, and education of healthcare workers on the specific needs of HIV care in older patients. Each priority will be reviewed and potential solutions discussed.