Evaluation and medical treatment of the HIV-exposed infant. American Academy of Pediatrics. Committee on Pediatric AIDS

Comorbidities in children and adolescents with AIDS acquired by HIV vertical transmission in Vitória, Brazil

BACKGROUND

Studying diseases associated with AIDS is essential for establishing intervention strategies because comorbidities can lead to death. The objectives were to describe the frequency of comorbidities and verify their distribution according to demographic, epidemiological and clinical data as well as to classify diseases in children and adolescents with AIDS in Vitória, Brazil.

METHODS

A retrospective cohort study was conducted among children with AIDS, as defined according to the criteria established by the Ministry of Health, who acquired HIV via vertical transmission, were aged 0 to 18 years, and were monitored at a referral hospital from January 2001 to December 2011.

RESULTS

A total of 177 patients were included, of whom 97 were female (55%). There were 60 patients (34%) <1 year old, 67 patients (38%) between the ages of 1 and 5, and 50 patients (28%) ≥6 years of age included at the time of admission to the Infectious Diseases Ward. Regarding clinical-immunological classification, 146 patients (82.5%) showed moderate/severe forms of the disease at the time of admission into the Ward, and 26 patients (14.7%) died during the study. The most common clinical signs were hepatomegaly (81.62%), splenomegaly (63.8%), lymphadenopathy (68.4%) and persistent fever (32.8%). The most common comorbidities were anaemia (67.2%), pneumonia/septicaemia/acute bacterial meningitis (ABM) (64.2%), acute otitis media (AOM)/recurrent sinusitis (55.4%), recurrent severe bacterial infections (47.4%) and dermatitis (43.1%). An association between severe clinical-immunological classification and admission to the Ward for children aged less than one year old was found for several comorbidities (p<0.001).

CONCLUSION

Delayed diagnosis was observed because the majority of patients were admitted to the Infectious Diseases Ward at ≥1 year of age and were already presenting with serious diseases. The general paediatrician should be alert to this possibility to make an early diagnosis in children infected with HIV.

Sero-prevalence of viral co-infections in HIV infected children of Northern India

OBJECTIVE

To assess the prevalence of viral co-infections in HIV infected children.

METHODS

Children born to HIV seropositive parents and those children who were suspected to be HIV infected based on clinical presentation by the pediatrician were screened for HIV -1 and 2 antibodies as per National Aids Control Organization (NACO) guidelines. Those found to be seropositive for HIV infection were further tested for Hepatitis B&C, Herpes simplex virus and Human cytomegalovirus infection.

RESULTS

Among 803 children screened, 101 were found positive for HIV antibodies. Among the five viral markers tested, HCMV IgG was positive in 88 children (87.1%). HCMV IgM was positive in 35 cases (34.6%). HBsAg tested positive in 30 children, while anti-HCV IgM was reactive in 27 cases. IgM anti- HSV antibodies were observed positive in 59 (58.4%) cases. Both hepatitis virus coinfection (HBsAg and anti- HCV IgM antibodies) was observed in 10 HIV positive children, while both Herpesviridae family viruses (HCMV -IgM antibodies and HSV -IgM antibodies) were positive in 30 cases (29.7%).

CONCLUSION

Viral co-infections are significantly higher in HIV positive children, which adds to significant mortality and morbidity and should therefore be screened in all HIV positive children for timely treatment in order to improve the quality of life and better survival of HIV infected children.

Effect of early antiretroviral therapy on the risk of AIDS/death in HIV-infected infants

OBJECTIVE

In the absence of treatment, rapid progression to AIDS occurs in approximately 20% of HIV-1-infected infants over the first year of life. The prognosis of these children has considerably improved with highly active antiretroviral therapy. As data from well resourced countries are lacking, the objective of this collaborative study was to evaluate the impact of early treatment in vertically infected infants.

DESIGN

Children born to HIV-infected mothers between 1 September 1996 and 31 December 2004, who were diagnosed with HIV and free of AIDS before 3 months, were eligible. Demographics and pregnancy data, details of antiretroviral therapy, and clinical outcome were collected from 11 European countries.

METHODS

The risk of AIDS or death, by whether or not an infant started treatment before 3 months of age, was estimated by Kaplan-Meier survival analysis and Cox proportional hazards models.

RESULTS

Among 210 children, 21 developed AIDS and three died. Baseline characteristics of the 124 infants treated before 3 months were similar to those of the 86 infants treated later. The risk of developing AIDS/death at 1 year was 1.6 and 11.7% in the two groups, respectively (P < 0.001). Deferring treatment was associated with increased risk of progression [crude hazard ratio 5.0; 95% confidence interval (CI) 2.0-12.6; P = 0.001] that persisted after adjusting for cohort in multivariate models (adjusted hazard ratio 3.0; 95% CI 1.2-7.9; P = 0.021).

CONCLUSION

In HIV-1 vertically infected infants, starting antiretroviral therapy before the age of 3 months is associated with a significant reduction in progression to AIDS and death.

Effects of maternal depressive symptoms and infant gender on the interactions between mothers and their medically at-risk infants

OBJECTIVE

To examine the effects of maternal depressive symptoms and infant gender on interactions between mothers and medically at-risk infants.

DESIGN

Longitudinal, descriptive secondary analysis.

SETTING

Neonatal intensive care unit, intermediate care unit, and infectious disease clinic of the tertiary medical centers in the Southeast and East.

PARTICIPANTS

One hundred and eight preterm infants and their mothers, 67 medically fragile infants and their mothers, and 83 infants seropositive for HIV and their primary caregivers were studied in their homes between 6 and 24 months.

MAIN OUTCOME MEASURES

Observation and the Home Observation for Measurement of the Environment Inventory were used to assess the interactions of mothers and their medically at-risk infants. Maternal depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale.

RESULTS

The level of depressive symptoms did not differ between the mothers of boys and mothers of girls in the three groups. Mothers of medically fragile infants had higher levels of depressive symptoms than mothers of preterm infants at 6 months corrected age and similar levels of depressive symptoms as HIV-positive mothers at 12 months. Mothers of medically fragile infants with elevated depressive symptoms were less attentive and more restrictive to their infants. HIV-positive mothers with elevated depressive symptoms were less attentive to their infants. The effects of gender on mother-infant interactions were not moderated by maternal depressive symptoms.

CONCLUSION

Maternal depressive symptoms had a somewhat negative effect on the interactions of mothers and medically at-risk infants.

Polymerase chain reaction for diagnosis of human immunodeficiency virus infection in infancy in low resource settings

BACKGROUND

Diagnosis of human immunodeficiency virus (HIV) is essential for accessing treatment. Current HIV diagnostic protocols for infants require adaptation and validation before they can be implemented in the developing world. The timing and type of HIV assays will be dictated by country-specific circumstances and experience from similar settings. The performance of an HIV-1 DNA polymerase chain reaction (PCR) test, and in particular a single test at 6 weeks of age, in diagnosing HIV subtype C infection acquired in utero or peripartum was assessed.

METHODS

A retrospective review of 1825 Amplicor HIV-1 DNA PCR version 1.5 tests performed between 2000 and 2004 in 2 laboratories in Johannesburg, South Africa on 769 effectively non-breast-fed infants from 3 clinically well characterized cohorts was undertaken. The HIV status of each infant was used as the standard against which the HIV PCR results were compared.

RESULTS

The overall sensitivity and specificity of the HIV PCR test were 99.3 and 99.5% respectively. A single test was 98.8% sensitive and 99.4% specific in the 627 infants tested at 6 weeks of age (58 HIV-infected and 569 HIV-uninfected). Repeat testing of all positive HIV PCR tests minimized false positive results.

CONCLUSIONS

In resource-poor settings where HIV PCR testing in an environment of good laboratory practice is feasible, a single 6-week HIV DNA PCR test can increase identification of HIV-infected children substantially from current levels. Further operational research on how best to implement and monitor such a diagnostic protocol in specific local settings, especially in breast-fed infants, is necessary.

The impact of expected HIV transmission rates on the effectiveness and cost of ruling out HIV infection in infants

OBJECTIVE

To quantify the costs and effectiveness of different strategies for ruling out HIV infection in infants born to HIV-infected mothers in the United States.

METHODS

The authors assessed 4 different testing strategies that incorporated serial HIV DNA polymerase chain reaction (PCR) testing with or without enzyme-linked immunosorbent assay (ELISA) antibody testing. Testing costs, false reassurance rates, and incremental cost-effectiveness ratios were compared for the 4 strategies.

RESULTS

In HIV-exposed infants, HIV DNA PCR testing at birth, 1 month, and 4 months of age results in a false reassurance rate of 21 per million (at a 2% transmission rate). Adding an ELISA test lowers the false reassurance rate to 0.052 per million at a cost of $570,000 per additional case detected; adding another PCR lowers the false reassurance rate to 1.49 per million at a cost of $720,000 per additional case detected compared with the 3-PCR strategy. At a high transmission rate (20%), there would be substantially more erroneously negative results (false reassurance rate is 256 per million with PCR testing at birth, 1 month, and 4 months) and consequently more favorable cost-effectiveness ratios with additional testing: $47,000 per additional case detected by adding 1 ELISA test and $59,000 per additional case detected by adding another PCR test.

CONCLUSIONS

False-negative HIV results after serial testing in exposed infants are rare, and the incremental cost-effectiveness ratios of additional tests are substantial at low transmission rates. However, the false reassurance rate increases considerably with a 3-PCR strategy and additional testing becomes more cost-effective at greater transmission rates; therefore, additional testing may be warranted in infants at greater risk of infection.

False negative DNA polymerase chain reaction in an infant with subtype C human immunodeficiency virus 1 infection

Diagnosis of HIV infection in early infancy generally relies on detection of HIV proviral DNA by PCR. However, many of the HIV DNA PCR assays currently in use are either not optimized or have not been validated for diagnosis of infection with non-subtype B HIV. We report the case of an HIV-infected African American immigrant infant with subtype C HIV infection who tested negative repeatedly by HIV DNA PCR. Clinicians should be aware of this particular limitation of HIV DNA PCR assays, because it is likely that an increasing proportion of the HIV-infected infants seen in US centers will be infected with non-subtype B HIV.

New methods for the detection of HIV

In the past few years, several strides have been made in the ability to detect the presence of HIV-1 and HIV-2. This article discusses recent advances in serologic testing, including routine ELISA and Western blot tests, rapid HIV tests, home collection kits, and HIV tests using nonserum samples. The clinical application of nucleic acid-based tests also is discussed. Finally, appropriate use of these tests in both acute HIV-1 infection and in infants is reviewed.

Rational testing of the HIV-exposed infant

OBJECTIVES

The objectives of this study were 1) to evaluate testing regimens of human immunodeficiency virus (HIV)-exposed infants and 2) to determine optimal methods of follow-up by enzyme-linked immunosorbent assay (ELISA) testing.

METHODS

We reviewed the results from 742 HIV-exposed infants in the state of North Carolina; 2474 samples were tested for HIV by DNA polymerase chain reaction (PCR) at the University of North Carolina Retrovirology Core Laboratory. We then reviewed the utility and costs of ELISA testing of all HIV-exposed infants who were seen at the Duke University Pediatric Infectious Disease Clinic between January 1, 1993, and May 5, 1998. We used likelihood ratios to model probability of HIV infection given 3 negative DNA (PCR) tests and to provide recommendations on the use of ELISA follow-up.

RESULTS

The overall sensitivity of the DNA PCR was 87.1%, and its specificity was 99.9%. We evaluated 224 HIV-exposed infants who were seen at Duke University and who had at least 3 negative diagnostic tests using either DNA PCR tests or HIV blood cultures. All 178 infants who subsequently underwent ELISA testing ultimately demonstrated seroreversion. The Duke University Pediatric Infectious Disease Clinic transferred the care of 65 patients to primary care physicians before ELISA testing and retained the care of the remaining 159 patients. Children who remained in Duke's care were more likely to have documentation of seroreversion (158 of 159 vs 20 of 65). We reviewed costs of travel, physician appointment, and HIV antibody testing in a tertiary care setting. Given 3 negative PCR tests, the expected cost per case of HIV detected by a positive ELISA assay is $23.8 million.

CONCLUSIONS

Documentation of seroreversion in this cohort was nearly complete in the multidisciplinary subspecialty clinic but not when such responsibility was left to the primary care physician. Given the low probability of disease in patients who have had 3 negative PCR tests, documentation of a negative ELISA may not be an appropriate use of medical resources.

Technical report: perinatal human immunodeficiency virus testing and prevention of transmission. Committee on Pediatric Aids

In 1994, the US Public Health Service published guidelines for the use of zidovudine to decrease the risk of perinatal transmission of human immunodeficiency virus (HIV). In 1995, the American Academy of Pediatrics and the US Public Health Service recommended documented, routine HIV education and testing with consent for all pregnant women in the United States. Widespread incorporation of these guidelines into clinical practice has resulted in a dramatic decrease in the rate of perinatal HIV transmission and has contributed to more than a 75% decrease in reported cases of pediatric acquired immunodeficiency syndrome (AIDS) since 1992. Substantial advances have been made in the treatment and monitoring of HIV infection; combination antiretroviral regimens that maximally suppress virus replication are now available. These regimens are recommended for pregnant and nonpregnant individuals who require treatment. Risk factors associated with perinatal HIV transmission are now better understood, and recent results from trials to decrease the rate of mother-to-child HIV transmission have contributed new strategies with established efficacy. However, perinatal HIV transmission still occurs; the Centers for Disease Control and Prevention estimates that 300 to 400 infected infants are born annually. Full implementation of recommendations for universal, routine prenatal HIV testing and evaluation of missed prevention opportunities will be critical to further decrease the incidence of pediatric HIV infection in the United States. This technical report summarizes recent advances in the prevention of perinatal transmission of HIV relevant to screening of pregnant women and their infants.

Antenatal screening for HIV: time to embrace change

In August 1999 the Government set a national objective of reducing the numbers of children acquiring human immunodeficiency virus (HIV) infection from their mothers by 80%. The key policy change towards achieving this objective was that HIV testing was to be recommended as a routine and integral part of antenatal care. The UK has fallen behind other Western industrialized countries in the uptake of antenatal testing and reduction in mother-to-child transmission. This article examines the background to these new recommendations, the substantial benefits of available interventions and the reasons why current testing policies have been failing.

HIV-infected parents and their children in the United States

OBJECTIVES

This study sought to determine the number, characteristics, and living situations of children of HIV-infected adults.

METHODS

Interviews were conducted in 1996 and early 1997 with a nationally representative probability sample of 2864 adults receiving health care for HIV within the contiguous United States.

RESULTS

Twenty-eight percent of infected adults in care had children. Women were more likely than men to have children (60% vs 18%) and to live with them (76% vs 34%). Twenty-one percent of parents had been hospitalized during the previous 6 months, and 10% had probably been drug dependent in the previous year. Parents continued to have children after being diagnosed with HIV: 12% of all women conceived and bore their youngest child after diagnosis, and another 10% conceived before but gave birth after diagnosis.

CONCLUSIONS

Clinical and support services for people affected by the HIV epidemic should have a family focus.

Identification and care of HIV-exposed and HIV-infected infants, children, and adolescents in foster care. American Academy of Pediatrics. Committee on Pediatric AIDS

As a consequence of the expanding human immunodeficiency virus (HIV) epidemic and major advances in medical management of HIV-exposed and HIV-infected persons, revised recommendations are provided for HIV testing of infants, children, and adolescents in foster care. Updated recommendations also are provided for the care of HIV-exposed and HIV-infected persons who are in foster care.

Cost-effectiveness of universal compared with voluntary screening for human immunodeficiency virus among pregnant women in Chicago

OBJECTIVES

To determine and compare the cost-effectiveness of implementing 3 screening strategies to detect human immunodeficiency virus (HIV) infection among pregnant women in Chicago, Illinois: no screening, voluntary screening, and universal screening.

METHODS

A decision-analysis model was developed, using standard cost-effectiveness analysis from a societal perspective. Reference case estimates were derived from a surveillance project conducted by the Illinois Department of Public Health and studies were published in the medical literature. Costs included direct and indirect medical costs associated with identification of pregnant women infected with HIV and identification, prevention, and treatment of perinatally HIV-infected newborns. Specifically, for each screening option, the cost per pregnant woman screened, the resulting number of pediatric HIV infections, and the number of newborn life-years were calculated. All costs were adjusted to the 1997 dollar value and discounted at 3%. Sensitivity analyses were determined for all variables included in the decision model.

RESULTS

The estimated prevalence of HIV infection among pregnant women in Chicago is .41%. For every 100,000 pregnant women, it is estimated that 104.6 children would be infected with HIV if no screening strategy were implemented and 44.8 children would be infected if voluntary HIV testing (assuming a 92.7% acceptance rate) were available. In comparison, if universal HIV testing was performed, the number of children infected with HIV would decrease to 40 cases. Sensitivity analysis across a maternal HIV prevalence rate of.01% to 2.2% found that universal screening would be cost-saving in communities where the seroprevalence is.21%. In Chicago, it would take an estimated 5. 2 months of screening pregnant women to avert 1 case of pediatric HIV. Taking into consideration the lifetime costs of treating a child with HIV infection, universal HIV testing of 100,000 pregnant women would result in a cost-savings of $3.69 million when compared with no screening, and $269,445 when compared with voluntary screening. We estimated that it would cost $11.1 million to screen 100,000 pregnant women in Chicago. The cost-savings produced with increased screening are the direct result of reduced cases of newborns infected with HIV. A 2-way sensitivity analysis was performed to examine how costs vary as a function of the voluntary rates for HIV-positive and HIV-negative women. When screening falls below 50% for HIV-positive mothers, universal screening becomes cheaper than voluntary screening even if no HIV-negative mothers were screened.

CONCLUSION

Reference case analyses showed that universal HIV screening of pregnant women in Chicago would both decrease the number of HIV-infected newborns and save money in comparison to voluntary or no testing strategies. Sensitivity analysis was robust across all variables for the conclusion that universal screening was more effective than voluntary screening. For many communities that have HIV prevalence rates for mothers of >.21%, universal screening would also save money in comparison to voluntary screening. For communities with prevalence rates <.21%, the benefits of universal screening may outweigh the costs for screening as we found that desirable incremental cost-effectiveness ratios were found for prevalence rates as low as.0075%.

Medical management of HIV disease in children

Significant advances have been made in the understanding of the pathophysiology of HIV infection since the beginning of the epidemic. This knowledge has translated into the development of new therapies for HIV and opportunistic infections, laboratory advances in monitoring viral and immune status, and a better understanding of factors affecting patient outcome. Concomitantly, significant progress has been made in the medical management of children with HIV infection in the past 5 years. The number of children reported with AIDS in the United States is decreasing, and efforts are shifting from caring for children with advanced immunosuppression and severe opportunistic infections to early HAART, maintenance of the immune system, and prevention of opportunistic infections. Primary care physicians are now more involved and informed in the care of HIV-infected patients. Although published data are limited, physicians who have been working with this population have observed a dramatic improvement in the quality of life and length of survival of these patients. Unfortunately, this progress is not shared by developing countries where resources are minimal and antiretroviral agents are commonly unavailable. Although efforts to develop a vaccine to prevent HIV infection are ongoing, progress has been slow. Education and awareness continue to be the most powerful weapons against HIV.

Immunological manifestations of HIV-infected children

This cross-sectional study of stable HIV-infected children was designed to document the immunological manifestations of paediatric HIV infection and to determine whether inexpensive markers of immunosuppression could be identified. Investigations included lymphocyte count and subset analysis, levels of total protein, albumin, immunoglobulins, beta-2 microglobulin and neopterin. The median age of the 74 children studied was 16.5 months and 76% and 39% had subnormal percentage CD4+ counts and absolute CD4+ counts, respectively. According to the Centers for Disease Control (CDC) guidelines, 85% were moderately or severely immunosuppressed. The majority had elevated neopterin, beta-2 microglobulin, IgG, IgM and IgA concentrations. The IgG concentration correlated positively with total globulin, IgG1 and IgG3 concentrations. On bivariate analysis, the absolute CD4+ count correlated positively with total lymphocyte count (r = 0.28 < 0.48 < 0.64) and negatively with total IgG concentration (r = -0.47 < -0.27 < -0.04), IgG1 concentration (r = -0.51 < -0.31 < -0.08), and neopterin concentration (r = -0.49 < -0.28 < -0.04). There was no correlation between CD4+ count, total globulin or beta-2 microglobulin concentration. On multiple linear regression analysis only the total lymphocyte count correlated with CD4+ count. Furthermore, on bivariate analysis total lymphocyte count correlated positively with absolute CD8+ count (r = 0.82 < 0.88 < 0.92). In conclusion, although there was a positive correlation between absolute CD4+ count and total lymphocyte count, the clinical significance is questionable as the total lymphocyte count correlated more strongly with the absolute CD8+ count.

Prevention of rotavirus disease: guidelines for use of rotavirus vaccine. American Academy of Pediatrics

Virtually all children experience rotavirus (Rv) infection before school entry. In the United States and other temperate countries, Rv disease peaks in the winter and during this time is responsible for the majority of episodes of diarrhea in infants and young children. 1-4 Data collected by the Centers for Disease Control and Prevention from 1979 through 1992 indicate that approximately 50 000 hospitalizations attributable to Rv occur annually in the United States, a number that approximates about 1 in 78 children being hospitalized with Rv diarrhea by 5 years of age.2,5 RotaShield (Wyeth-Lederle Vaccines and Pediatrics, Philadelphia, PA) was licensed by the Food and Drug Administration on August 31, 1998, for oral administration to infants at 2, 4, and 6 months of age. The rationale for using Rv immunization for prevention or modification of Rv disease is based on several considerations. First, the rate of illness attributable to Rv among children is comparable in industrialized and developing countries, which indicates that improved public sanitation is unlikely to decrease the incidence of disease.6,7 Second, although implementation of oral rehydration programs to prevent dehydration has improved in the United States, widespread use is inadequate to prevent significant morbidity.8-11 Third, trials of rhesus rotavirus-tetravalent (Rv) vaccine in the United States, Finland, and Venezuela show efficacy rates of approximately 80% for prevention of severe illness and 48% to 68% against Rv-induced diarrheal episodes.12-16 These results are similar to the protection observed after natural Rv infection, which also confers better protection against subsequent episodes of severe disease than against mild illness.17-19 This statement provides recommendations regarding the use of Rv vaccine in infants in the United States.