Use of HIV-1 specific immunoglobulin G3 as a serological marker of vertical transmission

HIV infection in children in developing countries

Disease progression in children acquiring HIV infection vertically from their mothers is more rapid in developing countries compared with developed countries. The probability of death by 12 months in sub-Saharan Africa ranges from 0.23 to 0.35, and by 5 years is 0.57-0.68. Data from Europe in the era before highly active anti-retroviral therapy (HAART) yielded probabilities of 0.1 and 0.2, respectively. Confirming the diagnosis can be difficult in resource-limited settings. Existing clinical case definitions are useful epidemiologically, but of low positive-predictive value in individual children. Priorities for research into management issues include nutrition (infant feeding, vitamin A and micronutrient supplementation), prophylaxis against Pneumocystis carinii pneumonia (PCP), and bacterial infections, case management of persistent diarrhoea, diagnosis/prevention/management of tuberculosis in children and prevention of sexual transmission in adolescents.

Tuberculous meningitis and co-infection with HIV

The clinical, laboratory and radiological features of 30 children with clinically diagnosed tuberculous meningitis (TBM) who were HIV-seronegative were compared with those of ten HIV-infected children with TBM. Such comparative data are not currently available in the literature and so are an important addition to our knowledge of the HIV-TB co-infection epidemic. In comparison with the HIV-negative children, those infected with HIV were younger, had a shorter duration of symptoms and were more often Mantoux-negative (HIV-positive 23% vs HIV-negative 70%; p = 0.01). On presentation, all children in both groups were in MRC TBM stages II or III. Clinical features were similar in both groups but computed tomography of the brain showed more ventricular enlargement (HIV-positive 80% vs HIV-negative 63%), gyral enhancement (HIV-positive 60% vs HIV-negative 17%; p = 0.01) and cerebral atrophy (HIV-positive 40% vs HIV-negative 17%). Outcome was considerably worse in the HIV-positive children, of whom 30% died (vs HIV-negative 0/30; p = 0.01) and the remainder were moderately (HIV-positive 30% vs HIV-negative 24%) or severely (HIV-positive 30% vs HIV-negative 19%) handicapped at the end of treatment. While clinical features were not markedly different in HIV-infected and uninfected children with TBM, abnormal radiological findings were more common in the HIV-infected group and outcome was considerably worse. Co-existing HIV encephalopathy and diminished immune competence undoubtedly contributed to the more severe clinical and neuro-radiological features.

Care of human immunodeficiency virus-infected children in developing countries. International Working Group on Mother-to-Child Transmission of HIV

CONTEXT

There is urgent need to strengthen the area of pediatric HIV/AIDS care in developing countries. Clinical research in this area is also scarce.

METHODOLOGY

A literature review and a postal survey were used to obtain updated information on mortality, morbidity and current standards of care of children born to HIV-infected mothers in developing countries. A 2-day workshop was organized to review the available data and to identify the key areas where clinical research should be conducted.

MAIN FINDINGS

Rates of mortality and morbidity were very different from one study to another but generally higher than in industrialized countries. Prognostic studies for HIV-1-infected children in developing countries were not available. Based on the report of 14 teams from 11 countries, specific protocols for HIV-infected children with persistent diarrhea or severe malnutrition were documented in fewer than one-half of the cases. Secondary antimicrobial prophylaxis after interstitial pneumonia or recurrent infections was still infrequent, as primary prophylaxis of opportunistic infections. The following list of clinical research priorities was identified by the workshop participants: primary prophylaxis of opportunistic and bacterial infections; case management of persistent diarrhea; reassessment of the performance of p24 antigen for diagnostic and prognosis use; studies on the etiology of pulmonary infections; long term observational pediatric cohorts; current weaning practices and duration of breast-feeding; counseling and HIV testing of children and families; prevention of HIV sexual transmission in children and adolescents.