Changing Trends in Complications and Mortality Rates Among US Youth and Young Adults With HIV Infection in the Era of Combination Antiretroviral Therapy

Overview of the Epidemiology and Clinical Care Considerations for Adolescents and Young Adults Living with or at Risk of Human Immunodeficiency Virus

This article provides an updated examination of human immunodeficiency virus (HIV) epidemiologic trends among adolescents and young adults (AYAs) in the United States, highlighting the significant public health challenge posed by HIV within this demographic. Despite a notable decline in HIV diagnoses among AYAs, challenges remain, particularly due to 50% of AYAs living with HIV being unaware of their status. The article aims to evaluate current clinical recommendations, identify deficiencies, and propose evidence-based improvements for HIV prevention, diagnosis, and care, with the goal of enhancing health outcomes and reducing HIV prevalence among AYAs.

Relationship between brain structural network integrity and emotional symptoms in youth with perinatally-acquired HIV

Perinatally acquired HIV infection (PHIV) currently affects approximately 1.7 million children worldwide. Youth with PHIV (YPHIV) are at increased risk for emotional and behavioral symptoms, yet few studies have examined relationships between these symptoms and brain structure. Previous neuroimaging studies in YPHIV report alterations within the salience network (SN), cognitive control network (CCN), and default mode network (DMN). These areas have been associated with social and emotional processing, emotion regulation, and executive function. We examined structural brain network integrity from MRI using morphometric similarity networks and graph theoretical measures of segregation (transitivity), resilience (assortativity), and integration (global efficiency). We examined brain network integrity of 40 YPHIV compared to 214 youths without HIV exposure or infection. Amongst YPHIV, we related structural brain network metrics to the Emotional Symptoms Index of the Behavioral Assessment System for Children, 2nd edition. We also examined the relationship of inflammatory biomarkers in YPHIV to brain network integrity. YPHIV had significantly lower global efficiency in the SN, DMN, and the whole brain network compared to controls. YPHIV also demonstrated lower assortativity or resilience (i.e., network robustness) compared to controls in the DMN and whole brain network. Further, higher emotional symptom score was associated with higher global efficiency in the SN and lower global efficiency in the DMN, signaling more emotional challenges. A significant association was also found between several inflammatory and cardiac markers with structural network integrity. These findings suggest an impact of HIV on developing brain networks, and potential dysfunction of the SN and DMN in relation to network efficiency.

Risk Factors Associated with Opportunistic Infections among People Living with HIV/AIDS and Receiving an Antiretroviral Therapy in Gabon, Central Africa

The Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is still one of the main causes of death in sub-Saharan Africa. Antiretroviral therapies (ARTs) have significantly improved the health conditions of people living with HIV/AIDS (PLWHA). Consequently, a significant drop in morbidity and mortality, along with a reduced incidence of opportunistic infections (OIs), has been observed. However, certain atypical and biological profiles emerge in ART patients post-examination. The objective of this study was to identify the risk factors that contributed to the onset of OIs in HIV patients undergoing ART in Gabon. Epidemiological and biological data were obtained from medical records (2017 to 2019) found at the outpatient treatment centre (CTA) of Franceville in Gabon. Samples for blood count, CD4, and viral load analysis at CIRMF were collected from PLWHA suffering from other pathogen-induced conditions. A survey was carried out and data were analysed using Rstudio 4.0.2 and Excel 2007 software. Biological and socio-demographic characteristics were examined concerning OIs through both a univariate analysis via Fisher's exact tests or chi2 (χ2), and a multivariate analysis via logistic regression. Out of the 300 participants initially selected, 223 were included in the study, including 154 (69.05%) women and 69 (30.95%) men. The mean age was 40 (38.6; 41.85), with individuals ranging from 2 to 77 years old. The study cohort was classified into five age groups (2 to 12, 20 to 29, 30 to 39, 40 to 49, and 50 to 77 years old), among which the groups aged 30 to 39 and 40 to 49 emerged as the largest, comprising 68 (30.5%) and 75 (33.6%) participants, respectively. It was noted that 57.9% of PLWHA had developed OIs and three subgroups were distinguished, with parasitic, viral, and bacterial infections present in 18%, 39.7%, and 55.4% of cases, respectively. There was a correlation between being male and having a low CD4 T-cell count and the onset of OIs. The study revealed a high overall prevalence of OIs, and extending the study to other regions of Gabon would yield a better understanding of the risk factors associated with the onset of these infections.

Validation of the combined Patient Health Questionnaire Anxiety and Depression Scale among people with HIV in Vietnam

BACKGROUND

Our study aims to examine the factor structure, validity, and reliability of the combined scale Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) among people with HIV (PWH) in Vietnam.

METHODS

Baseline data from an alcohol-reduction intervention trial among ART clients in Thai Nguyen, Vietnam were used for this analysis (n = 1547). A score ≥10 on the PHQ-9, GAD-7 and PHQ-ADS scale was considered having clinically meaningful depression, anxiety and distress symptoms. Factor structure of the combined PHQ-ADS scale was validated using confirmatory factor analysis, and three models were tested: a one-factor, a two-factor, and a bi-factor model. Reliability and construct validity were examined.

RESULTS

The prevalence of clinically meaningful depression and anxiety symptoms was 7% and 2%, respectively, while 19% had distress symptoms. A bi-factor model had the best fit to the data (RMSEA = 0.048; CFI = 0.99; TLI = 0.98). The Omega index of the bi-factor model was 0.97. The scale showed good construct validity through negative associations between depression, anxiety, distress symptoms and quality of life.

CONCLUSIONS

Our study supports the use of a combined scale to measure general distress for PWH, which has good validity, reliability and is unidimensional enough to justify the use of a composite depression and anxiety score.

Circadian-Coupled Genes Expression and Regulation in HIV-Associated Chronic Obstructive Pulmonary Disease (COPD) and Lung Comorbidities

People living with HIV (PLWH) have an elevated risk of chronic obstructive pulmonary disease (COPD) and are at a higher risk of asthma and worse outcomes. Even though the combination of antiretroviral therapy (cART) has significantly improved the life expectancy of HIV-infected patients, it still shows a higher incidence of COPD in patients as young as 40 years old. Circadian rhythms are endogenous 24 h oscillations that regulate physiological processes, including immune responses. Additionally, they play a significant role in health and diseases by regulating viral replication and its corresponding immune responses. Circadian genes play an essential role in lung pathology, especially in PLWH. The dysregulation of core clock and clock output genes plays an important role in chronic inflammation and aberrant peripheral circadian rhythmicity, particularly in PLWH. In this review, we explained the mechanism underlying circadian clock dysregulation in HIV and its effects on the development and progression of COPD. Furthermore, we discussed potential therapeutic approaches to reset the peripheral molecular clocks and mitigate airway inflammation.

Effect of Chinese herbal medicine therapy on risks of all-cause mortality, infections, parasites, and circulatory-related mortality in HIV/AIDS patients with neurological diseases

Introduction: Long-term living with human immunodeficiency virus (HIV) and/or antiretroviral therapy (ART) is associated with various adverse effects, including neurocognitive impairment. Heterogeneous neurocognitive impairment remains an important issue, affecting between 15-65% of human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) patients and resulting in work performance, safety, and health-related outcomes that have a heavy economic burden. Methods: We identified 1,209 HIV/AIDS patients with neurological diseases during 2010-2017. The Kaplan-Meier method, log-rank test, and Cox proportional hazards model were used to analyze 308 CHM users and 901 non-CHM users within this population. Major CHM clusters were determined using association rule mining and network analysis. Results and Discussion: Results showed that CHM users had a 70% lower risk of all-cause mortality (adjusted hazard ratio (aHR) = 0.30, 95% confidence interval (CI):0.16-0.58, p < 0.001) (p = 0.0007, log-rank test). Furthermore, CHM users had an 86% lower risk of infections, parasites, and circulatory-related mortality (aHR = 0.14, 95% confidence interval (CI):0.04-0.46, p = 0.001) (p = 0.0010, log-rank test). Association rule mining and network analysis showed that two CHM clusters were important for patients with neurological diseases. In the first CHM cluster, Huang Qin (HQ; root of Scutellaria baicalensis Georgi), Gan Cao (GC; root of Glycyrrhiza uralensis Fisch.), Huang Lian (HL; root of Coptis chinensis Franch.), Jie Geng (JG; root of Platycodon grandiflorus (Jacq.) A.DC.), and Huang Bai (HB; bark of Phellodendron amurense Rupr.) were identified as important CHMs. Among them, the strongest connection strength was identified between the HL and HQ. In the second CHM cluster, Suan-Zao-Ren-Tang (SZRT) and Ye Jiao Teng (YJT; stem of Polygonum multiflorum Thunb.) were identified as important CHMs with the strongest connection strength. CHMs may thus be effective in treating HIV/AIDS patients with neurological diseases, and future clinical trials are essential for the prevention of neurological dysfunction in the population.

Prevalence and determinants of opportunistic infections among HIV-infected adults receiving antiretroviral therapy in Ethiopia: A systematic review and meta-analysis

Background

Reliable data on the burden of opportunistic infections (OIs) after the initiation of antiretroviral therapy (ART) is critical for planning health services and reducing OI-related morbidity and mortality. Nevertheless, there has been no nationally representative information on the prevalence of OIs in our country. Therefore, we have undertaken this comprehensive systematic review and meta-analysis to estimate the pooled prevalence, and identify factors associated with the development of OIs in Human Immunodeficiency Virus (HIV)-infected adults receiving ART in Ethiopia.

Methods

Articles were searched in international electronic databases. A standardized Microsoft Excel spreadsheet and STATA software version 16 were used for data extraction and analysis, respectively. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was used to write this report. The random-effect meta-analysis model was used to estimate the pooled effect. The statistical heterogeneity of the meta-analysis was checked. Subgroup and sensitivity analyses were also performed. Publication bias was examined in funnel plots and the nonparametric rank correlation test of Begg and the regression-based test of Egger. Association was expressed through a pooled odds ratio (OR) with a 95% Confidence Interval (CI).

Results

A total of 12 studies with 6,163 study participants were included. The pooled prevalence of OIs was 43.97% [95% CI (38.59, 49.34)]. Poor adherence to ART [OR, 5.90, 95% CI (3.05, 11.40)], under nutrition [OR, 3.70, 95% CI (2.01, 6.80)], CD4 T lymphocyte count <200 cells /μL [OR, 3.23 95% CI (2.06, 5.07)], and advanced World Health Organization (WHO) HIV clinical stages [OR, 4.84 95% CI (1.83, 12.82)] were determinants of OIs.

Conclusion

The pooled prevalence of OIs among adults taking ART is high. Poor adherence to ART, under nutrition, a CD4 T lymphocyte count <200 cells /μL, and advanced WHO HIV clinical stages were factors associated with the development of OIs.

Incidence and predictors of opportunistic infections in adolescents and adults after the initiation of antiretroviral therapy: A 10-year retrospective cohort study in Ethiopia

Background

Opportunistic infections (OIs) are the leading cause of morbidity and mortality in people living with the human immunodeficiency virus (PLHIV). However, there are few robust recent data on the rates of OIs and the risk factors that contribute to their occurrence. Therefore, the current study sought to determine the incidence of OIs and identify predictors among adolescents and adults after the initiation of antiretroviral therapy (ART) at Wolaita Sodo University Comprehensive Specialized Hospital (WSUCSH), Southern Ethiopia.

Methods

A retrospective cohort study design was employed. The study population was adolescents and adults who initiated ART between 1 January 2012 and 31 December 2021. A simple random sampling technique was used to select 537 participants' records. We reviewed the medical records of the sampled individuals from 1 May 2022 to 15 June 2022. KoboCollect version 2021.2.4 and STATA version 14.0 software were used for data collection and analysis, respectively. We calculated the incidence rate per 100 person-years of observation (PYO) with 95% confidence intervals (CIs) for the occurrence of any OIs. The Weibull regression model was fitted after the goodness-of-fit test for the Cox proportional hazard model was deemed inadequate. An adjusted hazard ratio (AHR) with 95% CI was used to identify a significant predictor of OIs. The statistical significance was made at a 5% significance level.

Results

A total of 515 participants contributed to 1,829 person-years of risk, of whom 164 (31.84%) exhibited at least one OI. The overall incidence rate of OIs was 8.97 cases (95% CI: 7.69, 10.44) per 100 PYO. The independent predictors of OIs were being female [AHR: 1.65 (95% CI (1.15, 2.36), P = 0.007)], individuals classified as World Health Organization (WHO) HIV clinical stage III [AHR: 1.98 (95% CI (1.12, 3.51), P = 0.019)], individuals who did not take cotrimoxazole preventive therapy (CPT) [AHR: 2.58 (95% CI (1.62, 4.11), P < 0.001)], mild malnutrition [AHR: 1.62 (95% CI (1.06, 2.54), P = 0.035)], and poor adherence to ART [AHR: 4.21 (95% CI (2.39, 7.44), P < 0.001)].

Conclusion

The rate of OIs after the initiation of ART was still high. Moreover, being female, not taking CPT, poor adherence to ART, mild malnutrition, and advanced HIV disease at presentation were found to increase the hazards of developing OIs.

A Multilevel Integrated Intervention to Reduce the Impact of HIV Stigma on HIV Treatment Outcomes Among Adolescents Living With HIV in Uganda: Protocol for a Randomized Controlled Trial

BACKGROUND

HIV stigma remains a formidable barrier to HIV treatment adherence among school-attending adolescents living with HIV, owing to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support, and food insecurity. Thus, this protocol paper presents an evidence-informed multilevel intervention that will simultaneously address family- and school-related barriers to HIV treatment adherence and care engagement among adolescents living with HIV attending boarding schools in Uganda.

OBJECTIVE

The proposed intervention-Multilevel Suubi (MSuubi)-has the following objectives: examine the impact of M-Suubi on HIV viral suppression (primary outcome) and adherence to HIV treatment, including keeping appointments, pharmacy refills, pill counts, and retention in care; examine the effect of M-Suubi on HIV stigma (internalized, anticipated, and enacted), with secondary analyses to explore hypothesized mechanisms of change (eg, depression) and intervention mediation; assess the cost and cost-effectiveness of each intervention condition; and qualitatively examine participants' experiences with HIV stigma, HIV treatment adherence, and intervention and educators' attitudes toward adolescents living with HIV and experiences with group-based HIV stigma reduction for educators, and program or policy implementation after training.

METHODS

MSuubi is a 5-year multilevel mixed methods randomized controlled trial targeting adolescents living with HIV aged 10 to 17 years enrolled in a primary or secondary school with a boarding section. This longitudinal study will use a 3-arm cluster randomized design across 42 HIV clinics in southwestern Uganda. Participants will be randomized at the clinic level to 1 of the 3 study conditions (n=14 schools; n=280 students per study arm). These include the bolstered usual care (consisting of the literature on antiretroviral therapy adherence promotion and stigma reduction), multiple family groups for HIV stigma reduction plus family economic empowerment (MFG-HIVSR plus FEE), and Group-based HIV stigma reduction for educators (GED-HIVSR). Adolescents randomized to the GED-HIVSR treatment arm will also receive the MFG-HIVSR plus FEE treatment. MSuubi will be provided for 20 months, with assessments at baseline and 12, 24, and 36 months.

RESULTS

This study was funded in September 2021. Participant screening and recruitment began in April 2022, with 158 dyads enrolled as of May 2022. Dissemination of the main study findings is anticipated in 2025.

CONCLUSIONS

MSuubi will assess the effects of a combined intervention (family-based economic empowerment, financial literacy education, and school-based HIV stigma) on HIV stigma among adolescents living with HIV in Uganda. The results will expand our understanding of effective intervention strategies for reducing stigma among HIV-infected and noninfected populations in Uganda and improving HIV treatment outcomes among adolescents living with HIV in sub-Saharan Africa.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05307250; https://clinicaltrials.gov/ct2/show/NCT05307250.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/40101.

Analyzing Longitudinally Collected Viral Load Measurements in Youth With Perinatally Acquired HIV Infection: Problems and Possible Remedies

Human immunodeficiency virus (HIV) viral load (VL) is an important quantitative marker of disease progression and treatment response in people living with HIV infection, including children with perinatally acquired HIV. Measures of VL are often used to predict different outcomes of interest in this population, such as HIV-associated neurocognitive disorder. One popular approach to summarizing historical viral burden is the area under a time-VL curve (AUC). However, alternative historical VL summaries (HVS) may better answer the research question of interest. In this article, we discuss and contrast the AUC with alternative HVS, including the time-averaged AUC, duration of viremia, percentage of time with suppressed VL, peak VL, and age at peak VL. Using data on youth with perinatally acquired HIV infection from the Pediatric HIV/AIDS Cohort Study Adolescent Master Protocol, we show that HVS and their associations with full-scale intelligence quotient depend on when the VLs were measured. When VL measurements are incomplete, as can be the case in observational studies, analysis results may be subject to selection bias. To alleviate bias, we detail an imputation strategy, and we present a simulation study demonstrating that unbiased estimation of a historical VL summary is possible with a correctly specified imputation model.

Predictors of mortality among adolescents and young adults living with HIV on antiretroviral therapy in Dar es Salaam, Tanzania: a retrospective cohort study

INTRODUCTION

Global AIDS-related deaths have declined by only 10% among adolescents since its peak in 2003. This is disproportionately low compared to a decline of 74% among children aged 0-9 years old. We determined the magnitude of, and predictors of mortality among adolescents and young adults living with HIV on antiretroviral therapy (ART) in Dar-es-Salaam, Tanzania.

METHODS

A retrospective cohort study was conducted among adolescents (aged 10-19) and young adults (aged 20-24) living with HIV and enrolled in care and treatment centres in Dar es Salaam, Tanzania between January 2015 and December 2019. Data were analysed using STATA version 16. Cumulative hazard curves were used to estimate and illustrate 1-year mortality. Predictors for mortality were assessed by the Fine and Gray competing risk regression model. Sub-hazard ratios (SHR) and 95% confidence intervals (95% CI) were then reported.

RESULTS

A total of 15,874 young people living with HIV were included: 4916 (31.3%) were adolescents and 10,913 (68.7%) were young adults. A total of 3843 (77.5%) adolescents and 9517 (87.2%) young adults were female. Deaths occurred in 2.3% (114/4961) of adolescents and 1.2% (135/10,913) of young adults (p < 0.001). Over a follow-up of 9292 person-years, the mortality rate was 3.8 per 100 person years [95% CI 3.2-4.6/100 person-years] among adolescents and 2.1 per 100 person-years among young adults [95% CI 1.8-2.5/100 person-years]. Independent predictors of mortality among adolescents were male sex (adjusted (SHR) aSHR = 1.90, 95% CI: 1.3-2.8), CD4 count < 200 cells/mm³ (aSHR = 2.7, 95% CI: 1.4-5.0) and attending a private health facility (aSHR = 1.7, 95% CI: 1.1-2.5). Predictors of mortality among young adults were CD4 count < 200 cells/mm³ (aSHR = 2.8, 95% CI 1.7-4.5), being underweight (aSHR = 2.1, 95% CI: 1.4-3.3) and using nevirapine-based therapy (aHR = 8.3, 95% CI: 3.5-19.5).

CONCLUSIONS

The mortality rate for persons living with HIV and on ART in Tanzania was significantly higher in adolescents than young adults. Age- and sex-specific risk factors identify targets for intervention to reduce mortality among affected adolescents and young adults.

Persistently lower bone mass and bone turnover among South African children living with well controlled HIV

OBJECTIVE

We evaluated longitudinal trends and associations between bone mass, bone turnover and inflammatory markers among South African children living with HIV (CLHIV) and controls.

DESIGN

We previously reported decreased bone mass among CLHIV independent of marked inflammation and increased bone turnover. The goal of this study was to evaluate longitudinal changes in bone mass, bone turnover and inflammation over 2 years.

METHODS

Longitudinal analyses were conducted among 220 CLHIV and 220 controls. Anthropometric measurements, physical activity, antiretroviral regimen, virologic and immunologic status, whole body (WB) and lumbar spine (LS) bone mineral content (BMC) and bone mineral density (BMD) were collected (enrollment, 12 and 24 months). Bone turnover markers including C-telopeptide of type I collagen (CTx) and procollagen type I N-terminal propeptide (P1NP) and inflammatory markers including interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), soluble CD14 and high-sensitivity C-reactive protein (hsCRP) were collected at enrollment and 24 months.

RESULTS

Compared with controls, CLHIV had significantly lower mean WB-BMC, WB-BMD, WB-BMC z scores, LS-BMC and LS-BMD as well as lower bone formation (P1NP) and resorption (CTx), and higher hsCRP and soluble CD14 over 24 months. CLHIV on efavirenz (EFV) had consistently lower TNF-alpha and IL-6 compared with those on ritonavir-boosted lopinavir (LPV/r) at all time points.

CONCLUSION

Over 2 years of follow-up, South African CLHIV had persistently lower bone mass, bone turnover, and macrophage activation. Lower bone mass and higher pro-inflammatory cytokine profiles were consistently observed among those on LPV/r-based compared with EFV-based regimens.

The accumulation of plasma acylcarnitines are associated with poor immune recovery in HIV-infected individuals

BACKGROUND

Antiretroviral therapy (ART) can reduce opportunistic infections and mortality rates among individuals infected with human immunodeficiency virus (HIV); however, some HIV-infected individuals exhibit poor immune recovery after ART. Hence, we explored the association between metabolome profiles and immune recovery in HIV-infected individuals following ART.

METHODS

An untargeted metabolomics approach was used to analyze plasma samples from 18 HIV-negative individuals and 20 HIV-infected individuals, including 10 immunological non-responders (INR, CD4⁺ T cell rise < 100 cells/μl) and 10 immunological responders (IR, CD4⁺ T cell rise > 300 cells/μl) after 2 years of ART. These individuals were followed for the next 6 years and viral loads and CD4⁺ T cell count were measured regularly. Orthogonal projection on latent structures discriminant analysis (OPLS-DA), ANOVA, correlation, receiver operating characteristic (ROC), and survival analyses were used for selection of discriminant metabolites.

RESULTS

Eighteen lipid metabolites were identified which could distinguish among control, INR, and IR groups. Among them, myristoylcarnitine (MC), palmitoylcarnitine (PC), stearoylcarnitine (SC), and oleoylcarnitine (OC) were significantly elevated in INR plasma samples compared with those from the IR and control groups and were negatively associated with CD4⁺ T cell count. Additionally, ROC analysis using a combination of MC, PC, SC, and OC had high sensitivity and specificity for differentiating INR from IR (AUC = 0.94). Finally, survival analysis for the combination of MC, PC, SC, and OC demonstrated that it could predict CD4⁺ T cell count in patients undergoing long-term ART.

CONCLUSIONS

High levels of lipid metabolites, MC, PC, SC, and OC are associated with poor immune recovery in patients receiving ART and these data provide potential new insights into immune recovery mechanisms.

Opportunistic Illnesses in Children With HIV Infection in the United States, 1997-2016

BACKGROUND

Among children with HIV infection, opportunistic illness (OI) rates decreased after introduction of highly active antiretroviral therapy (ART) in 1997. We evaluated whether such decreases have continued.

METHODS

Data from the Centers for Disease Control and Prevention's National HIV Surveillance System for children with HIV living in the US during 1997-2016 was used to enumerate infants experiencing the first OI by birth year and OIs among all children <13 years of age (stratified by natality). We calculated the time to first OI among infants using Kaplan-Meier methods.

RESULTS

Among infants born during 1997-2016, 711 first OIs were diagnosed. The percentage of the first OIs diagnosed in successive 5-year birth periods was: 60.0% (1997-2001), 24.6% (2002-2006), 11.3% (2007-2011), and 3.4% (2012-2016). For every OI, the number of first cases decreased nearly annually. Time to first OI increased in successive birth periods. Among children <13 years of age, 2083 OI were diagnosed, including Pneumocystis jiroveci pneumonia, candidiasis, recurrent bacterial infection, wasting syndrome, cytomegalovirus, lymphocytic interstitial pneumonitis, tuberculosis, nontuberculous mycobacteriosis and herpes simplex virus. The rate (#/1000 person-years) decreased overall (60-7.2) and for all individual OIs. Earlier during 1997-2016, rates for all OIs were higher among foreign-born than US-born children but later became similar for all OIs except tuberculosis.

CONCLUSIONS

Among children with HIV in the US, numbers and rates of all OIs decreased during 1997-2016. Earlier, OI rates were highest among non-US-born children but were later comparable with those among US-born children for all OIs except tuberculosis.

Age-specific mortality rate ratios in adolescents and youth aged 10-24 years living with perinatally versus nonperinatally acquired HIV

OBJECTIVE

To measure mortality incidence rates and incidence rate ratios (IRR) in adolescents and youth living with perinatally acquired HIV (YPHIV) compared with those living with nonperinatally acquired HIV (YNPHIV), by region, by sex, and during the ages of 10-14, 15-19, and 20-24 years in IeDEA.

DESIGN AND METHODS

All those with a confirmed HIV diagnosis, antiretroviral therapy (ART)-naive at enrollment, and who have post-ART follow-up while aged 10-24 years between 2004 and 2016 were included. We estimated post-ART mortality incidence rates and 95% confidence intervals (95% CI) per 100 person-years for YPHIV (enrolled into care <10 years of age) and YNPHIV (enrolled ≥10 years and <25 years). We estimate mortality IRRs in a negative binomial regression model, adjusted for sex, region time-varying age, CD4+ cell count at ART initiation (<350 cells/μl, ≥350 cells/μl, unknown), and time on ART (<12 and ≥12 months).

RESULTS

Overall, 104 846 adolescents and youth were included: 21 340 (20%) YPHIV (50% women) and 83 506 YNPHIV (80% women). Overall mortality incidence ratios were higher among YNPHIV (incidence ratio: 2.3/100 person-years; 95% CI: 2.2-2.4) compared with YPHIV (incidence ratio: 0.7/100 person-years; 95% CI: 0.7-0.8). Among adolescents aged 10-19 years, mortality was lower among YPHIV compared with YNPHIV (all IRRs <1, ranging from 0.26, 95% CI: 0.13-0.49 in 10-14-year-old boys in the Asia-Pacific to 0.51, 95% CI: 0.30-0.87 in 15-19-year-old boys in West Africa).

CONCLUSION

We report substantial amount of deaths occurring during adolescence. Mortality was significantly higher among YNPHIV compared to YPHIV. Specific interventions including HIV testing and early engagement in care are urgently needed to improve survival among YNPHIV.

Recruitment of Youth Living With HIV to Optimize Adherence and Virologic Suppression: Testing the Design of Technology-Based Community Health Nursing to Improve Antiretroviral Therapy (ART) Clinical Trials

Background

Despite advances in HIV diagnosis and treatment, adolescents and young adults 12-25 years old have high HIV incidence, poor engagement and retention in treatment, and low rates of adherence and virologic suppression when compared to their older counterparts. HIV has emerged as a chronic disease for which antiretroviral therapy (ART) adherence is critical for virologic suppression and long-term survival. Virologic suppression has been elusive for many youth with HIV (YHIV). Novel strategies designed to facilitate health care systems’ support for YHIV between medical visits are essential for improving ART adherence, virologic suppression, and long-term survival.

Objective

The aim of this study is to compare the effectiveness of a technology-enhanced community health nursing intervention (TECH2CHECK) to a standard of care (SOC) control group for improving ART adherence and subsequent viral suppression using a randomized trial design. The objectives are to assess the feasibility, acceptability, and cost-effectiveness of TECH2CHECK as compared to SOC for management of HIV in the outpatient setting and to examine the sustainability of self-care behavior, adherence, and virologic suppression among youth following the intervention period.

Methods

We will recruit 120 adherence-challenged YHIV being followed at clinics specializing in HIV care in the Baltimore-Washington metropolitan area and in Jacksonville. Eligible participants complete an audio, computer-assisted self-interview and are randomized to either TECH2CHECK intervention or the SOC (60 participants in each arm). The primary outcome of interest is virologic suppression (viral load <20 copies/mL) and improved treatment adherence. Participants in the intervention arm receive community health nursing visits at 2 weeks, 6 weeks, 10 weeks, 14 weeks, and 26 weeks. The intervention arm also receives SMS messaging comprising daily adherence and appointment reminders and positive reinforcement for medication adherence daily for 2 weeks, on alternate days for 2 weeks, thrice weekly for 1 month, weekly for 3 months, and every 2 weeks for the rest of the study duration. The control group receives appointment reminders and SOC per clinic protocol. Exploratory analysis will be conducted to determine differences in medication adherence and virologic suppression in the 2 arms and to assess cost-effectiveness and study feasibility and acceptability.

Results

In the first 23 months of the study (July 2018-April 2020), 56 (55%) of 102 eligible patients were enrolled and randomized. At present, participating youths are primarily African American (53/56, 95%), male (37/56, 66%), and ≥18 years old (53/56, 95%). Follow-up study visits, as required per the protocol, have been completed by 77% (43/56), 94% (45/48), 95% (37/39), 96% (24/25), and 100% (10/10) of participants at the 1-month, 3-month, 6-month, 12-month, and 18-month follow-ups, respectively.

Conclusions

Preliminary accrual and retention data suggest that TECH2CHECK is feasible and acceptable.

Trial Registration

ClinicalTrials.gov NCT03600103 https://clinicaltrials.gov/ct2/show/NCT03600103

International Registered Report Identifier (IRRID)

DERR1-10.2196/23480

ECG abnormalities among HIV infected children placed on ART at Enugu, South East of Nigeria

Background

Cardiovascular abnormalities are not much reported among human immunodeficiency virus (HIV) infected children especially in Africa where there is high HIV disease. In addition, the use of highly active antiretroviral therapy (HAART) in such children may have a protective effect on the cardiovascular system.

Methods

Cross-sectional study of randomly selected eighty HIV infected and 80 aged matched non- HIV-infected children were used. HIV-infected children were on HAART for more than 5years and had steadily received the treatment for 6 months prior to the time of the tests. Heights and weights were measured and body mass index calculated. Cardiac indices evaluated were heart rate (HR), PR interval, QRS duration, QT/QTC Interval, P/QRS/T Axis, RV5/SV1 voltage and RV5+SV1 voltage.

Results

The average heart rate was significantly higher among HIV infected children on HAART than their non-infected counterparts (P= 0.019). At 0.05 significance level, their PR interval was significantly higher than those in the control group (P=0.050). The average QRS duration result also showed a significant difference between that of test and control subjects (P = 0.022)

Conclusion

The HAART usage possibly improved the cardiovascular functioning in the infected children but the protective effects diminish with increase age and longer exposure

Fractures in children and adolescents living with perinatally acquired HIV

BACKGROUND

Across numerous settings, bone mineral density for age and sex is lower in children/adolescents living with perinatally-acquired HIV (PHIV) compared to uninfected peers. We assessed incidences of any fracture/any long bone fracture, and osteoporosis prevalence in PHIV and HIV-exposed uninfected (PHEU) participants in the Pediatric HIV/AIDS Cohort Study (PHACS).

METHODOLOGY

Lifetime history of fracture events from birth up to age 20 years was obtained by chart review and/or interview, including age at fracture, mechanism, and bone(s) fractured. Poisson regression models were fit comparing fracture incidence by HIV status adjusted for age, sex, and race, with effect modification by age (<6, ≥6 yr).

RESULTS

PHIV (N = 412) were older (median 17.5 vs 16.7 yr) and more frequently reported black race (72% vs 61%) than PHEU children/adolescents (N = 206). 17% of PHIV and 12% of PHEU ever reported a fracture. Among children <6 yr, the adjusted incidence rate ratio of ≥1 fracture was higher (7.23; 95% CI 0.98, 53.51) in PHIV than PHEU, but similar among children/adolescents ≥6 years (1.20; 95% CI: 0.77, 1.87). Results were similar for long bone fracture. The most common fracture mechanisms were falling to the ground from a standing height (23.6% PHIV vs 8.8% PHEU) and sports injuries (21.3% vs 32.4%), and the most commonly fractured sites were the forearm and small bones of the wrist/hands. None of the children had osteoporosis.

CONCLUSIONS

Among children/adolescents ≥6 yr of age, fractures were similar by perinatal HIV status. Prospective, targeted collection of fracture history will be necessary to determine rates of fracture as PHIV and PHEU age into adulthood.

SUMMARY

Lifetime fracture history was collected in children/adolescents living with perinatally-acquired HIV (PHIV) and HIV-exposed uninfected (PHEU) children from birth up to age 20 years. Fracture incidence was higher in PHIV compared to PHEU among children <6 years old, but not among older children/adolescents.

Language Bias in Health Research: External Factors That Influence Latent Language Patterns

Background: Concerns with problematic research are primarily attributed to statistics and methods used to support data. Language, as an extended component of problematic research in published work, is rarely given the same attention despite language's equally important role in shaping the discussion and framings of presented data. Purpose: This study uses a topic modeling approach to study language as a predictor of potential bias among collected publication histories of several health research areas. Methods: We applied Latent Dirichlet Allocation (LDA) topic models to dissect publication histories disaggregated by three factors commonly cited as language influencers: (1) time, to study ADHD pharmacotherapy; (2) funding source, to study sugar consumption; and (3) nation of origin, to study Pediatric Highly-Active Anti-Retroviral Therapy (P-HAART). Results: We found that, for each factor, there were notable differences in language among each corpus when disaggregated by each factor. For time, article content changed to reflect new trends and research practices for the commonly prescribed ADHD medication, Ritalin. For funding source, industry and federally funded studies had differing foci, despite testing the same hypothesis. For nation of origin, regulatory structures between the United States and Europe seemingly influenced the direction of research. Conclusion: This work presents two contributions to ethics research: (1) language and language framing should be studied as carefully as numeric data among studies of rigor, reproducibility, and transparency; and (2) the scientific community should continue to apply topic models as mediums to answer hypothesis-driven research questions.

The Brain Retains: Nonhuman Primate Models for Pediatric HIV-1 in the CNS

PURPOSE OF REVIEW

Perinatal HIV-1 infection is associated with an increased risk for neurologic impairments. With limited access to clinical specimens, animal models could advance our understanding of pediatric central nervous system (CNS) disease and viral persistence. Here, we summarize current findings on HIV-1 CNS infection from nonhuman primate (NHP) models and discuss their implications for improving pediatric clinical outcomes.

RECENT FINDINGS

SIV/SHIV can be found in the CNS of infant macaques within 48 h of challenge. Recent studies show an impermeable BBB during SIV infection, suggesting neuroinvasion in post-partum infection is likely not wholly attributed to barrier dysfunction. Histopathological findings reveal dramatic reductions in hippocampal neuronal populations and myelination in infected infant macaques, providing a link for cognitive impairments seen in pediatric cases. Evidence from humans and NHPs support the CNS as a functional latent reservoir, harbored in myeloid cells that may require unique eradication strategies. Studies in NHP models are uncovering early events, causes, and therapeutic targets of CNS disease as well as highlighting the importance of age-specific studies that capture the distinct features of pediatric HIV-1 infection.

Determining standardized causes of death of infants, children, and adolescents living with HIV in Asia

OBJECTIVE

To implement a standardized cause of death reporting and review process to systematically disaggregate causes of HIV-related deaths in a cohort of Asian children and adolescents.

DESIGN

Death-related data were retrospectively and prospectively assessed in a longitudinal regional cohort study.

METHODS

Children under routine HIV care at sites in Cambodia, India, Indonesia, Malaysia, Thailand, and Vietnam between 2008 and 2017 were followed. Causes of death were reported and then independently and centrally reviewed. Predictors were compared using competing risks survival regression analyses.

RESULTS

Among 5918 children, 5523 (93%; 52% male) had ever been on combination antiretroviral therapy. Of 371 (6.3%) deaths, 312 (84%) occurred in those with a history of combination antiretroviral therapy (crude all-cause mortality 9.6 per 1000 person-years; total follow-up time 32 361 person-years). In this group, median age at death was 7.0 (2.9-13) years; median CD4 cell count was 73 (16-325) cells/μl. The most common underlying causes of death were pneumonia due to unspecified pathogens (17%), tuberculosis (16%), sepsis (8.0%), and AIDS (6.7%); 12% of causes were unknown. These clinical diagnoses were further grouped into AIDS-related infections (22%) and noninfections (5.8%), and non-AIDS-related infections (47%) and noninfections (11%); with 12% unknown, 2.2% not reviewed. Higher CD4 cell count and better weight-for-age z-score were protective against death.

CONCLUSION

Our standardized cause of death assessment provides robust data to inform regional resource allocation for pediatric diagnostic evaluations and prioritization of clinical interventions, and highlight the continued importance of opportunistic and nonopportunistic infections as causes of death in our cohort.

Language Bias in Health Research: External Factors That Influence Latent Language Patterns

Background: Concerns with problematic research are primarily attributed to statistics and methods used to support data. Language, as an extended component of problematic research in published work, is rarely given the same attention despite language's equally important role in shaping the discussion and framings of presented data. Purpose: This study uses a topic modeling approach to study language as a predictor of potential bias among collected publication histories of several health research areas. Methods: We applied Latent Dirichlet Allocation (LDA) topic models to dissect publication histories disaggregated by three factors commonly cited as language influencers: (1) time, to study ADHD pharmacotherapy; (2) funding source, to study sugar consumption; and (3) nation of origin, to study Pediatric Highly-Active Anti-Retroviral Therapy (P-HAART). Results: We found that, for each factor, there were notable differences in language among each corpus when disaggregated by each factor. For time, article content changed to reflect new trends and research practices for the commonly prescribed ADHD medication, Ritalin. For funding source, industry and federally funded studies had differing foci, despite testing the same hypothesis. For nation of origin, regulatory structures between the United States and Europe seemingly influenced the direction of research. Conclusion: This work presents two contributions to ethics research: (1) language and language framing should be studied as carefully as numeric data among studies of rigor, reproducibility, and transparency; and (2) the scientific community should continue to apply topic models as mediums to answer hypothesis-driven research questions.

Prevalence of Systemic Hypertension Among HIV-Infected and HIV-Uninfected Young Adults in Baltimore, Maryland

OBJECTIVES

Adults with perinatally acquired human immunodeficiency virus (PHIV) infection may be at increased risk for nonacquired immunodeficiency syndrome (AIDS) diseases, including systemic hypertension (HTN). The purpose of this study was to examine the prevalence of HTN among young adults with PHIV compared with recently infected and uninfected young adults.

METHODS

We conducted a cross-sectional study of young adults with PHIV, frequency matched on race and sex to a stratified random sample of young adults with nonperinatally acquired HIV (NPHIV) and HIV-uninfected young adults. All of the subjects were aged 18 to 29 years. HTN was defined as two systolic blood pressure measurements ≥140 mm Hg or diastolic ≥90 mm Hg at least 3 months apart and/or prescription for an antihypertensive medication. Logistic regression was used to estimate adjusted prevalence odds ratios and 95% confidence intervals (CIs) for the association between HIV infection and HTN.

RESULTS

A total of 324 patients were included-108 per exposure group. The prevalence of HTN was 23% among individuals with PHIV, 10% among individuals with NPHIV, and 8% among HIV-uninfected patients. PHIV patients had 3.4 (95% CI 1.48-7.66) times the base odds of having HTN compared with HIV-uninfected patients, and 2.7 (95% CI 1.23-5.71) times the odds compared with NPHIV patients. By multivariable analysis, PHIV patients had 4.7 and 2.9 times the odds of having HTN compared with HIV-uninfected patients and NPHIV patients, respectively, after controlling for sex, race, and family history of hypertension.

CONCLUSIONS

Our findings suggest that HTN prevalence among PHIV young adults is significantly higher than sex- and race-matched NPHIV and HIV-uninfected patients of similar age.

Pathogenesis of HIV-Related Lung Disease: Immunity, Infection, and Inflammation

Despite anti-retroviral therapy (ART), human immunodeficiency virus-1 (HIV)-related pulmonary disease continues to be a major cause of morbidity and mortality for people living with HIV (PLWH). The spectrum of lung diseases has changed from acute opportunistic infections resulting in death to chronic lung diseases for those with access to ART. Chronic immune activation and suppression can result in impairment of innate immunity and progressive loss of T cell and B cell functionality with aberrant cytokine and chemokine responses systemically as well as in the lung. HIV can be detected in the lungs of PLWH and has profound effects on cellular immune functions. In addition, HIV-related lung injury and disease can occur secondary to a number of mechanisms including altered pulmonary and systemic inflammatory pathways, viral persistence in the lung, oxidative stress with additive effects of smoke exposure, microbial translocation, and alterations in the lung and gut microbiome. Although ART has had profound effects on systemic viral suppression in HIV, the impact of ART on lung immunology still needs to be fully elucidated. Understanding of the mechanisms by which HIV-related lung diseases continue to occur is critical to the development of new preventive and therapeutic strategies to improve lung health in PLWH.

Severe hepatotoxicity induced by efavirenz in a treatment-naïve, low body mass index HIV-infected, female patient with no hepatitis and other virus co-infections

Combined antiretroviral therapy (cART) consisting of two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI), such as efavirenz, is still the first-line treatment in resource-limited settings. However, efavirenz has shown strong prominence of disadvantages with variance in plasma concentration and central nervous side effects. Our study presents HIV infected, drug naïve, female patient with relatively low BMI, CYP2B6 516G>T (rs3745274) genotype with high efavirenz plasma concentration. In this case report, the patient was admitted at the hospital 6 months after cART initiation with drug-induced severe hepatotoxicity. Furthermore, pathophysiological findings proved confluent parenchymal necrosis after aspiration liver biopsy, with mild to moderate inflammation in portal tracts with focal interface hepatitis. All other possible causes were excluded. Thus, we conclude that efavirenz has a potential harmful effect in patients with low BMI, specific genotyping and interindividual pharmacokinetics affecting high plasma concentration.

HIV-infected youths transitioning from pediatric to adult outpatient care in a teaching tertiary care hospital in São Paulo city, Brazil

Background

HIV-infected children surviving until adulthood have been transitioning to adult outpatient health care service in Brazil since the late 2000's. Deterioration of clinical condition is expected during this period, as reported among youths with non-communicable chronic diseases. Despite their young age, they are long-term hosts of the virus, have prolonged exposure to antiretroviral therapy and have suffered from the social determinants and stigma of HIV infection since early childhood.

Objectives

This study aimed to 1) describe demographic and clinical characteristics at the first appointment at adult care service following pediatric care of a cohort of Brazilian youths living with HIV since childhood; and 2) retrospectively address adherence and clinical variables in the last two years of pediatric follow-up.

Methods

Descriptive study.

Results

41 consecutive patients referred to adult outpatient care from a pediatric HIV unit were enrolled, median age 19 years, and median lifetime CD4 + nadir 117 cell/mm³; 89% reported previous AIDS-defining conditions. At first laboratory assessment in adult care, only 46% had undetectable (<400 copies/ml) HIV viral load and the median CD4 + count was 250 cell/mm³.

Conclusion

Youths living with HIV at the transition from pediatric to adult care had poor treatment adherence, low lifetime CD4 + cell nadir, low CD4 cell count and detectable HIV viral load. Health care providers should closely monitor these adolescents in a youth friendly environment, prepared for open communication about all aspects of their health.

Airway mycosis in allergic airway disease

The allergic airway diseases, including chronic rhinosinusitis (CRS), asthma, allergic bronchopulmonary mycosis (ABPM) and many others, comprise a heterogeneous collection of inflammatory disorders affecting the upper and lower airways and lung parenchyma that represent the most common chronic diseases of humanity. In addition to their shared tissue tropism, the allergic airway diseases are characterized by a distinct pattern of inflammation involving the accumulation of eosinophils, type 2 macrophages, innate lymphoid cells type 2 (ILC2), IgE-secreting B cells, and T helper type 2 (Th2) cells in airway tissues, and the prominent production of type 2 cytokines including interleukin (IL-) 33, IL-4, IL-5, IL-13, and many others. These factors and related inflammatory molecules induce characteristic remodeling and other changes of the airways that include goblet cell metaplasia, enhanced mucus secretion, smooth muscle hypertrophy, tissue swelling and polyp formation that account for the major clinical manifestations of nasal obstruction, headache, hyposmia, cough, shortness of breath, chest pain, wheezing, and, in the most severe cases of lower airway disease, death due to respiratory failure or disseminated, systemic disease. The syndromic nature of the allergic airway diseases that now include many physiological variants or endotypes suggests that distinct endogenous or environmental factors underlie their expression. However, findings from different perspectives now collectively link these disorders to a single infectious source, the fungi, and a molecular pathogenesis that involves the local production of airway proteinases by these organisms. In this review, we discuss the evidence linking fungi and their proteinases to the surprisingly wide variety of chronic airway and systemic disorders and the immune pathogenesis of these conditions as they relate to environmental fungi. We further discuss the important implications these new findings have for the diagnosis and future therapy of these common conditions.

CNS Persistence of HIV-1 in Children: the Untapped Reservoir

PURPOSE OF REVIEW

The central nervous system (CNS) represents a potential HIV-1 reservoir that may need to be specifically targeted by remission strategies. Perinatally HIV-1-infected children and youth are exposed to HIV-1 at a critical period of brain development. This review summarizes the current literature regarding HIV-1 and the CNS in perinatal infection.

RECENT FINDINGS

HIV-1-associated encephalopathy is prevalent with perinatal infection and neurocognitive impairment persists even following antiretroviral treatment (ART)-mediated suppression of viremia. Compartmentalization of HIV-1 between plasma and CSF of ART-naïve, perinatally infected children suggests the presence of a CNS reservoir; however, similar studies have not yet been conducted with ART suppression. CSF viral escape where CSF and plasma virus concentrations are discordant has been reported in this population, but larger studies with well-defined virologic and immunologic parameters are needed. A better understanding of HIV-1 persistence in the CNS with perinatal infection is essential for improving long-term neurocognitive outcomes and for designing strategies to induce HIV-1 remission in this population.

Lower Optimal Treatment Adherence Among Youth Living With HIV in a Universal Health Care Setting Where ART Is Available at No Cost

PURPOSE

We assessed differences in optimal adherence between youth (aged 15-29 years) and adults (aged ≥30 years) enrolled in the British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program from 2010 to 2016.

METHODS

Population-level clinical data were used to compare optimal antiretroviral therapy adherence (≥95%), based on pharmacy refill data, among youth and adults. Unadjusted and adjusted generalized estimating estimates were performed to examine the independent relationship between time-dependent age categories and optimal adherence, adjusting for confounders. Factors associated with optimal adherence among youth were examined.

RESULTS

Data for 7,485 individuals living with HIV were included. Median follow-up was 7 years (Q1-Q3: 4-7). Over the study period, the number of individuals categorized as "youth" ranged from 820 in 2010 to 291 in 2016. Multivariable models found youth living with HIV were significantly less likely to be optimally adherent than adults (adjusted odds ratio [aOR] = .55; 95% confidence interval [CI]: .49-.62), after controlling for potential confounders, although youth adherence improved significantly during the study period. Among youth, increasing time-dependent age (aOR = 1.18/year older; 95%CI: 1.11-1.25) and number of years on antiretroviral therapy (aOR = 1.15, 95%CI: 1.10-1.19) were independently associated with optimal adherence, while Hepatitis C-positive serostatus (aOR = .55; 95%CI: .33-.92) and multiple treatment regimen change (aOR = .89/regimen change; 95%CI: .81-.97) were negatively associated with optimal adherence.

CONCLUSIONS

Youth were less likely to be optimally adherent throughout the study period. Findings suggest implications for increased youth-centered adherence support, particularly for youth living with HIV concurrently living with Hepatitis C, newly initiating treatment, and going through medication change.

Growth and pubertal development in HIV-infected adolescents

PURPOSE OF REVIEW

We present an overview of recent research in the inter-related areas of growth and pubertal development among adolescents with HIV. Growth deficits early in childhood can lead to delayed puberty, with subsequent effects on pubertal growth spurts and bone health.

RECENT FINDINGS

Impaired growth remains a critical concern, particularly in low-resource settings, where stunting, wasting and underweight remain pervasive. Antiretroviral treatment (ART) initiation results in improved growth, with greatest growth recovery in the first years and more improvement in weight than in height. However, even years after ART initiation, growth deficits persist in low-resource settings (LRS), and adolescents appear at particularly increased risk. The high prevalence of stunting translates to delays in pubertal onset and sexual maturity. In contrast, HIV-infected adolescents in developed countries do not demonstrate persistent wasting, yet still have delayed pubertal development. Impaired growth increases the risk for mortality, virologic failure, and abnormal bone health, as well as increased depression and stigma.

SUMMARY

Early initiation of ART across all age groups regardless of immunological status is essential for restoring growth. Coordination of ART initiation, nutritional supplementation programs, and concurrent prophylaxis is required to ameliorate growth deficits and pubertal delays, particularly in LRS.

Training Internal Medicine Residents to Provide Care and Treatment for Human Immunodeficiency Virus-1-Infected Patients

Background

Human immunodeficiency virus (HIV) infection is now considered a chronic infection manageable on antiretroviral therapy. If trained in HIV care, primary care physicians would be well suited to work in consultation with infectious disease specialists to provide care for HIV patients.

Methods

Human immunodeficiency virus training was incorporated into our internal medicine residency program. All residents were given an internally developed preprogram survey about HIV infection to establish a baseline level of HIV knowledge; at the end of 1 year, a postprogram survey was distributed. These results were compared. Human immunodeficiency virus didactic lectures were mandatory for attendance. Human immunodeficiency virus training included methods of testing, treatment including all classes of antiretroviral therapy, and prevention methods. Additional, mandatory online training modules were used. All program year-2 residents were assigned to an outpatient HIV clinical rotation.

Results

Eighty-three residents participated. Residents received either 1 or 2 years of training. Results of preprogram scores and postprogram scores were calculated for each resident. Year 1-test scores preprogram were 52.2% vs postprogram 87.1%; year 2-test scores preprogram were 56.3% vs postprogram 89.8% (both P < .0001). There was no difference in posttest scores among residents who attended a clinical rotation.

Conclusions

Residents showed significant improvement in HIV knowledge between preprogram and postprogram test scores. Postgraduate surveys showed among those who completed the survey, and most found the program helpful to in their current practice.

Changing Spectrum of Opportunistic Illnesses among HIV-Infected Taiwanese Patients in Response to a 10-Year National Anti-TB Programme

The current trends and spectrum of acquired immunodeficiency syndrome (AIDS)-related opportunistic illnesses (AOIs) among newly diagnosed human immunodeficiency virus (HIV)-infected patients after the implementation of the 2006–2015 national anti-tuberculosis (TB) programmes in Taiwan remain unknown. We retrospectively reviewed 1757 patients at two centres in southern Taiwan between 2001 and 2015. Based on the anti-TB programme, patients were classified into periods 1 (2001–2005), 2 (2006–2010), and 3 (2011–2015). We further analysed factors associated with Mycobacterium tuberculosis (MTB) at presentation and during follow-up. The overall AOI incidence rate (23.6%) remained unchanged across the periods, with 81.4% of AOIs occurring at presentation. Pneumocystis jirovecii pneumonia was the leading AOI across the periods. MTB declined significantly from period 1 to period 3 (39.3% vs. 9.3%). Age and CD4+ cell count <200 cells/µL (vs. ≥501) were the risk factors associated with MTB at presentation, whereas period 2/3 (vs. period 1) was the protective factor. Intravenous drug use (vs. homosexual contact) was the risk factor associated with MTB during follow-up, and period 3 (vs. period 1) was the protective factor. AOI statistics in Taiwan must be closely monitored for fluctuations. Although MTB decreased substantially after implementation of the anti-TB programmes, additional efforts to reduce MTB are required.

A Presumed Etiology of Kawasaki Disease Based on Epidemiological Comparison With Infectious or Immune-Mediated Diseases

Background: Kawasaki disease (KD) may be associated with infection of unknown pathogen(s). For predicting of the etiology of KD, we evaluated epidemiological characteristics in KD, common infectious diseases and immune-mediated diseases in childhood. Methods: We respectively, reviewed the data of patients with KD, influenza, aseptic meningitis, exanthem subitum (ES), Mycoplasma pneumoniae (MP) pneumonia, acute pyelonephritis (APN), Henoch-Schönlein purpura (HSP), acute poststreptococcal glomerulonephritis (APSGN), and childhood asthma. We compared and interpreted epidemiological data across the groups. Results: In age distribution, KD, APN, and ES showed a similar pattern in that majority of patients were infants or young children, and other diseases showed a relatively even age-distribution which had a peak age, mainly 5-6 years, with bell-shape patterns. In annual-case pattern, there were epidemic years in aseptic meningitis and MP pneumonia, and the fluctuated annual cases were seen in other diseases. The trends of decreasing cases were seen in APSGN, HSP, and childhood asthma in recent years. In seasonal frequency, influenza or aseptic meningitis occurred in mainly winter or summer season, respectively. HSP and APSGN cases had less in summer, and KD, APN, and ES showed relatively even occurrence throughout a year without significant seasonal variations. Conclusions: Our results suggest that KD agents may be associated with normal flora that are influenced by environmental changes, since pathogens of APN and ES could be regarded as normal flora that originate from the host itself or ubiquitously existing human reservoirs.

Mononeuritis multiplex: an uncommon neurological manifestation of cytomegalovirus reactivation in an HIV-infected patient

Background

Cytomegalovirus (CMV) reactivation with neurological involvement in patients with acquired immunodeficiency syndrome (AIDS) is increasingly rare since the introduction of antiretroviral therapy (ART). Manifestations include encephalitis, myelitis, polyradiculopathy and, less commonly, mononeuritis multiplex (MNM). We report a case of disseminated CMV disease with gastrointestinal and peripheral and central nervous system involvement in a patient with AIDS, manifesting primarily as MNM.

Case presentation

A 31-year old woman with AIDS presented with a clinical picture of MNM. Electromyography confirmed the clinical findings. CMV DNA was detected in cerebrospinal fluid (CSF) and blood. Gastrointestinal involvement was histologically documented. HIV RNA was also detected in CSF and brain MRI was consistent with HIV encephalopathy. A diagnosis of disseminated CMV disease (with esophagitis, colitis, encephalitis and MNM) and HIV encephalopathy was made. Treatment consisted of ganciclovir and foscarnet, followed by maintenance therapy with valganciclovir. Evolution was favorable and valganciclovir was stopped after sustained immune recovery following ART initiation.

Conclusion

We discuss the diagnostic approach to CMV neurological disease, with a focus on MNM and CMV encephalitis. Combination therapy with ganciclovir and foscarnet should be considered for all forms of neurological involvement, although available data are scarce. Since there is significant overlap between CMV encephalitis and HIV encephalopathy, ART drugs with higher CSF penetration may have to be considered. ART and immune recovery are essential to improve outcomes.

Behavioral Health and Adult Milestones in Young Adults With Perinatal HIV Infection or Exposure

BACKGROUND

Young adults living with perinatally acquired HIV infection (PHIVYAs) are at risk for poor biomedical and behavioral health outcomes. Few studies offer a comprehensive overview of the functioning of this population in young adulthood and the role of HIV.

METHODS

Data come from the Child and Adolescent Self-Awareness and Health Study, a longitudinal behavioral health cohort study of PHIVYAs and perinatally HIV-exposed but uninfected young adults (PHEUYAs) who are compared on psychiatric and neurocognitive functioning, sexual and substance use behaviors, health and reproductive outcomes, and young adult milestones.

RESULTS

Overall, 27% of participants met criteria for a psychiatric disorder, including mood (11%), anxiety (22%), and substance use (28%), with no HIV status differences. PHIVYAs performed worse on 2 neurocognitive tests. There were no HIV status differences in condomless sex (41%) or pregnancies (41% women; 38% men). Both groups exhibited similar adult milestones: 67% graduated high school or an equivalent, 19% were in college, and 42% were employed. However, 38% were neither in school or working, 12% reported incarceration, and 16% were ever homeless. Among PHIVYAs, 36% were viremic (>200 copies per mL), and 15% were severely immunocompromised (CD4⁺ cell count <100 cells per mm³).

CONCLUSIONS

Many PHIVYAs achieve adult milestones related to school, employment, sexual relationships, and starting families. However, they and PHEUYAs have high rates of psychiatric and substance use disorders and behavioral risks, which can jeopardize long-term health and adult functioning, particularly in the context of HIV. These findings underscore an urgent need to escalate interventions.

AIDS-related opportunistic illnesses and early initiation of HIV care remain critical in the contemporary HAART era: a retrospective cohort study in Taiwan

BACKGROUND

No study has reported the epidemiology of AIDS-related opportunistic illnesses (AOIs) in patients with newly diagnosed HIV infection in Taiwan in the past decade. Understanding the current trends in AOI-related morbidity/mortality is essential in improving patient care and optimizing current public health strategies to further reduce AOIs in Taiwan in the era of contemporary highly active antiretroviral therapy (HAART).

METHODS

Eligible patients were evaluated at two referral centers between 2010 and 2015. The patients were stratified by date of diagnosis into three periods: 2010-2011, 2012-2013, and 2014-2015. The demographics, HIV stage at presentation according to the United States CDC 2014 case definition, laboratory variables, and the occurrence of AOIs and associated outcomes were compared among the patients. Logistic regression and Cox regression were respectively used to identify variables associated with the occurrence of AOIs within 90 days of HIV enrollment and all-cause mortality.

RESULTS

Over a mean observation period of 469 days, 1264 patients with newly diagnosed HIV with a mean age of 29 years and mean CD4 count of 275 cells/μL experienced 394 AOI episodes in 290 events. At presentation, 37.7% of the patients had AIDS; the frequency did not significantly differ across groups. The overall proportion of AOIs within the study period was 21.0%, and no decline across groups was observed. The majority of AOIs (91.7%) developed within 90 days of enrollment. All-cause and AOI-related mortality did not significantly differ across groups. Throughout the three study periods, AOIs remained the main cause of death (47/56, 83.9%), especially within 180 days of enrollment (40/42, 95.2%). A CD4 cell count of < 200 cells/μL at presentation was associated with increased adjusted odds of an AOI within 90 days [adjusted odds ratio, 40.84; 95% confidence intervals (CI), 12.59-132.49] and an elevated adjusted hazard of all-cause mortality (adjusted hazard ratio, 11.03; 95% CI, 1.51-80.64).

CONCLUSIONS

Despite efforts toward HIV prevention and management, early HIV care in Taiwan continues to be critically affected by AOI-related morbidity and mortality in the era of contemporary HAART. Additional targeted interventions are required for the earlier diagnosis of patients with HIV.

Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patients with Pneumocystis jirovecii Pneumonia

The substantial decline in the Pneumocystis jirovecii pneumonia (PCP) incidence in HIV-infected patients after the introduction of antiretroviral therapy (ART) in resource-rich settings and the growing number of non-HIV-infected immunocompromised patients at risk leads to considerable epidemiologic changes with clinical, diagnostic, and treatment consequences for physicians. HIV-infected patients usually develop a subacute course of disease, while non-HIV-infected immunocompromised patients are characterized by a rapid disease progression with higher risk of respiratory failure and higher mortality. The main symptoms usually include exertional dyspnea, dry cough, and subfebrile temperature or fever. Lactate dehydrogenase may be elevated. Typical findings on computed tomography scans of the chest are bilateral ground-glass opacities with or without cystic lesions, which are usually associated with the presence of AIDS. Empiric treatment should be initiated as soon as PCP is suspected. Bronchoalveolar lavage has a higher diagnostic yield compared to induced sputum. Immunofluorescence is superior to conventional staining. A combination of different diagnostic tests such as microscopy, polymerase chain reaction, and (1,3)-β-D-glucan is recommended. Trimeth-oprim/sulfamethoxazole for 21 days is the treatment of choice in adults and children. Alternative treatment regimens include dapsone with trimethoprim, clindamycin with primaquine, atovaquone, or pentamidine. Patients with moderate to severe disease should receive adjunctive corticosteroids. In newly diagnosed HIV-infected patients with PCP, ART should be initiated as soon as possible. In non-HIV-infected immunocompromised patients, improvement of the immune status should be discussed (e.g., temporary reduction of immunosuppressive agents). PCP prophylaxis is effective and depends on the immune status of the patient and the underlying immunocompromising disease.

High rates of incident diabetes and prediabetes are evident in men with treated HIV followed for 11 years

OBJECTIVE

To determine the long-term incidence of glucose disorders in treated HIV infection, associations with traditional and HIV-specific risk factors.

METHODS

Observational cohort of 104 men with treated HIV infection and without diabetes, aged 43 ± 8 years at baseline, with (mean ± SD) 11.8 ± 3.5 years follow-up. Ascertainment of glucose status by fasting glucose or, in a subset (n = 33), a 75 g oral glucose tolerance test by 10-12 years follow-up. A subset underwent sequential body composition measures (n = 58) to determine changes in total body and central abdominal adiposity.

RESULTS

The cumulative incidence of glucose disorders was 48.1% (prediabetes 35.6%, diabetes 12.5%), with an incidence rate of 34.5/1000 years of patient follow-up (PYFU) (prediabetes: 24.3/1000 PYFU; diabetes: 10.2/1000 PYFU). Incident glucose disorders were independently associated with higher age (44.9 ± 8.4 vs. 41.1 ± 7.5 years, P = 0.027), baseline C-peptide (2.9 ± 1.3 vs. 2.4 ± 1.1 ng/ml, P = 0.019) and baseline 2-h glucose (135 ± 41 vs. 95 ± 25 mg/dl, P < 0.001). A prior AIDS-defining illness was independently associated with higher follow-up fasting glucose (108 ± 38 vs. 94 ± 16 mg/dl, P = 0.007). Abdominal fat gain over 2-4 years was associated with a 3.16-fold increased risk of incident glucose disorders (95% CI 1.30-7.68, P = 0.011). In a subgroup who underwent further oral glucose tolerance testing, 60% had a glucose disorder, the majority not detected by fasting glucose.

CONCLUSION

Men with long-term treated HIV infection have high rates of incident glucose disorders associated with modest abdominal fat gain. Directed measures to prevent diabetes in this population are warranted.

Ganciclovir and foscarnet dual-therapy for cytomegalovirus encephalitis: A case report and review of the literature

Cytomegalovirus (CMV) is a ubiquitous herpesvirus which establishes lifelong latency following primary infection. It is then capable of reactivating in the face of immunosuppression. Encephalitis is a less common, but particularly devastating syndrome associated with CMV. Here, we describe a case of CMV encephalitis in an allogeneic hematopoietic stem cell transplant recipient who received dual antiviral therapy with ganciclovir and foscarnet. The case presentation is followed by a summary of cases reported in the last ten years, with the goal of describing vulnerable patient populations, treatment courses, and outcomes. Finally, the discussion includes a review of the literature, with a focus on diagnostic criteria and the role for dual antiviral therapy in CMV encephalitis.

Bronchiectasis and other chronic lung diseases in adolescents living with HIV

PURPOSE OF REVIEW

The incidence of pulmonary infections has declined dramatically with improved access to antiretroviral therapy (ART) and cotrimoxazole prophylaxis, but chronic lung disease (CLD) is an increasingly recognized but poorly understood complication in adolescents with perinatally acquired HIV.

RECENT FINDINGS

There is a high prevalence of chronic respiratory symptoms, abnormal spirometry and chest radiographic abnormalities among HIV-infected adolescents in sub-Saharan Africa, wherein 90% of the world's HIV-infected children live. The incidence of lymphocytic interstitial pneumonitis, the most common cause of CLD in the pre-ART era, has declined with increased ART access. Small airways disease, particularly constrictive obliterative bronchiolitis and bronchiectasis, are emerging as leading causes of CLD among HIV-infected adolescents in low-income and middle-income countries. Asthma may be more common in high-income settings. Likely risk factors for CLD include recurrent pulmonary infections, air pollution, HIV-related immune dysfunction, and untreated HIV infection, particularly during critical stages of lung development.

SUMMARY

Globally, the importance of HIV-associated CLD as a cause of morbidity and mortality is increasing, especially as survival has improved dramatically with ART and growing numbers of children living with HIV enter adolescence. Further research is urgently needed to elucidate the natural history and pathogenesis of CLD, and to determine optimal screening, diagnostic and treatment strategies.

Long-term trends in mortality and AIDS-defining events after combination ART initiation among children and adolescents with perinatal HIV infection in 17 middle- and high-income countries in Europe and Thailand: A cohort study

BACKGROUND

Published estimates of mortality and progression to AIDS as children with HIV approach adulthood are limited. We describe rates and risk factors for death and AIDS-defining events in children and adolescents after initiation of combination antiretroviral therapy (cART) in 17 middle- and high-income countries, including some in Western and Central Europe (W&CE), Eastern Europe (Russia and Ukraine), and Thailand.

METHODS AND FINDINGS

Children with perinatal HIV aged <18 years initiating cART were followed until their 21st birthday, transfer to adult care, death, loss to follow-up, or last visit up until 31 December 2013. Rates of death and first AIDS-defining events were calculated. Baseline and time-updated risk factors for early/late (≤/>6 months of cART) death and progression to AIDS were assessed. Of 3,526 children included, 32% were from the United Kingdom or Ireland, 30% from elsewhere in W&CE, 18% from Russia or Ukraine, and 20% from Thailand. At cART initiation, median age was 5.2 (IQR 1.4-9.3) years; 35% of children aged <5 years had a CD4 lymphocyte percentage <15% in 1997-2003, which fell to 15% of children in 2011 onwards (p < 0.001). Similarly, 53% and 18% of children ≥5 years had a CD4 count <200 cells/mm3 in 1997-2003 and in 2011 onwards, respectively (p < 0.001). Median follow-up was 5.6 (2.9-8.7) years. Of 94 deaths and 237 first AIDS-defining events, 43 (46%) and 100 (42%) were within 6 months of initiating cART, respectively. Multivariable predictors of early death were: being in the first year of life; residence in Russia, Ukraine, or Thailand; AIDS at cART start; initiating cART on a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen; severe immune suppression; and low BMI-for-age z-score. Current severe immune suppression, low current BMI-for-age z-score, and current viral load >400 c/mL predicted late death. Predictors of early and late progression to AIDS were similar. Study limitations include incomplete recording of US Centers for Disease Control (CDC) disease stage B events and serious adverse events in some countries; events that were distributed over a long time period, and that we lacked power to analyse trends in patterns and causes of death over time.

CONCLUSIONS

In our study, 3,526 children and adolescents with perinatal HIV infection initiated antiretroviral therapy (ART) in countries in Europe and Thailand. We observed that over 40% of deaths occurred ≤6 months after cART initiation. Greater early mortality risk in infants, as compared to older children, and in Russia, Ukraine, or Thailand as compared to W&CE, raises concern. Current severe immune suppression, being underweight, and unsuppressed viral load were associated with a higher risk of death at >6 months after initiation of cART.

Effects of Vitamin D Supplementation on Bone Mineral Density and Bone Markers in HIV-Infected Youth

BACKGROUND

Low bone mineral density (BMD) is a significant comorbidity in HIV. However, studies evaluating vitamin D supplementation on bone health in this population are limited. This study investigates changes in bone health parameters after 12 months of supplementation in HIV-infected youth with vitamin D insufficiency.

METHODS

This is a randomized, active-control, double-blind trial investigating changes in bone parameters with 3 different vitamin D3 doses [18,000 (standard/control dose), 60,000 (moderate dose), and 120,000 IU/monthly (high dose)] in HIV-infected youth 8-25 years old with baseline serum 25-hydroxyvitamin D (25(OH)D) concentrations <30 ng/mL. BMD and bone turnover markers were measured at baseline and 12 months.

RESULTS

One hundred two subjects enrolled. Over 12 months, serum 25(OH)D concentrations increased with all doses, but the high dose (ie, 120,000 IU/monthly) maintained serum 25(OH)D concentrations in an optimal range (≥30 or ≥20 ng/mL) throughout the study period for more subjects (85% and 93%, respectively) compared with either the moderate (54% and 88%, respectively) or standard dose (63% and 80%, respectively). All dosing groups showed some improvement in BMD; however, only the high-dose arm showed significant decreases in bone turnover markers for both procollagen type 1 aminoterminal propeptide (-3.7 ng/mL; P = 0.001) and Β-CrossLaps (-0.13 ng/mL; P = 0.0005).

CONCLUSIONS

High-dose vitamin D supplementation (120,000 IU/mo) given over 12 months decreases bone turnover markers in HIV-infected youth with vitamin D insufficiency, which may represent an early, beneficial effect on bone health. High vitamin D doses are needed to maintain optimal serum 25(OH)D concentrations.

The role of human dopamine transporter in NeuroAIDS

HIV-associated neurocognitive disorder (HAND) remains highly prevalent in HIV infected individuals and represents a special group of neuropathological disorders, which are associated with HIV-1 viral proteins, such as transactivator of transcription (Tat) protein. Cocaine abuse increases the incidence of HAND and exacerbates its severity by enhancing viral replication. Perturbation of dopaminergic transmission has been implicated as a risk factor of HAND. The presynaptic dopamine (DA) transporter (DAT) is essential for DA homeostasis and dopaminergic modulation of the brain function including cognition. Tat and cocaine synergistically elevate synaptic DA levels by acting directly on human DAT (hDAT), ultimately leading to dysregulation of DA transmission. Through integrated computational modeling and experimental validation, key residues have been identified in hDAT that play a critical role in Tat-induced inhibition of DAT and induce transporter conformational transitions. This review presents current information regarding neurological changes in DAT-mediated dopaminergic system associated with HIV infection, DAT-mediated adaptive responses to Tat as well as allosteric modulatory effects of novel compounds on hDAT. Understanding the molecular mechanisms by which Tat induces DAT-mediated dysregulation of DA system is of great clinical interest for identifying new targets for an early therapeutic intervention for HAND.

Trends in Diagnoses Among Hospitalizations of HIV-infected Children and Adolescents in the United States: 2003-2012

OBJECTIVE

Using data from 2003-2012, we updated a previous analysis of trends in hospitalizations of HIV-infected children and adolescents in the United States.

METHODS

We used data from the Kids´ Inpatient Database of the Healthcare Cost and Utilization Project to derive nationally representative estimates of the number of hospitalizations and the rates per 1000 hospitalizations of select discharge diagnoses and procedures in 2003, 2006, 2009 and 2012 among HIV-infected and HIV-uninfected children and adolescents ≤18 years, excluding hospitalizations for conditions related to pregnancy/delivery and neonatal diagnoses. We also examined trends in the prevalence of select discharge diagnoses and procedures using multivariable logistic regression models.

RESULTS

During 2003-2012, the number of hospitalizations for HIV-infected children declined 58% versus 17% for uninfected, but the odds of having discharge codes for most of the diagnoses and procedures studied, including death during hospitalization, remained higher among HIV-infected compared with uninfected children. Among HIV-infected children, the prevalence of discharge diagnoses for pneumonia, pneumococcal disease and varicella/herpes zoster infections and odds of death during hospitalization decreased over time, while bacterial infections/sepsis and methicillin-resistant Staphylococcus aureus increased. Among HIV-uninfected children, there was no increase in diagnoses of bacterial infection/sepsis, but otherwise trends were similar.

CONCLUSIONS

The number of hospitalizations for HIV-infected children declined from 2003 to 2012. The decreased prevalence of several discharge diagnoses and lower risk of death during hospitalization likely reflect improvements in HIV therapies and increased uptake of other preventive strategies. However, the increasing prevalence of discharge diagnoses for bacterial infections/sepsis warrants further attention and monitoring.

Efficacy and safety of nucleoside-sparing regimen based on raltegravir and ritonavir-boosted darunavir in HIV-1-infected treatment-experienced patients

AIM

To assess the efficacy and tolerability of dual therapy containing raltegravir (RAL) and ritonavir boosted darunavir (DRV/r) in HIV-1-infected treatment-experienced patients.

METHOD

Retrospective analysis of 81 HIV-1-infected treatment-experienced patients (56 male and 25 female, 5 Polish centers) who switched to RAL/DRV/r.

RESULTS

The main reasons for the introduction of dual therapy were renal dysfunction (16/81 patients-19.8%) and virologic failure on previous regimens (15/81 patients-18.5%). At 48 weeks the treatment was continued in 58/81 (71.6% of patients). In three patients the therapy was discontinued because of virologic failure. However, no mutations to DRV or integrase inhibitors (InI) were detected. At 48 weeks of treatment CD4⁺ lymphocyte count increased statistically significantly (median 121 cells/μL) P < 0.005. The main reasons for the discontinuation of therapy were treatment simplification (11/23-47.8% patients), adverse events (7/23 patients 30.4%), virologic failure (3/23 patients 13.0%). All patients who switched to RAL/DRV/r therapy because of prior renal impairment were maintained on the treatment for 48 weeks. In this group, before the introduction of dual therapy eGFR (estimated glomerular filtration rate) <60 mL/min/1.72 m² was reported in nine patients and after 48 weeks in four patients (56.3% vs 25%) (P > 0.05). We found a statistically significant decrease in the prevalence of proteinuria or eGFR <60 mL/min/1.72 m² (93.8% vs 37.5%; P = 0.004 before and after the introduction of dual therapy, respectively).

CONCLUSIONS

Dual therapy was effective and safe for the vast majority of antiretroviral-experienced subjects. Such therapy can be recommended especially for patients with renal impairment or NRTIs intolerance.

Interventions to improve treatment, retention and survival outcomes for adolescents with perinatal HIV-1 transitioning to adult care: moving on up

PURPOSE OF REVIEW

There is an increasing number of deaths among adult survivors of perinatal HIV. Multiple and complex factors drive this mortality, including problems with retention in care and adherence during adolescence, coupled with the critical period of transition from paediatric to adult care, increasing their risk of treatment failure and severe immunosuppression. We reviewed studies that evaluated the impact of service delivery interventions to improve the health of perinatally infected adolescents living with HIV (P-ALHIV) to gain insight into what might help them survive the vulnerable period of adolescence.

RECENT FINDINGS

Youth-focused health services and individual-level interventions may improve P-ALHIV adherence and retention in care. However, there have been few studies, many with small sample sizes and with short durations of follow-up that end before the transition period. Studies from other childhood-onset chronic diseases are similarly limited.

SUMMARY

Further studies are urgently needed to identify optimal intervention strategies to reduce mortality and poor outcomes as the adolescent population expands and ages into adult care. Until we have a more robust evidence base, programmes can develop transition plans based on best practice recommendations to optimize the health and longevity of ALHIV in adulthood.