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Chiappini E, Lisi C, Giacomet V, Erba P, Bernardi S, Zangari P, Di Biagio A, Taramasso L, Giaquinto C, Rampon O, Gabiano C, Garazzino S, Tagliabue C, Esposito S, Bruzzese E, Badolato R, Zanaboni D, Cellini M, Dedoni M, Mazza A, Pession A, Giannini AM, Salvini F, Dodi I, Carloni I, Cazzato S, Tovo PA, de Martino M, Galli L. Off-label use of combined antiretroviral therapy, analysis of data collected by the Italian Register for HIV-1 infection in paediatrics in a large cohort of children. BMC Infect Dis 2022; 22:55. [PMID: 35033018 PMCID: PMC8760752 DOI: 10.1186/s12879-022-07026-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 12/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early start of highly active antiretroviral therapy (HAART) in perinatally HIV-1 infected children is the optimal strategy to prevent immunological and clinical deterioration. To date, according to EMA, only 35% of antiretroviral drugs are licenced in children < 2 years of age and 60% in those aged 2-12 years, due to the lack of adequate paediatric clinical studies on pharmacokinetics, pharmacodynamics and drug safety in children. METHODS An observational retrospective study investigating the rate and the outcomes of off-label prescription of HAART was conducted on 225 perinatally HIV-1 infected children enrolled in the Italian Register for HIV Infection in Children and followed-up from 2001 to 2018. RESULTS 22.2% (50/225) of included children were receiving an off-label HAART regimen at last check. Only 26% (13/50) of off-label children had an undetectable viral load (VL) before the commencing of the regimen and the 52.0% (26/50) had a CD4 + T lymphocyte percentage > 25%. At last check, during the off label regimen, the 80% (40/50) of patients had an undetectable VL, and 90% (45/50) of them displayed CD4 + T lymphocyte percentage > 25%. The most widely used off-label drugs were: dolutegravir/abacavir/lamivudine (16%; 8/50), emtricitbine/tenofovir disoproxil (22%; 11/50), lopinavir/ritonavir (20%; 10/50) and elvitegravir/cobicistat/emtricitabine/ tenofovir alafenamide (10%; 10/50). At logistic regression analysis, detectable VL before starting the current HAART regimen was a risk factor for receiving an off-label therapy (OR: 2.41; 95% CI 1.13-5.19; p = 0.024). Moreover, children < 2 years of age were at increased risk for receiving off-label HAART with respect to older children (OR: 3.24; 95% CI 1063-7.3; p = 0.001). Even if our safety data regarding off-label regimens where poor, no adverse event was reported. CONCLUSION The prescription of an off-label HAART regimen in perinatally HIV-1 infected children was common, in particular in children with detectable VL despite previous HAART and in younger children, especially those receiving their first regimen. Our data suggest similar proportions of virological and immunological successes at last check among children receiving off-label or on-label HAART. Larger studies are needed to better clarify efficacy and safety of off-label HAART regimens in children, in order to allow the enlargement of on-label prescription in children.
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Affiliation(s)
- Elena Chiappini
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Viale Pieraccini, 24, 50100, Florence, Italy.
| | - Catiuscia Lisi
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Viale Pieraccini, 24, 50100, Florence, Italy
| | - Vania Giacomet
- Paediatric Infectious Diseases Unit, Department of Paediatrics, ASST FBF SACCO, University of Milan, Milan, Italy
| | - Paola Erba
- Paediatric Infectious Diseases Unit, Department of Paediatrics, ASST FBF SACCO, University of Milan, Milan, Italy
| | - Stefania Bernardi
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola Zangari
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonio Di Biagio
- Infectious Disease Unit, Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Lucia Taramasso
- Infectious Disease Unit, Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Carlo Giaquinto
- Department of Women and Child Health, University of Padova, Padova, Italy
| | - Osvalda Rampon
- Department of Women and Child Health, University of Padova, Padova, Italy
| | - Clara Gabiano
- Paediatric Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Silvia Garazzino
- Paediatric Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Claudia Tagliabue
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Susanna Esposito
- Paediatric Clinic, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
| | - Eugenia Bruzzese
- Department of Translational Medical Sciences, Section of Paediatrics, University of Naples Federico II, Naples, Italy
| | - Raffaele Badolato
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Domenico Zanaboni
- Department On Internal Medicine and Therapeutics, IRCCS Policlinico "S. Matteo" Foundation, University of Pavia, Pavia, Italy
| | - Monica Cellini
- Department of Medical and Surgical Sciences, Section of Paediatric Hemato-Oncology, University of Modena and Reggio Emilia, Modena, Italy
| | - Maurizio Dedoni
- Department of Paediatrics, Ospedale Microcitemico, Cagliari, Italy
| | - Antonio Mazza
- Paediatric Unit, "S. Chiara" Hospital, Trento, Italy
| | - Andrea Pession
- Andrea Pession, Paediatric Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | - Anna Maria Giannini
- Paediatric Infectious Diseases Unit, University Hospital Policlinico Giovanni XXIII, Bari, Italy
| | - Filippo Salvini
- Department of Paediatrics, University of Milan, Niguarda Hospital, Milan, Italy
| | - Icilio Dodi
- Paediatric Clinic, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
| | - Ines Carloni
- Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | | | - Pier Angelo Tovo
- Paediatric Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Maurizio de Martino
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Viale Pieraccini, 24, 50100, Florence, Italy
| | - Luisa Galli
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Viale Pieraccini, 24, 50100, Florence, Italy
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Chiappini E, Larotonda F, Lisi C, Giacomet V, Erba P, Bernardi S, Zangari P, Di Biagio A, Taramasso L, Giaquinto C, Rampon O, Gabiano C, Garazzino S, Tagliabue C, Esposito S, Bruzzese E, Badolato R, Zanaboni D, Cellini M, Dedoni M, Mazza A, Pession A, Giannini AM, Salvini F, Dodi I, Carloni I, Cazzato S, Tovo PA, de Martino M, Galli L. Real-World Analysis of Survival and Clinical Events in a Cohort of Italian Perinatally HIV-1 Infected Children From 2001 to 2018. Front Pediatr 2021; 9:665764. [PMID: 34336735 PMCID: PMC8322739 DOI: 10.3389/fped.2021.665764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Combined antiretroviral therapy (cART) has been associated with a steep decrease in mortality and morbidity in HIV-1 infected children. New antiretroviral molecules and drug classes have been developed and the management of HIV-infected children has improved, but recent data on survival are limited. Methods: An observational retrospective study investigating changes in mortality and morbidity was conducted on 1,091 perinatally HIV-1 infected children enrolled in the Italian Register for HIV Infection in Children and followed-up from 2001 to 2018. Results: Three hundred and fifty-four (32%) AIDS events and 26 (2%) deaths occurred overtime. Mortality rates decreased from 0.4/100 person-years in 2001-2006 to 0.27/100 person-years in 2007-2012 and 0.07/100 person-years in 2013-2018. Notably, 92% of the dead children were born in Italy, but only 50% were followed-up since birth or within three months of age. Seventy three percent of children had started cART at age ≥6 months; 23% were treated for <30 days before death. B and C clinical events progressively decreased (P < 0.0001). Opportunistic infections significantly decreased over time, but still were the most common events in all the periods (6.76/100 person-years in 2013-2018). In the last period, severe bacterial infections were the most common ones. Cancer rates were 0.07/100; 0.17/100; 0.07/100 person-years in the three periods, respectively. Conclusions: Progressive reductions both in mortality and in rates of class B and C clinical events and OIs have been observed during the cART era. However, deaths were still registered; more than half of dead children were enrolled after birth and had belatedly started cART.
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Affiliation(s)
- Elena Chiappini
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's Hospital, University of Florence, Florence, Italy.,Department of Paediatric Medicine, Anna Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Francesca Larotonda
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's Hospital, University of Florence, Florence, Italy.,Department of Paediatric Medicine, Anna Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Catiuscia Lisi
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's Hospital, University of Florence, Florence, Italy.,Department of Paediatric Medicine, Anna Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Vania Giacomet
- Paediatric Infectious Diseases Unit, Department of Paediatrics, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Paola Erba
- Paediatric Infectious Diseases Unit, Department of Paediatrics, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Stefania Bernardi
- Unit of Immune and Infectious Diseases, Stefania Bernardi Academic Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Paola Zangari
- Research Unit of Clinical Immunology and Vaccinology, Paola Zangari Academic Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Antonio Di Biagio
- Infectious Diseases Unit, Policlinico San Martino Hospital, University of Genova, Genoa, Italy
| | - Lucia Taramasso
- Infectious Diseases Unit, Policlinico San Martino Hospital, University of Genova, Genoa, Italy
| | - Carlo Giaquinto
- Department of Women and Child Health, University of Padova, Padua, Italy
| | - Osvalda Rampon
- Department of Women and Child Health, University of Padova, Padua, Italy
| | - Clara Gabiano
- Paediatric Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Silvia Garazzino
- Paediatric Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Claudia Tagliabue
- Paediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Istituti di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico Foundation, University of Milan, Milan, Italy
| | - Susanna Esposito
- Paediatric Department, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
| | - Eugenia Bruzzese
- Paediatric Unit, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Raffaele Badolato
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Domenico Zanaboni
- Department on Internal Medicine and Therapeutics, Istituti di Ricovero e Cura a Carattere Scientifico Policlinico "S. Matteo" Foundation, University of Pavia, Pavia, Italy
| | - Monica Cellini
- Paediatric Hemato-Oncology Unit, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Maurizio Dedoni
- Department of Paediatrics, Ospedale Microcitemico, Cagliari, Italy
| | - Antonio Mazza
- Department of Paediatrics, "S. Chiara" Hospital, Trento, Italy
| | - Andrea Pession
- Paediatric Unit, IRCCS Scientific Institute for Research and Healthcare, Sant'Orsola Hospital, Bologna, Italy
| | - Anna Maria Giannini
- Paediatric Infectious Diseases Unit, University Hospital Policlinico Giovanni XXIII, Bari, Italy
| | - Filippo Salvini
- Department of Paediatrics, Niguarda Hospital, University of Milan, Milan, Italy
| | - Icilio Dodi
- Department of Medicine and Surgery, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
| | - Ines Carloni
- Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | - Salvatore Cazzato
- Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | - Pier Angelo Tovo
- Paediatric Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Maurizio de Martino
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's Hospital, University of Florence, Florence, Italy.,Department of Paediatric Medicine, Anna Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Luisa Galli
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's Hospital, University of Florence, Florence, Italy.,Department of Paediatric Medicine, Anna Meyer Children's Hospital, University of Florence, Florence, Italy
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Di Biagio A, Taramasso L, Gustinetti G, Burastero G, Giacomet V, La Rovere D, Genovese O, Giaquinto C, Rampon O, Carloni I, Hyppolite TK, Palandri L, Bernardi S, Bruzzese E, Badolato R, Gabiano C, Chiappini E, De Martino M, Galli L. Missed opportunities to prevent mother-to-child transmission of HIV in Italy. HIV Med 2019; 20:330-336. [PMID: 30924576 DOI: 10.1111/hiv.12728] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Vertical transmission of HIV can be effectively controlled through antenatal screening, antiretroviral treatment and the services provided during and after childbirth for mother and newborn. In Italy, the National Health Service guarantees universal access to prenatal care for all women, including women with HIV infection. Despite this, children are diagnosed with HIV infection every year. The aim of the study was to identify missed opportunities for prevention of mother-to-child transmission of HIV. METHODS The Italian Register for HIV Infection in Children, which was started in 1985 and involves 106 hospitals throughout the country, collects data on all new cases of HIV infection in children. For this analysis, we reviewed the database for the period 2005 to 2015. RESULTS We found 79 HIV-1-infected children newly diagnosed after birth in Italy. Thirty-two of the mothers were Italian. During the pregnancy, only 15 of 19 women with a known HIV diagnosis were treated with antiretroviral treatment, while, of 34 women who had received an HIV diagnosis before labour began, only 23 delivered by caesarean section and 17 received intrapartum prophylaxis. In 25 mothers, HIV infection was diagnosed during pregnancy or in the peripartum period. Thirty-one newborns received antiretroviral prophylaxis and 39 received infant formula. CONCLUSIONS We found an unacceptable number of missed opportunities to prevent mother-to-child transmission (MCTC). Eliminating HIV MTCT is a universal World Health Organization goal. Elucidating organization failures in Italy over the past decade should help to improve early diagnosis and to reach the zero transmission target in newborns.
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Affiliation(s)
- A Di Biagio
- Infectious Diseases Unit, Department of Internal Medicine, Policlinico San Martino Hospital, Genoa, Italy
| | - L Taramasso
- Infectious Diseases Unit, Department of Health Sciences (DISSAL), University of Genoa, Policlinico San Martino Hospital, Genoa, Italy.,Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - G Gustinetti
- Infectious Diseases Unit, Department of Health Sciences (DISSAL), University of Genoa, Policlinico San Martino Hospital, Genoa, Italy
| | - G Burastero
- Infectious Diseases Unit, Department of Health Sciences (DISSAL), University of Genoa, Policlinico San Martino Hospital, Genoa, Italy
| | - V Giacomet
- Department of Pediatrics, University of Milan, L. Sacco Hospital, Milan, Italy
| | - D La Rovere
- Ospedale Pediatrico Giovanni XXIII, Bari, Italy
| | - O Genovese
- Pediatric Intensive Care Unit, A. Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - C Giaquinto
- Department of Child's and Woman's Health, University of Padova, Padova, Italy
| | - O Rampon
- Department of Child's and Woman's Health, University of Padova, Padova, Italy
| | - I Carloni
- Pediatric Unit, Department of Child and Mother Health, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - T K Hyppolite
- Unit of Immune and Infectious Diseases, Children's Hospital Bambino Gesù, Rome, Italy
| | - L Palandri
- Unit of Immune and Infectious Diseases, Children's Hospital Bambino Gesù, Rome, Italy
| | - S Bernardi
- Unit of Immune and Infectious Diseases, Children's Hospital Bambino Gesù, Rome, Italy
| | - E Bruzzese
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - R Badolato
- Department of Clinical and Experimental Sciences, Institute of Molecular Medicine 'Angelo Nocivelli', University of Brescia, Brescia, Italy
| | - C Gabiano
- SC Pediatric Unit, Regina Margherita Hospital, Turin, Italy
| | - E Chiappini
- Department of Health Sciences, University of Florence, Meyer Children's Hospital, Florence, Italy
| | - M De Martino
- Department of Health Sciences, University of Florence, Meyer Children's Hospital, Florence, Italy
| | - L Galli
- Department of Health Sciences, University of Florence, Meyer Children's Hospital, Florence, Italy
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Mozzo E, Donà D, Zannin ME, Giaquinto C, Rampon O. Ocular involvement in an HIV-infected patient: not always an infectious disease. An interesting case without apparent cause. Int J STD AIDS 2016; 27:1130-1133. [PMID: 26823370 DOI: 10.1177/0956462416629263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/29/2015] [Indexed: 11/16/2022]
Abstract
We describe the case of a young girl with vertically-transmitted HIV infection who presented with chronic ocular inflammation characterized by several relapses and remissions. Good viral and immunological status made infective or neoplastic causes unlikely; the diagnosis was challenging and finally spontaneous remission was observed after several months. Clinical and histopathological findings made idiopathic orbital inflammatory syndrome the most probable diagnosis for our patient.
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Affiliation(s)
- Elena Mozzo
- Department of Child's and Woman's Health, University of Padova, Italy
| | - Daniele Donà
- Department of Child's and Woman's Health, University of Padova, Italy
| | | | - Carlo Giaquinto
- Department of Child's and Woman's Health, University of Padova, Italy
| | - Osvalda Rampon
- Department of Child's and Woman's Health, University of Padova, Italy
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Rampon O, Canale E, Rossi A, Mazza A, D'Elia R, Giaquinto C, Penazzato M. Congenital Plasmodium ovale malaria in an infant born to HIV positive mother. J PEDIAT INF DIS-GER 2015. [DOI: 10.1055/s-0035-1557031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | - Ettore Canale
- Clinical Microbiology and Virology, Padua University Hospital, Padua, Italy
| | - Anita Rossi
- Department of Oncology and Surgical Sciences, AIDS Reference Center, University of Padua, Italy
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Giacomet V, Fabiano V, Lo Muto R, Caiazzo MA, Curto A, Rampon O, Zuccotti GV, Garattini L. Resource utilization and direct costs of pediatric HIV in Italy. AIDS Care 2013; 25:1392-8. [PMID: 23414422 DOI: 10.1080/09540121.2013.769494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This multicenter, prospective, observational study assessed the global economic impact of HIV care in a large cohort of HIV-infected children and adolescents in Italy. Three pediatric departments of reference participated on a voluntary basis. Centers were asked to enroll all their children during the period April 2010-March 2011. At enrollment, a pediatrician completed a questionnaire for each patient, including the type of service at access (outpatient consultation or day hospital), laboratory tests, instrumental examinations, specialists' consultations, antiretroviral therapy and opportunistic illness prophylaxis. Eligible patients had a confirmed diagnosis of HIV infection caused by direct vertical maternal-fetal transmission, their age ranging from 0 to 24 years. Since patients routinely have quarterly check-ups in all three centers, we adopted a three-month time horizon. Health-care services were priced using outpatient and inpatient tariffs. Drug costs were calculated by multiplying the daily dose by the public price for each active ingredient. A total of 142 patients were enrolled. More than half the patients were female and the mean age was 14 years, with no significant differences by center. There were substantial differences in health-care management among the three centers, particularly as regards the type of access. One center enrolled the majority of its patients in day-hospital and prescribed a large number of clinical tests, while children accessed another center almost exclusively through outpatient consultation. Drug therapy was the main cost component and was very similar in all three centers. The day-hospital was the second highest cost component, much higher than outpatient consultation (including examinations), leading to significant differences between total costs per center. These findings suggest that a recommendation to the Italian National Health Service would be to use more outpatient consultation for patients' access in order to increase their efficiency in treating pediatric HIV infection.
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Affiliation(s)
- V Giacomet
- a Department of Pediatrics , Università degli Studi di Milano , Luigi Sacco Hospital, Milan , Italy
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Harrison L, Ananworanich J, Hamadache D, Compagnucci A, Penazzato M, Bunupuradah T, Mazza A, Ramos JT, Flynn J, Rampon O, Mellado Pena MJ, Floret D, Marczynska M, Puga A, Forcat S, Riault Y, Lallemant M, Castro H, Gibb DM, Giaquinto C. Adherence to antiretroviral therapy and acceptability of planned treatment interruptions in HIV-infected children. AIDS Behav 2013; 17:193-202. [PMID: 22584916 PMCID: PMC3548111 DOI: 10.1007/s10461-012-0197-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There have been no paediatric randomised trials describing the effect of planned treatment interruptions (PTIs) of antiretroviral therapy (ART) on adherence, or evaluating acceptability of such a strategy. In PENTA 11, HIV-infected children were randomised to CD4-guided PTIs (n = 53) or continuous therapy (CT, n = 56). Carers, and children if appropriate, completed questionnaires on adherence to ART and acceptability of PTIs. There was no difference in reported adherence on ART between CT and PTI groups; non-adherence (reporting missed doses over the last 3 days or marking <100 % adherence since the last clinical visit on a visual analogue scale) was 18 % (20/111) and 14 % (12/83) on carer questionnaires in the CT and PTI groups respectively (odds ratios, OR (95 % CI) = 1.04 (0.20, 5.41), χ2 (1) = 0.003, p = 0.96). Carers in Europe/USA reported non-adherence more often (31/121, 26 %) than in Thailand (1/73, 1 %; OR (95 % CI) = 54.65 (3.68, 810.55), χ2 (1) = 8.45, p = 0.004). The majority of families indicated they were happy to have further PTIs (carer: 23/36, 64 %; children: 8/13, 62 %), however many reported more clinic visits during PTI were a problem (carer: 15/36, 42 %; children: 6/12, 50 %).
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Gianesin K, Freguja R, Carmona F, Zanchetta M, Del Bianco P, Malacrida S, Montagna M, Rampon O, Giaquinto C, De Rossi A. The role of genetic variants of Stromal cell-Derived Factor 1 in pediatric HIV-1 infection and disease progression. PLoS One 2012; 7:e44460. [PMID: 22962615 PMCID: PMC3433455 DOI: 10.1371/journal.pone.0044460] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 08/02/2012] [Indexed: 02/04/2023] Open
Abstract
Stromal cell-Derived Factor 1 (SDF1) is the natural ligand of CXCR4, the coreceptor of HIV-1 X4 viruses. This study investigated the role of the single nucleotide polymorphism (SNP) rs1801157 (NM_000609.5:c.*519G>A) of the SDF1 gene in the natural history of mother-to-child transmission of HIV-1 and disease progression of HIV-1-infected children. The study was conducted in 428 children born to HIV-1-seropositive mothers, who had not undergone antiretroviral therapy (ART) during pregnancy, and in 120 HIV-1-infected children for whom the end-point was the onset of AIDS or the initiation of ART; 16 children developed early AIDS (<24 months of life), 13 from 24 to 84 months of age, and 14 had late AIDS (>84 months). The rs1801157 SNP was not associated with risk of perinatal infection in any genetic models tested. By contrast, this SNP influenced disease progression in a time-dependent manner. rs1801157 GA heterozygous children had a higher risk of late AIDS (HR = 6.3, 95%CI 1.9–20.7, p = 0.002) than children with the rs1801157 GG genotype. Children were studied for viral coreceptor usage at birth, after 84 months of age and/or at AIDS onset. While R5 viruses using CCR5 coreceptor were predominant at birth (94%) and at early AIDS (85%), viruses using CXCR4 coreceptor emerged during the course of infection and were detected in 49% of children older than 84 months and in 62% of late AIDS. The rs1801157 SNP did not influence the emergence of R5X4 viruses, but children with the rs1801157 GA genotype and R5X4 viruses were at significantly higher risk of late AIDS than children with rs1801157 GG genotype (OR = 8.0, 95% CI 1.2–52.2, p = 0.029). Our results indicate that the rs1801157 SNP does not influence perinatal infection, but impacts disease progression. This effect is time-dependent and linked to the coreceptor-usage of viral variants that undergo evolution during the course of HIV-1 infection.
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Affiliation(s)
- Ketty Gianesin
- Section of Oncology and Immunology, AIDS Reference Center, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Riccardo Freguja
- Section of Oncology and Immunology, AIDS Reference Center, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | | | | | | | - Sandro Malacrida
- Department of Neurosciences, University of Padova, Padova, Italy
| | | | - Osvalda Rampon
- Department of Pediatrics, University of Padova, Padova, Italy
| | - Carlo Giaquinto
- Department of Pediatrics, University of Padova, Padova, Italy
| | - Anita De Rossi
- Section of Oncology and Immunology, AIDS Reference Center, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
- Istituto Oncologico Veneto – IRCCS, Padova, Italy
- * E-mail:
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Nesti M, Carli E, Giaquinto C, Rampon O, Nastasio S, Giuca MR. Correlation between viral load, plasma levels of CD4 - CD8 T lymphocytes and AIDS-related oral diseases: a multicentre study on 30 HIV+ children in the HAART era. J BIOL REG HOMEOS AG 2012; 26:527-537. [PMID: 23034272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This experimental retrospective multicenter study carried out on 30 seropositive children treated with Highly Active Antiretroviral Therapy (HAART), between the ages of 18 months and 14 years, in the clinical categories Centers for Disease Control (CDC) classification 1993 A (mildly symptomatic), B (moderately symptomatic) and C (severely symptomatic) aims to: 1) clinically and immunologically demonstrate the therapeutic benefits of HAART; 2) monitor the frequency of AIDS-related oral diseases in seropositive children with HAART therapy; 3) monitor the plasma levels of total CD4, CD4 percent, CD8 percent, CD4-CD8 lymphocytes and viral load from 1997 to 30 April, 2011. The statistic methods used are the analysis of covariance and the Bonferroni Test. More than 100 AIDS-related oral diseases were found in the study samples, the most frequent being: oral candidiasis, oropharyngeal candidiasis, HSV-1 herpetic esophagyitis, herpetic gingivolstomatitis (RHOG), recurrent aphthous stomatitis (RAS), parotid swelling, oral hairy leukoplakia (OHL), Herpes simplex 1 (HSV-1), linear gingival erythema (LGE), necrotizing gingivitis (NUG), facial lipodistrophy, facial-cervical lymphadenopathy (FCL), xerostomia, dysgeusia, hyposmia, oral mucosa hyperpigmentation (OMP). The Bonferroni test showed a significant difference between the mean plasma values (mpVTL) of total CD4, CD4 percentage, CD4-CD8 T lymphocytes and Viral Load (VL) of the various oral diseases found in the study samples. The therapeutic benefits of HAART are: immune reconstitution; reduction of the HIV/AIDS-related stomatology diseases; prevention and cure of the AIDS correlated neoplasias; reduction in maternal-fetal transmission of the HIV virus. The negative effects of HAART in relation to odontostomatolgy are: increase in oral lesions from HPV; xerostomia; dysgeusia/ageusia, hyposmia, perioral paresthesia; hyperpigmentation of oral mucosa; facial lipodystrophy, recurrent aphthous stomatitis (RAS). No case of immune reconstitution inflammatory syndrome or human papillomavirus (HPV)-related oral diseases were found in this study.
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Affiliation(s)
- M Nesti
- Dipartimento di Chirurgia, Sezione di Odontostomatologia, Università di Pisa, Italy.
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Freguja R, Gianesin K, Zanchetta M, Carmona F, Malacrida S, Rampon O, Giaquinto C, De Rossi A. Polymorphims of innate immunity genes influence disease progression in HIV-1 infected children. Retrovirology 2012. [PMCID: PMC3360254 DOI: 10.1186/1742-4690-9-s1-p14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Freguja R, Gianesin K, Mosconi I, Zanchetta M, Carmona F, Rampon O, Giaquinto C, De Rossi A. Regulatory T cells and chronic immune activation in human immunodeficiency virus 1 (HIV-1)-infected children. Clin Exp Immunol 2011; 164:373-80. [PMID: 21438872 DOI: 10.1111/j.1365-2249.2011.04383.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The function of CD4(+) T cells with regulatory activity (T(regs)) is the down-regulation of immune responses. This suppressive activity may limit the magnitude of effector responses, resulting in failure to control human immunodeficiency virus 1 (HIV-1) infection, but may also suppress chronic immune activation, a characteristic feature of HIV-1 disease. We evaluated the correlation between viral load, immune activation and T(regs) in HIV-1-infected children. Eighty-nine HIV-1-infected children (aged 6-14 years) were included in the study and analysed for HIV-1 plasmaviraemia, HIV-1 DNA load, CD4 and CD8 cell subsets. T(reg) cells [CD4(+)CD25(high)CD127(low) forkhead box P3 (FoxP3(high))] and CD8-activated T cells (CD8(+)CD38(+)) were determined by flow cytometry. Results showed that the number of activated CD8(+)CD38(+)T cells increased in relation to HIV-1 RNA plasmaviraemia (r = 0·403, P < 0·0001). The proportion of T(regs) also correlated positively with HIV-1 plasmaviraemia (r = 0·323, P = 0·002), but correlated inversely with CD4(+) cells (r = -0·312, P = 0·004), thus suggesting a selective expansion along with increased viraemia and CD4(+) depletion. Interestingly, a positive correlation was found between the levels of T(regs) and CD8(+)CD38(+)T cells (r = 0·305, P = 0·005), and the percentage of T(regs) tended to correlate with HIV-1 DNA load (r = 0·224, P = 0·062). Overall, these findings suggest that immune activation contributes to the expansion of T(reg) cells. In turn, the suppressive activity of T(regs) may impair effector responses against HIV-1, but appears to be ineffective in limiting immune activation.
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Affiliation(s)
- R Freguja
- Department of Oncology and Surgical Sciences, Section of Oncology, AIDS Reference Center, Padova, Italy
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Giaquinto C, Penazzato M, Rosso R, Bernardi S, Rampon O, Nasta P, Ammassari A, Antinori A, Badolato R, Castelli Gattinara G, d'Arminio Monforte A, De Martino M, De Rossi A, Di Gregorio P, Esposito S, Fatuzzo F, Fiore S, Franco A, Gabiano C, Galli L, Genovese O, Giacomet V, Giannattasio A, Gotta C, Guarino A, Martino A, Mazzotta F, Principi N, Regazzi MB, Rossi P, Russo R, Saitta M, Salvini F, Trotta S, Viganò A, Zuccotti G, Carosi G. Italian consensus statement on paediatric HIV infection. Infection 2010; 38:301-19. [PMID: 20514509 DOI: 10.1007/s15010-010-0020-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 03/17/2010] [Indexed: 02/01/2023]
Abstract
The objective of this document is to identify and reinforce current recommendations concerning the management of HIV infection in infants and children in the context of good resource availability. All recommendations were graded according to the strength and quality of the evidence and were voted on by the 57 participants attending the first Italian Consensus on Paediatric HIV, held in Siracusa in 2008. Paediatricians and HIV/AIDS care specialists were requested to agree on different statements summarizing key issues in the management of paediatric HIV. The comprehensive approach on preventing mother-to-child transmission (PMTCT) has clearly reduced the number of children acquiring the infection in Italy. Although further reduction of MTCT should be attempted, efforts to personalize intervention to specific cases are now required in order to optimise the treatment and care of HIV-infected children. The prompt initiation of treatment and careful selection of first-line regimen, taking into consideration potency and tolerance, remain central. In addition, opportunistic infection prevention, adherence to treatment, and long-term psychosocial consequences are becoming increasingly relevant in the era of effective antiretroviral combination therapies (ART). The increasing proportion of infected children achieving adulthood highlights the need for multidisciplinary strategies to facilitate transition to adult care and maintain strategies specific to perinatally acquired HIV infection.
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Affiliation(s)
- C Giaquinto
- Dipartimento di Pediatria, Università degli Studi di Padova, Padova, Italy
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Penazzato M, Donà D, Wool PS, Rampon O, Giaquinto C. Update on antiretroviral therapy in paediatrics. Antiviral Res 2009; 85:266-75. [PMID: 19879898 DOI: 10.1016/j.antiviral.2009.10.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 10/19/2009] [Accepted: 10/21/2009] [Indexed: 11/27/2022]
Abstract
This review provides an update on the most relevant issues concerning the current management of HIV infection in infants and children. Tremendous progress has been made over the last few years to diagnose and treat infants and children with HIV infection, yet much remains to be done. Every day there are nearly 1150 new infections in children under 15 years of age, more than 90% of them occurring in the developing world and most being the result of transmission from mother-to-child (WHO 2008). The comprehensive approach to preventing mother-to-child transmission (MTCT) has clearly reduced the number of children acquiring the infection in Western countries; while a further reduction of mother-to-child transmission should be aimed for personalized setting, specific intervention needs to be put in place and new efforts are now required in order to optimise treatment and care in HIV-infected children. The prompt initiation of treatment and a careful selection of first-line regimen, which considers potency as well as tolerability remain central. In addition, occurrence and prevention of opportunistic infections, adherence as well as long-term psychosocial consequences are becoming more and more relevant in the era of effective antiretroviral therapy. This article forms part of a special issue of Antiviral Research marking the 25th anniversary of Antiretroviral Drug Discovery and Development, vol. 85, issue 1, 2010.
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Affiliation(s)
- Martina Penazzato
- Department of Paediatrics, University of Padua, Via Giustiniani 3, 35128 Padova, Italy
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Giaquinto C, Morelli E, Fregonese F, Rampon O, Penazzato M, de Rossi A, D'Elia R. Current and future antiretroviral treatment options in paediatric HIV infection. Clin Drug Investig 2008; 28:375-97. [PMID: 18479179 DOI: 10.2165/00044011-200828060-00005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Because of a lack of prevention policies or problems in implementing prevention of mother-to-child transmission (P-MTCT), most of the 1500 daily new HIV infections in children aged<15 years are caused by MTCT. Fifteen percent of all HIV-infected individuals are children, but the vast majority lack access to highly active antiretroviral therapy (HAART), which can drastically reduce morbidity and mortality. There are 22 antiretroviral drugs currently approved by the US FDA for use in the treatment of HIV-infected adults and adolescents, but only 12 of these drugs are approved for use in children. Antiretroviral drugs belong to four major classes: nucleoside and nucleotide analogue reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors and fusion inhibitors. According to international guidelines developed by organizations including WHO, the Paediatric European Network for Treatment of AIDS (PENTA) and the US National Institutes of Health (US-NIH), the treatment of choice for HIV-infected children and adults is a combination of two NRTIs (backbone treatment) plus a third potent agent from a different class, either an NNRTI or a ritonavir-boosted protease inhibitor. There are specific challenges in treating HIV-infected children, including uncertainty about the best time to start treatment, the need for more paediatric formulations, the lack of pharmacokinetic studies for new drugs, and incomplete dosing guidelines. Furthermore, the most appropriate regimen for an individual child depends on a variety of factors, including the age of the child; the availability of appropriate drug formulations; the potency, complexity and toxicity of the drug regimen; the home situation; the child and caregiver's ability to adhere to the regimen; and the child's antiretroviral treatment history. In addition, antiretroviral drugs are not licensed for all age groups and the drugs are often not affordable. This review describes NNRTI and protease inhibitors as key components of first- and second-line antiretroviral therapy (ART), focusing on the rationale for choosing an NNRTI- versus protease inhibitor-based regimen based on the results of available phase II and III studies. Some of the new agents available for children as second-line and salvage therapy both on- and off-label are also discussed. The drug regimens described in this review are relevant to clinicians in developed and developing countries. The availability of new, potent compounds with different resistance and toxicity profiles may represent an alternative option to interclass switching and could redefine ART strategy, including the option of first-line NRTI-sparing regimens.
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Affiliation(s)
- Carlo Giaquinto
- Department of Paediatrics, University of Padova, Padova, Italy.
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Zanchetta M, Anselmi A, Vendrame D, Rampon O, Giaquinto C, Mazza A, Accapezzato D, Barnaba V, Rossi AD. Early Therapy in HIV-1-Infected Children: Effect on HIV-1 Dynamics and HIV-1-Specific Immune Response. Antivir Ther 2008. [DOI: 10.1177/135965350801300105] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Perinatal HIV-1 infection is acquired in the milieu of a developing immune system, leading to high levels of uncontrolled viral replication. Few data have been reported that address the viral dynamics and immunological response in infants who initiated aggressive antiretroviral therapy (ART) shortly after birth. Methods Six HIV-1-infected infants who started ART within 3 months of age were studied. The median follow-up was 61 months. Plasma HIV-1 RNA, cell-associated HIV-1 DNA, unspliced and multiply spliced HIV-1 mRNAs, HIV-1 antibodies, and CD4+ and CD8+ T-cell subsets were assessed in sequential peripheral blood samples. HIV-1 cellular immune response was measured by EliSpot assay. Results All children showed a decline in plasma viraemia to undetectable levels. HIV-1 DNA persisted in four children, but only two of these had detectable HIV-1 mRNA. All viral parameters remained persistently negative in two children. Only two children produced HIV-1 antibodies, while the others, after having lost maternal antibodies, remained seronegative. No HIV-1 cellular immune response was observed in any child. Therapy interruption was performed in two children: one HIV-1-seropositive and one HIV-1-seronegative with persistently undetectable levels of all viral parameters. Rebound of HIV-1 plasma viraemia in the seronegative child was more rapid and higher than that observed in the seropositive child. Conclusions Early ART treatment in infants modifies the natural course of infection by controlling HIV-1 replication and reducing viral load to below the threshold levels required for onset of HIV-1 immune response, but does not prevent the establishment of a reservoir of latently infected cells that precludes virus eradication.
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Affiliation(s)
- Marisa Zanchetta
- AIDS Reference Center, Unit of Viral Oncology, Department of Oncology and Surgical Sciences, University of Padova, IOV-IRCCS, Italy
| | - Alessia Anselmi
- AIDS Reference Center, Unit of Viral Oncology, Department of Oncology and Surgical Sciences, University of Padova, IOV-IRCCS, Italy
| | - Daniela Vendrame
- AIDS Reference Center, Unit of Viral Oncology, Department of Oncology and Surgical Sciences, University of Padova, IOV-IRCCS, Italy
| | | | | | | | | | - Vincenzo Barnaba
- Department of Internal Medicine, University ‘La Sapienza’ Rome, Italy
| | - Anita De Rossi
- AIDS Reference Center, Unit of Viral Oncology, Department of Oncology and Surgical Sciences, University of Padova, IOV-IRCCS, Italy
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Zanchetta M, Anselmi A, Vendrame D, Rampon O, Giaquinto C, Mazza A, Accapezzato D, Barnaba V, De Rossi A. Early therapy in HIV-1-infected children: effect on HIV-1 dynamics and HIV-1-specific immune response. Antivir Ther 2008; 13:47-55. [PMID: 18389898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Perinatal HIV-1 infection is acquired in the milieu of a developing immune system, leading to high levels of uncontrolled viral replication. Few data have been reported that address the viral dynamics and immunological response in infants who initiated aggressive antiretroviral therapy (ART) shortly after birth. METHODS Six HIV-1-infected infants who started ART within 3 months of age were studied. The median followup was 61 months. Plasma HIV-1 RNA, cell-associated HIV-1 DNA, unspliced and multiply spliced HIV-1 mRNAs, HIV-1 antibodies, and CD4+ and CD8+ T-cell subsets were assessed in sequential peripheral blood samples. HIV-1 cellular immune response was measured by EliSpot assay. RESULTS All children showed a decline in plasma viraemia to undetectable levels. HIV-1 DNA persisted in four children, but only two of these had detectable HIV-1 mRNA. All viral parameters remained persistently negative in two children. Only two children produced HIV-1 antibodies, while the others, after having lost maternal antibodies, remained seronegative. No HIV-1 cellular immune response was observed in any child. Therapy interruption was performed in two children: one HIV-1-seropositive and one HIV-1-seronegative with persistently undetectable levels of all viral parameters. Rebound of HIV-1 plasma viraemia in the seronegative child was more rapid and higher than that observed in the seropositive child. CONCLUSIONS Early ART treatment in infants modifies the natural course of infection by controlling HIV-1 replication and reducing viral load to below the threshold levels required for onset of HIV-1 immune response, but does not prevent the establishment of a reservoir of latently infected cells that precludes virus eradication.
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Affiliation(s)
- Marisa Zanchetta
- AIDS Reference Center, Unit of Viral Oncology, Department of Oncology and Surgical Sciences, University of Padova, IOV-IRCCS, Italy
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Anselmi A, Vendrame D, Rampon O, Giaquinto C, Zanchetta M, De Rossi A. Immune reconstitution in human immunodeficiency virus type 1-infected children with different virological responses to anti-retroviral therapy. Clin Exp Immunol 2007; 150:442-50. [PMID: 17956580 DOI: 10.1111/j.1365-2249.2007.03526.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Immune repopulation, despite virological failure, often occurs in children under highly active anti-retroviral therapy (HAART). The aim of this study was to analyse the characteristics of immune repopulation and activation in children with and without virological response to HAART. Fourteen human immunodeficiency virus type 1 (HIV-1)-infected children with suppression of HIV-1 plasma viraemia (virological responders, VR) and 16 virological non-responders (VNR) to therapy were studied at baseline and after approximately 2 years of HAART. During therapy, CD4+ T cells increased in both groups, but were higher in the VR than in the VNR group. All CD4+ T cell subsets (naive, central memory, effector/memory and CD38+) increased significantly in VR children, while there was a significant increase only in naive cells in VNR children. Naive CD8+ T cells and T cell receptor rearrangement excision circles (TREC), an indicator of thymic output, increased in both VR and VNR children. Activated CD8+ CD38+ T cells decreased in VR but remained high in VNR children. Levels of circulating lipopolysaccharide (LPS), an indicator of microbial translocation, further increased in VNR children. In conclusion, HAART induced an increase in naive cells in all children, regardless of their virological response. However, the persistence of viraemia resulted in an impaired expansion of memory CD4+ T cells susceptible to HIV-1 infection, and together with the microbial translocation sustained the persistence of a high level of immune activation.
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Affiliation(s)
- A Anselmi
- Department of Oncology and Surgical Sciences, Oncology Section, Unit of Viral Oncology, AIDS Reference Center, University of Padova, IOV-IRCCS, Padova, Italy
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Abstract
By the end of 2006, approximately 2.3 million children worldwide were living with HIV infection, representing about 15% of all HIV-infected individuals but only 5-7% of the total population of treated patients worldwide. Despite a general increase in the use of antiretroviral therapy (ART) in resource-limited settings, appropriate care and ART remain inaccessible for most of the world's HIV-infected children. ART of children is challenging because of a general lack of paediatric formulations (including tablets in paediatric strengths), limited options of drugs available for children (some have been approved only for use in adults), different viral and immunological responses, dependency on caregivers for administration of the therapy, and specific issues of toxicity in long-term therapy related to maturation and development. As in adults, nucleoside reverse transcriptase inhibitors (NRTIs) are a key component of any ART schedule in children, being the recommended 'backbone' treatment in US, European and WHO guidelines, and, indeed, NRTIs have been extensively studied in children. NRTIs are the class of antiretroviral drugs that have more drugs licensed for paediatric use and more paediatric formulations.Generally, the dual NRTI backbone treatment of combination with a non-NRTI (NNRTI) or protease inhibitor (PI) should comprise a cytidine analogue (lamivudine, emtricitabine) and a thymidine analogue (stavudine, zidovudine), guanosine analogue (i.e. abacavir), or nucleotide RTI (NtRTI; i.e. tenofovir). European and US guidelines recommend the use of triple NRTI therapy (abacavir/lamivudine/zidovudine) in children with anticipated poor adherence to other treatment regimens because of tablet burden. In conclusion, while use of ART in children needs to be dramatically increased, selecting and administering the best drug combination for children is still limited by a lack of paediatric formulations and knowledge of drug metabolism, safety and efficacy in children. NRTIs are already a key component of paediatric ART, but fixed-dose combinations and specific research in children are needed to optimise their use. In this article we review the available information to facilitate selection of the best NRTI for backbone treatment in combination ART for HIV-infected children.
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Affiliation(s)
- Carlo Giaquinto
- Department of Pediatrics, Università di Padova, Padova, Italy.
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Chiappini E, Galli L, Tovo PA, Gabiano C, Lisi C, Giaquinto C, Rampon O, Gattinara GC, De Marco G, Osimani P, Manzionna M, Miniaci A, Pintor C, Rosso R, Esposito S, Viganò A, Dodi I, Maccabruni A, Fundarò C, de Martino M. Cancer rates after year 2000 significantly decrease in children with perinatal HIV infection: a study by the Italian Register for HIV Infection in Children. J Clin Oncol 2007; 25:97-101. [PMID: 17194910 DOI: 10.1200/jco.2006.06.6506] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the impact of highly active antiretroviral therapy (HAART) on cancer incidence in HIV-infected children throughout a 20-year period. PATIENTS AND METHODS An observational population study was conducted on 1,190 perinatally HIV-infected children enrolled onto the Italian Register for HIV Infection in Children from 1985 to 2004 and never lost to follow-up (total observation time, 10,037.66 years). Cancer rates were calculated in the pre-HAART (1985 to 1995), early HAART (1996 to 1999), and late HAART (2000 to 2004) periods and compared using Poisson regression adjusted for age. The proportion of HAART-treated children increased from 4.1% in 1996 to 60.4% in 1999 and to 81.5% in 2004. In the same time frame, the proportion of children receiving HAART for at least 2 years increased from 3.1% to 77.0%. RESULTS Overall, 35 cancers occurred. Cancer rates were 4.49 (95% CI, 2.37 to 6.64), 4.09 (95% CI, 1.68 to 6.50), and 0.76 (95% CI, 0.00 to 1.80) per 1,000 children per year in 1985 to 1995, 1996 to 1999, and 2000 to 2004, respectively. Notably, there was no significant difference comparing the periods from 1985 to 1995 and 1996 to 1999 (P = .081). By contrast, cancer rates were significantly lower in the period from 2000 to 2004 than in 1996 to 1999 (P < .0001). Results were confirmed by separately analyzing data from children observed from birth (P = .418 for 1985 to 1995 v 1996 to 1999; P = .001 for 1996 to 1999 v 2000 to 2004). CONCLUSION Dramatically reduced cancer rates were observed only in the late HAART period in parallel to the increasing proportion of children receiving HAART therapy.
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Affiliation(s)
- Elena Chiappini
- Department of Pediatrics, University of Florence, Florence, Italy
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Zanchetta M, Walker S, Burighel N, Bellanova D, Rampon O, Giaquinto C, De Rossi A. Long‐Term Decay of the HIV‐1 Reservoir in HIV‐1–Infected Children Treated with Highly Active Antiretroviral Therapy. J Infect Dis 2006; 193:1718-27. [PMID: 16703516 DOI: 10.1086/504264] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Accepted: 01/25/2006] [Indexed: 11/03/2022] Open
Abstract
To investigate the decay of the human immunodeficiency virus type 1 (HIV-1) reservoir in children receiving highly active antiretroviral therapy (HAART), we measured HIV-1 DNA in peripheral blood mononuclear cells from 14 children who achieved and maintained suppression of plasma viremia up to 48 months after the initiation of HAART. Levels of intracellular unspliced and multiply spliced HIV-1 RNA were used as markers of residual viral replication. During the first month of HAART, there were significant decays in levels of both plasma HIV-1 RNA and multiply spliced HIV-1 RNA, yet unspliced HIV-1 RNA persisted in most of the children. Greater HIV-1 DNA decay during the first month of HAART correlated with a higher concomitant increase in CD4(+) cell counts (P=.028) and a smaller subsequent HIV-1 DNA decay (P=.0012). Furthermore, HIV-1 DNA decayed faster from 1 to 9 months of HAART (median half-life, 5 months) than during the subsequent follow-up period (median half-life, 30 months). Moreover, after 9 months of HAART, HIV-1 DNA tended to decay more slowly in children with detectable levels of unspliced HIV-1 RNA. These findings suggest that clearance of the viral reservoir in HAART-treated children may be influenced by immune repopulation and residual viral replication and may help in refining long-term treatment strategies.
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Affiliation(s)
- Marisa Zanchetta
- Department of Oncology and Surgical Sciences, Unit of Viral Oncology, AIDS Reference Center, Padova, Italy
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Rosso R, Di Biagio A, Dentone C, Gattinara GC, Martino AM, Viganò A, Merlo M, Giaquinto C, Rampon O, Bassetti M, Gatti G, Viscoli C. Lopinavir/ritonavir exposure in treatment-naive HIV-infected children following twice or once daily administration. J Antimicrob Chemother 2006; 57:1168-71. [PMID: 16606636 DOI: 10.1093/jac/dkl136] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Lopinavir/ritonavir is approved for treatment of HIV-infected children at a dosage regimen of 230/57.5 mg/m(2) twice daily. However, once daily administration could increase convenience and patient adherence. Our study aimed at evaluating whether inhibitory concentrations are maintained in plasma following administration of lopinavir/ritonavir once daily. PATIENTS AND METHODS Lopinavir/ritonavir was administered at the standard twice daily regimen to 21 HIV-infected children, as a component of their antiretroviral treatment. Following at least 1 month of administration, seven patients received a dose of 460/115 mg/m(2) once daily for three consecutive days. After the third dose of once daily administration, blood samples were drawn at the following times: 0 (pre-dose), 1, 2 and 4 h following administration. The pre-dose (C(min)) and the peak (C(max)) concentrations were compared with the values obtained following twice daily administration in all the study patients. RESULTS Median (interquartile range) C(min) with the once daily regimen was 1.59 (0.77-6.85) mg/L versus 7.90 (5.45-9.77) mg/L with the twice daily regimen (P < 0.05). C(min) was considered inhibitory for wild-type virus (>1.0 mg/L) in four out of seven patients. C(max) did not differ significantly between the once daily and twice daily regimens. CONCLUSIONS Our small pilot study suggests that lopinavir/ritonavir once daily may be a suitable regimen for antiretroviral-naive children. However, due to the high interindividual variability and low concentrations in some patients, therapeutic drug monitoring may be necessary to ensure that concentrations are adequate to inhibit viral replication. A formal clinical study of lopinavir/ritonavir once daily in treatment-naive children is warranted.
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Affiliation(s)
- Raffaella Rosso
- Department of Infectious Diseases, San Martino Hospital and University of Genoa, Largo Rosanna Benzi 10, 16132 Genoa, Italy
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Abstract
Administration of potent antiretroviral combination therapy in the second and third trimester of pregnancy and during delivery, and for 6 weeks postpartum to the infant, may reduce HIV transmission from the mother to the child to <2% in formula-fed infants. In resource-constrained settings where women have limited access to antenatal care, use of shorter and more practical regimens, including nucleoside reverse transcriptase inhibitors (NRTIs) and/or non-NRTIs (NNRTIs) commenced later in pregnancy, has demonstrated efficacies ranging from 18% to 70% in breast- and bottle-fed populations. Because shorter interventions include regimens such as single-dose nevirapine or zidovudine monotherapy, which do not provide maximal suppression of viral replication, emergence of resistant mutations in mother and infant occurs frequently, primarily after exposure to drugs with low genetic barriers (i.e. those requiring only one genotypic mutation to develop resistance), such as nevirapine. Different studies have reported nevirapine resistance rates ranging from 25% to 69% in mothers receiving single-dose nevirapine alone. Because NNRTI-based combinations of antiretroviral agents are recommended as first-line therapy in countries where single-dose nevirapine is the main option for preventing mother-to-child transmission of HIV, concerns have been raised as to whether single-dose nevirapine prophylaxis can compromise the efficacy of subsequent NNRTI-based antiretroviral therapy regimens. However, although some studies have shown that nevirapine exposure may impact on short-term virological outcome, the clinical relevance of nevirapine resistance remains unclear, especially in women who start treatment >6 months after delivery or in those who are not severely immunocompromised. Furthermore, studies have shown that adding short-course (up to 7 days) zidovudine or zidovudine/lamivudine prophylaxis after delivery may dramatically reduce the occurrence of nevirapine resistance in both mothers and infants. Until data are available that allow a better understanding of the relevance of antiretroviral drug resistance acquired as a result of mother-to-child HIV transmission prophylaxis, women and children who have previously received single- dose nevirapine as part of a mother-to-child transmission prevention strategy should be considered eligible for NNRTI-based regimens and should not be denied access to antiretroviral therapy.
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Affiliation(s)
- Carlo Giaquinto
- Dipartimento di Pediatria, Università di Padova, Padova, Italy.
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Casado C, Giaquinto C, Rampon O, D'Elia R, Lopez-Galindez C, De Rossi A. Intrafamilial transmission of HIV-1. AIDS 2003; 17:2673-4. [PMID: 14685067 DOI: 10.1097/00002030-200312050-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ghiro L, Zanconato S, Rampon O, Piovan V, Pasquale MF, Baraldi E. Effect of montelukast added to inhaled corticosteroids on fractional exhaled nitric oxide in asthmatic children. Eur Respir J 2002; 20:630-4. [PMID: 12358339 DOI: 10.1183/09031936.02.01512002] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this prospective, self-controlled, single-blind study was to assess the effect of montelukast added to maintenance therapy with inhaled corticosteroids (ICS) on fractional exhaled nitric oxide (FENO) in asthmatic children. Thirty-five children (age 11.2+/-0.4 yrs (mean+/-SEM)) with mild-to-moderate persistent asthma treated with low to medium doses of ICS and FENO > 20 parts per billion (ppb) were included. The patients were randomly assigned to two groups: 17 patients continued ICS (group C) and 18 had montelukast added to ICS for 3 weeks (group M). FENO measurements were performed in both groups at baseline (T1) and after 3 weeks (T2), and in group M also after 2 weeks of washout. FENO was measured by a chemiluminescence analyser using an on-line method (50 mL x s(-1)) with nitric oxide-free air. The overall mean daily dose of ICS was equivalent to 530+/-58 microg x day(-1) of beclomethasone in group M and to 564+/-55 microg x day(-1) of beclomethasone in group C. There were no significant differences in baseline FENO and forced expiratory volume in one second (FEV1) between the two groups. After 3 weeks there was a significant reduction of FENO values in patients of group M (T1 52.2+/-7.8 ppb, T2 36.1+/-4.6 ppb) but no significant changes in group C (T1 43.5+/-6.0 ppb, T2 47.8+/-9.4 ppb). In group M after 2 weeks of montelukast withdrawal, FENO rose to baseline values (55.6+/-8.7 ppb). In conclusion, after montelukast treatment there is a fractional exhaled nitric oxide reduction in asthmatic children receiving maintenance therapy with inhaled corticosteroids. This suggests an anti-inflammatory effect of montelukast additive to that of inhaled corticosteroids.
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Affiliation(s)
- L Ghiro
- Dept of Paediatrics, University of Padua, Italy
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Giaquinto C, De Romeo A, Giacomet V, Rampon O, Ruga E, Burlina A, De Rossi A, Sturkenboom M, D'Elia R. Lactic acid levels in children perinatally treated with antiretroviral agents to prevent HIV transmission. AIDS 2001; 15:1074-5. [PMID: 11399997 DOI: 10.1097/00002030-200105250-00023] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- C Giaquinto
- Department of Pediatrics, University of Padova, Padua, Italy
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Ometto L, Bertorelle R, Mainardi M, Zanchetta M, Tognazzo S, Rampon O, Ruga E, Chieco-Bianchi L, De Rossi A. Polymorphisms in the CCR5 promoter region influence disease progression in perinatally human immunodeficiency virus type 1-infected children. J Infect Dis 2001; 183:814-8. [PMID: 11181160 DOI: 10.1086/318828] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2000] [Revised: 11/17/2000] [Indexed: 11/03/2022] Open
Abstract
The effect of CC-chemokine receptor 5 (CCR5) promoter polymorphisms on the natural history of human immunodeficiency virus (HIV) disease was studied in 73 HIV-1-infected children. The CCR5(59338-59537) promoter haplotype, CCR5-59029A/G polymorphism, and CCR5Delta32 and CCR2-64I alterations were investigated. After exclusion of carriers of CCR5Delta32 or CCR2-64I, Kaplan-Meier analysis disclosed that children with the P1/P1(59353C,59356C,59402A) genotype progressed faster to disease than did children with other haplotypes (P=.016). When CCR2-64I carriers were included, this effect had borderline significance (P=.065) and was lost when CCR5Delta32 carriers were also considered (P=.387). The P1/P1 effect was strongest early after infection, when progression to disease was mainly associated with CCR5 coreceptor-using viruses. These results indicate that the P1/P1 genotype is predictive of rapid progression in HIV-1-infected children lacking CCR5Delta32 or CCR5-64I alleles. The observation of a linkage disequilibrium between P1 and 59029A might explain the previously reported association between 59029A homozygosity and rapid disease progression.
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Affiliation(s)
- L Ometto
- Department of Oncology and Surgical Sciences, Oncology Section, AIDS Reference Center, Via Gattamelata 64, 35128 Padova, Italy
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Abstract
It is estimated that approximately 6000 women of childbearing age, mostly living in the developing world, acquire HIV infection every day. Taking into account that approximately 98% of HIV infected children have acquired HIV from the mother, during pregnancy, at delivery or through breastfeeding, therefore, prevention of mother-to-child transmission (MTCT) is a major health priority. Several studies have showed how MTCT of HIV may be prevented using antiretrovirals. Results from a study conducted in Thailand have also recently showed how a short oral zidovudine course during pregnancy and labor may reduce the risk of HIV transmission by approximately 50%. These findings represent a major challenge for the International Health Agencies and Organizations that will have the major obligation to provide HIV tests, counseling and antiviral drugs in settings with high HIV prevalence.
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