Neuropsychologic functioning of human immunodeficiency virus-infected children with hemophilia

Is There Evidence for Neurocognitive Dysfunctions in Patients with Postnatal HIV Infection? A Review on the Cohort of Hemophilia Patients

The debate regarding neurocognitive functions in the early stages of HIV infection is still ongoing; different studies have reached contrasting conclusions, probably because many of them take into account different cohorts of patients. A main distinction is between HIV seropositive patients infected perinatally, and those infected postnatally. The aim of this paper is to review results on neurocognitive dysfunctions and other types of neurological involvement in a specific cohort of HIV+ patients infected postnatally: hemophilia patients. Such a review is relevant, as HIV seropositive patients infected postnatally are understudied with respect to patients infected perinatally, and as the results of the few studies aiming at comparing them are contrasting. Taken together, the 11 studies reviewed suggest the presence of both long-term neurocognitive dysfunctions and neurological alterations, such as the presence of atrophic changes and lesions in the white matter. The current review may offer new research insights into the neurocognitive dysfunctions in HIV-patients, and on the nature of such dysfunctions.

Behavioural disorders in 6-11-year-old, HIV-infected Indian children

BACKGROUND

HIV-infected children are at risk of behaviour problems. The transition of HIV from an acute, lethal disease to survival with sub-acute, chronic disease has enormous implications for the psychosocial development and requirement for support of affected children and families.

AIM

To study the behavioural patterns and factors responsible for psychiatric disorders among HIV-infected and uninfected children in the age group 6-11 years.

METHODS

A prospective, random-sampling study was undertaken to examine the unique and combined influences of HIV and socio-demographic characteristics on the behaviour of 140 infected and 301 age- and income-matched controls. Controls were normal children recruited from government schools. The Child Behaviour Check List was used to assess behaviour patterns.

RESULTS

Multivariate analyses comparing HIV-infected children with their uninfected peers from similar backgrounds showed more subjective distress in the HIV-infected group. Behaviour problems in HIV-infected children were reported by 80.7% of primary caregivers compared with 18.3% for controls. Psychiatric behaviour in HIV-infected children as a risk factor for HIV was also identified in a significant proportion (p<0.0001).

CONCLUSIONS

By analysing behaviour, a psycho-medical team can examine the extent to which psychosocial and demographic factors are involved in causing and exacerbating behaviour problems in HIV-infected children.

Is attention deficit hyperactivity disorder over-represented among HIV-seronegative boys with haemophilia? Preliminary results from our centre

Haemophilia care providers report anecdotally that many boys under their care bear the diagnosis of attention deficit hyperactivity disorder (ADHD). This study investigated the hypothesis that ADHD is over-represented among boys with haemophilia. All the boys with haemophilia, aged 5-14 years, who receive their comprehensive care at our centre were solicited to participate in this study. Of the 78 eligible boys, 34 (44%) were successfully contacted and agreed to participate. All participants were HIV-negative on both serological and PCR-based assays. The presence of ADHD symptoms was established via a parent- and teacher-completed standardized rating instrument. On the parent-rating scale, 26% of the participants exceeded the cut-off for inattentive ADHD, 18% for hyperactive/impulsive ADHD, and 18% for combined. On the teacher rating scale, 4% of the participants exceeded the cut-off for inattentive ADHD, but no participants were rated as having extreme hyperactive/impulsive or combined ADHD symptoms. Retrospectively, 29% of the participants had previously been diagnosed with ADHD, all treated with stimulant medications. Of note, 38% of our participants were enrolled in special education programmes. All of the above were more common in boys with haemophilia compared with national controls. A chart review of non-participating patients from the same clinic suggested that sampling bias is unlikely to account for these differences. These results provide the first empirical evidence that ADHD may be over-represented among boys with haemophilia.

Neurologic aspects of HIV infection in infants and children: therapeutic approaches and outcome

Central nervous system (CNS) HIV-related disorders frequently have devastating consequences. Significant progress has been made in the early diagnosis and treatment of the HIV-infected patient. As a result, the prevalence and natural history of neurologic illnesses have changed. This paper reviews the epidemiology, clinical manifestations, and neuropathogenesis of HIV-related CNS disorders. Advances in antiretroviral therapy, neuroprophylaxis, and neuroprotective strategies are also discussed.

Cognitive development in school-age children with vertically transmitted HIV infection

We examined a broad range of neuropsychological functioning in school-age children with vertically transmitted HIV infection and a control group made up of siblings of children with HIV infection. Fourteen children with HIV (2 asymptomatic, 8 mildly symptomatic, and 4 with AIDS) and 11 control children were administered a battery of neuropsychological tests assessing intelligence, receptive language, expressive language, visual and verbal memory, visual-motor speed and coordination, visual-motor and visual-spatial processing, fine motor skill, and academic achievement. Results revealed that school-age children with vertically transmitted HIV infection show many areas of cognitive function within the normal range. Despite normal cognitive development, subtle motor impairments were documented in children with vertically transmitted HIV infection. Our results are the first report of fine motor and motor strength deficits in school-age children with vertically transmitted HIV. Lastly, computed tomography (CT) results suggest that children with HIV who have documented structural anomalies in the brain may be at risk for deficits in visual-motor and visual-spatial processing. This finding should be explored with larger samples and other measures to determine its generalizability.

High rates of behavioral problems in perinatally HIV-infected children are not linked to HIV disease

OBJECTIVE

Descriptive studies and clinical reports have suggested that human immunodeficiency virus (HIV)-positive children are at risk for behavioral problems. Inadequate control groups and sample sizes have limited the ability of investigators to consider multiple influences that place HIV-positive children at risk for poor behavioral outcomes. We examined the unique and combined influences of HIV, prenatal drug exposure, and environmental factors on behavior in children who were perinatally exposed to HIV.

METHODS

Participants included 307 children who were born to HIV-positive mothers (96 HIV infected and 211 seroreverters) and enrolled in a natural history, longitudinal study of women to infant HIV transmission. Caregivers completed parent behavioral rating scales, beginning when the children were 3 years old. Data were also collected on prenatal drug exposure; child age, gender, and ethnicity; caregiver relationship to child; and birth complications.

RESULTS

Multivariate analyses comparing the HIV-infected children with perinatally exposed but uninfected children from similar backgrounds failed to find an association between either HIV status or prenatal drug exposure and poor behavioral outcomes. The strongest correlates of increased behavioral symptoms were demographic characteristics.

CONCLUSIONS

This study suggests that although a high prevalence of behavioral problems does exist among HIV-infected children, neither HIV infection nor prenatal drug exposure is the underlying cause. Rather, other biological and environmental factors are likely contributors toward poor behavioral outcomes.

Neurological and developmental effects of HIV and AIDS in children and adolescents

HIV-related encephalopathy is an important problem in vertically infected children with HIV. Infected infants may manifest early, catastrophic encephalopathy, with loss of brain growth, motor abnormalities, and cognitive dysfunction. Even without evidence of AIDS, infected infants score lower than serorevertors on developmental measures, particularly language acquisition. Children with perinatal or later transfusion-related infection generally are roughly comparable developmentally to their peers until late in their course. Symptoms similar to adult AIDS dementia complex are occasionally seen in adolescents with advanced AIDS, including dementia, bradykinesia, and spasticity. Opportunistic CNS infections such as toxoplasmosis and progressive multifocal leukoencephalopathy are less common in children and adolescents than in adults. Increasing evidence suggests that aggressive antiretroviral treatment may halt or even reverse encephalopathy. Neuroimaging changes may precede or follow clinical manifestations, and include early lenticulostriate vessel echogenicity on cranial ultrasound, calcifying microangiopathy on CT scan, and/or white matter lesions and central atrophy on MRI. Differential diagnosis of neurological dysfunction in an HIV-infected infant includes the effects of maternal substance abuse, other CNS congenital infections, and other causes of early static encephalopathy. Initial entry of HIV into the nervous system occurs very early in infection. The risk of clinical HIV encephalopathy increases with very early age of infection and with high viral loads. Virus is found in microglia and brain derived macrophages, not neurons. The neuronal effect of HIV is probably indirect, with various cytokines implicated. Apoptosis is the presumed mechanism of damage to neurons by HIV.

Predicting HIV disease progression in children using measures of neuropsychological and neurological functioning. Pediatric AIDS clinical trials 152 study team

BACKGROUND

Neuropsychological testing and 2 measures of neurological status, cortical atrophy, and motor dysfunction were assessed for their usefulness in predicting human immunodeficiency virus (HIV) disease progression in infants, children, and adolescents who participated in Pediatric AIDS Clinical Trials Group Protocol 152 (PACTG 152).

METHODS

A cohort of 722 antiretroviral therapy-naive children with symptomatic HIV infection were assessed at study entry and at later intervals. Assessments included neurodevelopmental testing, neuroradiologic imaging, and neurological examination of motor function. CD4 cell count and plasma RNA viral load also were measured.

RESULTS

Children with the lowest neuropsychological functioning (IQ < 70) at baseline had the highest risk for later HIV disease progression (56%), compared with those with borderline/low (IQ = 70-89) functioning (26%), or with average or above (IQ > 90) functioning (18%). This was also true of week 48 neuropsychological functioning. Motor dysfunction (especially reduced muscle mass) at entry also predicted disease progression. Furthermore, motor dysfunction and week 48 neuropsychological functioning provided predictive information beyond that obtainable from surrogate markers of HIV disease status (eg, CD4 count, HIV RNA level). Children with cortical atrophy also were at higher risk for later disease progression, but when CD4 count and RNA viral load were known, cortical atrophy information provided no additional predictive information.

CONCLUSIONS

Measures of neuropsychological and motor function status provide unique information regarding pediatric HIV disease progression. As such, these findings have important implications for predicting long-term outcomes (eg, longevity) in pediatric patients.

Hemophilia morbidity, cognitive functioning, and academic achievement

Data from the Hemophilia Growth and Development Study (HGDS) were used to evaluate the association between hemophilia morbidity, measured by abnormalities in coordination and gait (CG), and intellectual ability and academic achievement. The CG abnormalities observed in the HGDS participants (n = 333) were primarily due to hemophilia-related morbidity. Although HGDS participants performed within the average range for age on measures of intellectual ability, there were meaningful differences between CG outcomes at baseline and throughout the 4 years of study. Participants without CG abnormalities consistently achieved higher scores than those with CG abnormalities on Reading, Spelling, and Arithmetic subtests of the Wide Range Achievement Test-Revised. Our findings suggest that lowered achievement is related to the functional severity of hemophilia.

Longitudinal neurological follow-up of a group of HIV-seropositive and HIV-seronegative hemophiliacs: results from the hemophilia growth and development study

BACKGROUND

Boys and young men with hemophilia treated with factor infusions before 1985 had a substantial risk of acquiring the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome. This study was designed to assess the effects of HIV and hemophilia per se on neurological function in a large cohort of subjects with hemophilia, and to investigate the relationships between neurological disease and death during follow-up.

METHODS

Three hundred thirty-three boys and young men (207 HIV seropositive and 126 HIV seronegative) were evaluated longitudinally in a multicenter, multidisciplinary study. Neurological history and examination were conducted at baseline and annually for 4 years. The relationship between neurological variables, HIV serostatus, CD4+ cell counts, and vital status at the conclusion of the study was examined using logistic regression models.

RESULTS

The risks of nonhemophilia-associated muscle atrophy, behavior change, and gait disturbance increased with time in immune compromised HIV-seropositive subjects compared with HIV seronegative or immunologically stable HIV-seropositive subjects. The risk of behavior change in immune compromised HIV-seropositive hemophiliacs, for example, rose to 60% by year 4 versus 10% to 17% for the other study groups. Forty-five subjects (13.5%), all of whom were HIV seropositive, died by year 4. Subjects who died had had increased risks of hyperreflexia, nonhemophilia-associated muscle atrophy, and behavior change.

CONCLUSIONS

These results indicate that immune compromised, HIV-seropositive hemophiliacs have high rates of neurological abnormalities over time and that neurological abnormalities were common among subjects who later died. By contrast, immunologically stable HIV-seropositive subjects did not differ from the HIV-seronegative participants. Hemophilia per se was associated with progressive abnormalities of gait, coordination, and motor function.

School-related issues among HIV-infected children

OBJECTIVE

Many children with human immunodeficiency virus (HIV) infection are surviving long enough to reach school age. This study describes issues related to school attendance and disclosure of HIV infection in a population of HIV-infected children.

METHODS

A statewide pediatric HIV surveillance system was used to collect data on school-age (>/=5 years old) HIV-infected children. In addition, HIV clinic nurses familiar with the child's history participated in a cross-sectional survey that collected information on school-related issues during the 1993-1994 school year.

RESULTS

Of the 92 school-age children, only 3 were too ill to attend school. Another 5 children were home-schooled. Of the 84 who attended school outside the home, 25% had severe symptoms of HIV infection (Centers for Disease Control and Prevention [CDC] clinical category C). Absence from school ranged from less than 2 weeks during the year for half of the children (51%) to more than 8 weeks for 9 children (12%). Twenty-nine percent of the children received medication in school, usually administered by the school nurse. Over two thirds of the 50 children ages 5 to 10 years had not been told that they had HIV infection. Only 1 of the 20 children more than 10 years of age was not aware of her HIV infection. For 53% of the children attending school, no school personnel had been informed of the child's HIV infection. Administration of HIV medications at school, age of child, and treatment at one particular HIV clinic were associated with the parents' decision to inform school personnel. In the 47% of cases where the school had been informed, school nurses were most frequently notified, followed by principals and teachers.

CONCLUSION

Only 3% of school-age children were too ill to attend school, and almost all were enrolled in public schools. The number of HIV-infected children reaching school age will continue to grow, and public schools will bear the responsibility for educating these children. Health care providers will increasingly be called upon for guidance by both educators and families to assure that HIV-infected children receive the best education possible.

A profile of human immunodeficiency virus-infected adolescents receiving health care services at selected sites in the United States

OBJECTIVE

To determine the demographic/clinical profile of human immunodeficiency virus (HIV)-infected adolescents in care at selected sites.

METHODS

We mailed surveys requesting prevalence data from physicians in government-funded HIV research and care programs on HIV-infected youth (10-21 years) receiving care.

RESULTS

A total of 49% responses yielded information on 978 subjects. Vertical, blood, and sexual were predominant transmission modes. Three-quarters were of an ethnic/racial minority; 50% were female. The earliest median CD4 count was 0.467 x 10(9)/liter (467/microliter). Percent asymptomatic varied by transmission: vertical (16%), blood products (40%), male-male sexual (67%) and female-male sexual (M:73%) (F:74%). Clinical indicated Pneumocystis carinii pneumonia prophylaxis was differentially prescribed: vertical (96%), blood (89%), and sexually (male-male-47%) (female-male: M: 36% and F: 56%). Of these youth 78% are not represented in national AIDS case data.

CONCLUSIONS

Examination of numerator data from selected sites indicates three transmission-driven adolescent HIV epidemics with different characteristics. Minority youth are disproportionately represented; many vertically infected infants are surviving to adolescence; sexual activity is a significant transmission avenue. HIV-infected youth appear to enter care with considerable immunosuppression. Clinical profiles and treatment patterns appear to differ by transmission mode. Further study is needed on adolescent HIV disease progression and determinants of access to care and treatment.

Pediatric HIV infection: neurologic and neuropsychologic findings

Neurologic and neuropsychologic findings are early and important prognostic indicators of symptomatic HIV disease among infants and young children. The most common presentations include progressive encephalopathy, loss of motor milestones, and corticospinal tract abnormalities. It is hypothesized that, in some instances, the more severe neurologic manifestations of HIV noted in infancy may reflect the consequences of in utero HIV infection, or the increased vulnerability of infants to HIV infection during a time of rapid brain growth. Current research suggests that infants with basal ganglia calcification and those with plummeting or low CD4+ counts are at particular risk of severe central nervous disease progression. In contrast to infants and toddlers, older children and adolescents appear to demonstrate only subtle neurologic dysfunction until very late in their illness. Findings seen include attentional difficulties, fine motor tremors, visual sequencing problems, and depressive affect. One of the challenges for the 1990s will be rapidly to identify those infants who are at high risk of central nervous system disease progression, and to institute effective treatments that can halt the devastating effects of HIV on the developing brain. In addition to early identification of the high-risk infants, neuropsychologic, neuroimaging and laboratory measures need to be identified that will allow effective monitoring of responses to therapy.