Predictors of survival in children with acquired immunodeficiency syndrome in Italy, 1983 to 1995

Understanding the contribution of common childhood illnesses and opportunistic infections to morbidity and mortality in children living with HIV in resource-limited settings

OBJECTIVE

Although antiretroviral treatment (ART) has reduced the incidence of HIV-related opportunistic infections among children living with HIV, access to ART remains limited for children, especially in resource-limited settings. This paper reviews current knowledge on the contribution of opportunistic infections and common childhood illnesses to morbidity and mortality in children living with HIV, highlights interventions known to improve the health of children, and identifies research gaps for further exploration.

DESIGN AND METHODS

Literature review of peer-reviewed articles and abstracts combined with expert opinion and operational experience.

RESULTS

Morbidity and mortality due to opportunistic infections has decreased in both developed and resource-limited countries. However, the burden of HIV-related infections remains high, especially in sub-Saharan Africa, where the majority of HIV-infected children live. Limitations in diagnostic capacity in resource-limited settings have resulted in a relative paucity of data on opportunistic infections in children. Additionally, the reliance on clinical diagnosis means that opportunistic infections are often confused with common childhood illnesseswhich also contribute to excess morbidity and mortality in these children. Although several preventive interventions have been shown to decrease opportunistic infection-related mortality, implementation of many of these interventions remains inconsistent.

CONCLUSIONS

In order to reduce opportunistic infection-related mortality, early ART must be expanded, training for front-line clinicians must be improved, and additional research is needed to improve screening and diagnostic algorithms.

Long-term nonprogression of HIV infection in children: evaluation of the ANRS prospective French Pediatric Cohort

BACKGROUND

Some children who are infected with human immunodeficiency virus type 1 (HIV-1) during the perinatal period remain asymptomatic for very long periods in the absence of antiretroviral treatment, as is the case for some adults. Our objective was to estimate the proportion of children who developed neither symptoms nor major immunological perturbations to the age of > or = 10 years in a prospective cohort of infected children who had been observed since birth.

METHODS

The ongoing prospective French Pediatric Cohort includes 568 HIV-1-infected children. Here, we report the follow-up data for all 348 HIV-1-infected children who were born before 1 January 1994. Children with long-term nonprogression of infection (LTNPs) were defined as HIV-1-infected children who had been observed for at least 10 years, never received antiretroviral treatment other than zidovudine monotherapy, never developed symptoms of Centers for Disease Control and Prevention clinical category C or B, and had a CD4+ cell percentage of < 25% no more than once during follow-up. Other definitions were compared.

RESULTS

The Kaplan-Meier estimate of long-term nonprogression was 2.4% (95% confidence interval, 1.1%-4.6%) at 10 years of age, and 7 children were classified as LTNPs. The Kaplan-Meier estimates decreased slightly with age, to 1.8% at 12 years of age and 1.4% at 14 years of age. Plasma HIV-1 replication rates were low (< 1000 copies RNA/mL) for 2 of the 7 LTNPs at the age of 10 years (0.6% of the total denominator). None of the routinely measured maternal or perinatal markers were significantly linked to long-term nonprogression, with the exception of the mother's Centers for Disease Control and Prevention clinical category at the time of delivery.

CONCLUSIONS

Approximately 2% of children who were infected during the perinatal period displayed no immunological or clinical progression by the age of 10 years. This figure is close to that reported for adults in studies that have used similar definitions.

Selection and Persistence of Viral Resistance in HIV-Infected Children After Exposure to Single-Dose Nevirapine

BACKGROUND

Single-dose nevirapine (sd-NVP) is the mainstay of prevention of mother-to-child transmission programs in developing countries. Exposure to sd-NVP selects for resistance mutations, however. We longitudinally assessed these mutations in HIV-1-infected infants from Soweto and Durban, South Africa.

METHODS

We prospectively followed 465 infants who received sd-NVP after enrolling their mothers when pregnant. If HIV infected, their virus was genotyped, using the ViroSeq HIV-1 Genotyping System, to detect resistant mutations. Those with resistance were genotyped at 6 months and then every 6 months out to 18 months if resistance was detected at the previous visit.

RESULTS

Of 53 HIV-infected infants, 24 (45.3%) had detectable resistance at their first visit, when the most frequent mutations were Y181C (75%), K103N (25%), and Y188C (12%). Of those whose visit was before 12 weeks of age, 2 of 42 infants shared identical resistance mutations with their mothers. By 18 months of age, 11 of 24 infants with resistance had died and 1 still had the Y181C mutation.

CONCLUSIONS

Resistant mutations were selected in half of the infants exposed to sd-NVP, but fewer were detected over time and, unlike the case in their mothers, Y181C dominated initially and persists. Transient resistance mutations may have a negative impact on highly active antiretroviral therapy in infants and children.

Prevalence of oral lesions in Mexican children with perinatally acquired HIV: association with immunologic status, viral load, and gender

It has been proposed that HIV-related oral lesions (HIV-ROL) have a significant diagnostic and prognostic value for human immunodeficiency virus (HIV) infection in adult patients. However, in HIV-infected children, the relation between HIV-ROL and immune and virologic status is not well established. The principal objective of this paper is to assess the prevalence of HIV-related oral lesions (HIV-ROL) in Mexican HIV-infected children in relation to their immunologic status, viral load, and gender. Forty-eight HIV-infected children from Immunodeficiency Clinic, Child's Hospital of México, México City, were examined for oral pathology. The data obtained from medical records were: name, gender, age, route of infection, CD4 lymphocytes cells count/mL, HIV-1-RNA level of copies/mL (viral load), and type and time of treatment. The prevalence of HIV-ROL was 29.2%. Oral candidosis was the most prevalent oral lesion (20.8%) followed by periodontal and gingival disease (4.2%), herpes simplex (2.1%), and parotid enlargement (2.1%). There was no association between the prevalence of HIV-ROL and gender, immunological status, or viral load. The most frequent clinical form of oral candidosis was erythematous candidosis (12.5%, N = 6). Our results do not suggest a direct relationship between prevalence of HIV-ROL, severe immunodepression, and/or viral load > 100000 copies in this population.