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

Research priority setting in childhood chronic disease: a systematic review

OBJECTIVE

To evaluate research priority setting approaches in childhood chronic diseases and to describe the priorities of stakeholders including patients, caregivers/families and health professionals.

DESIGN

We conducted a systematic review of MEDLINE, Embase, PsycINFO and CINAHL from inception to 16 October 2016. Studies that elicited stakeholder priorities for paediatric chronic disease research were eligible for inclusion. Data on the prioritisation process were extracted using an appraisal checklist. Generated priorities were collated into common topic areas.

RESULTS

We identified 83 studies (n=15 722). Twenty (24%) studies involved parents/caregivers and four (5%) children. The top three health areas were cancer (11%), neurology (8%) and endocrine/metabolism (8%). Priority topic areas were treatment (78%), disease trajectory (48%), quality of life/psychosocial impact (48%), disease onset/prevention (43%), knowledge/self-management (33%), prevalence (30%), diagnostic methods (28%), access to healthcare (25%) and transition to adulthood (12%). The methods included workshops, Delphi techniques, surveys and focus groups/interviews. Specific methods for collecting and prioritising research topics were described in only 60% of studies. Most reviewed studies were conducted in high-income nations.

CONCLUSIONS

Research priority setting activities in paediatric chronic disease cover many discipline areas and have elicited a broad range of topics. However, child/caregiver involvement is uncommon, and the methods often lack clarity. A systematic and explicit process that involves patients and families in partnership may help to inform a more patient and family-relevant research agenda in paediatric chronic disease.

Predictors of early mortality in a cohort of HIV-infected children receiving high active antiretroviral treatment in public hospitals in Ethiopia

Highly active antiretroviral therapy (HAART) is the breakthrough in care and treatment of people living with HIV, leading to a reduction in mortality and an improvement in the quality of life. Without antiretroviral treatment, most HIV-infected children die before their fifth birthday. So the objective of this study is to determine the mortality and associated factors in a cohort of HIV-infected children receiving ART in Ethiopia. A multicentre facility-based retrospective cohort study was done in selected pediatric ART units in hospitals found in Addis Ababa, Ethiopia. The probability of survival was estimated using the Kaplan-Meier method, and multivariate analysis by Cox proportional hazards regression models was conducted to determine the independent predictor of survival. A total of 556 children were included in this study. Of the total children, 10.4% were died in the overall cohort. More deaths (70%) occurred in the first 6 months of ART initiation, and the remaining others were still on follow-up at different hospitals. Underweight (moderate and severe; HR: 10.10; 95% CI: 2.08, 28.00; P = 0.004; and HR: 46.69; 95% CI: 9.26, 200.45; P < 0.01, respectively), advanced disease stage (WHO clinical stages III and IV; HR: 10.13: 95% CI: 2.25, 45.58; P = 0.003), poor ART adherence (HR: 11.72; 95% CI: 1.60, 48.44; P = 0.015), and hemoglobin level less than 7 g/dl (HR: 4.08: 95% CI: 1.33, 12.56; P = 0.014) were confirmed as significant independent predictors of death after controlling for other factors. Underweight, advanced disease stage, poor adherence to ART, and anemia appear to be independent predictor of survival in HIV-infected children receiving HAART at the pediatric units of public hospitals in Ethiopia. Nutritional supplementations, early initiation of HAART, close supervision, and monitoring of patients during the first 6 months, the follow up period is recommended.

Left ventricular systolic function in Nigerian children with human immunodeficiency virus infection

OBJECTIVE

The objective of this article was to compare the left ventricular (LV) systolic function of human immunodeficiency virus (HIV)-infected children with that of healthy controls, determine the prevalence of LV systolic dysfunction in HIV-infected children, and its association with age, stage of disease, and use of zidovudine.

STUDY DESIGN

This was a comparative cross-sectional descriptive study.

SETTING

A University Teaching Hospital in North-Central Nigeria in 2008.

PATIENTS

One hundred fifty HIV-infected children aged 6 weeks-14 years, and an equal number of age- and sex-matched apparently healthy controls.

OUTCOME MEASURES

Left ventricular internal dimensions in diastole and systole, LV fractional shortening (FS) and ejection fraction (EF). Left ventricular systolic dysfunction was considered present when FS was <28% or EF was <50%.

RESULTS

Mean LV internal dimensions in diastole was similar in subjects and controls (P= .26). Left ventricular internal dimensions in systole was significantly larger in subjects (2.7 cm, 95% confidence interval [CI] 2.6-2.8 cm) than controls (2.4 cm, 95% CI 2.3-2.5 cm) (P < .001). Mean FS of 27.8% (26.8-28.8%) in subjects was significantly reduced compared with 33.7% (33.1-34.3%) in controls (P < .001), as was EF 61.5% (60.7-62.3%) in subjects and 70.5% (69.7-71.3%) in controls (P < .001). Left ventricular systolic dysfunction was detected in 75 (50.0%, 95% CI 41.7-58.3%) subjects and 5 (3.3%, 95% CI 2.2-6.7) controls (P < .001). Subjects with left ventricular systolic dysfunction were significantly older than those without (P < .001) but did not differ significantly from them with respect to zidovudine therapy or stage of disease.

CONCLUSIONS

Left ventricular systolic dysfunction is significantly more frequent in HIV-infected children compared with controls. Left ventricular systolic function in HIV-infected children deteriorates with increasing age and should be serially evaluated in them.

Burkitt's lymphoma mimicking EBV disease as first sign of vertical HIV infection in an adolescent

Burkitt's Lymphoma (BL) rarely represents the first clinical manifestation of vertical HIV infection in adolescent in Western Europe. We report the case of a 17 year-old boy with two week history of fever and enlarged cervical lymph nodes firstly misdiagnosed as EBV infection, subsequently diagnosed as Burkitt's Lymphoma and vertical HIV infection.

Heart disease among children with HIV/AIDS attending the paediatric infectious disease clinic at Mulago Hospital

BACKGROUND

There are very few published studies of heart disease in HIV infected children living in sub-Saharan Africa, a region with more than 50% of the world's population of HIV infected patients.

OBJECTIVES

To determine the prevalence, and describe the type and clinical presentation of heart disease among children with HIV attending an ambulatory clinic.

METHODOLOGY

Two hundred and thirty (230) HIV infected children attending the Paediatric Infectious Disease Clinic at Mulago hospital were recruited by simple random sampling in a cross-sectional study. The children were evaluated clinically, and investigated by electrocardiography and echocardiography.

RESULTS

Thirty-two children (13.9%) had asymptomatic HIV disease, 156 (67.8%) had AIDS related complex while 42 (18.3%) had AIDS. Heart abnormalities were detected in 51% of the children (40.0% by echocardiography alone and 26.5% by electrocardiography alone). Heart abnormalities were most prevalent in children with AIDS (76.2%) and least prevalent in children with asymptomatic HIV disease (25.0%). The abnormalities included; Sinus tachycardia (21%), left ventricular systolic dysfunction (17%), right ventricular dilatation (14%), congenital heart disease (4.8%), dilated cardiomyopathy (3.0%), pericarditis (2.2%) and cor pulmonale (1.3%). Children with left ventricular systolic dysfunction significantly had easy fatigability, dyspnoea on exertion and tachypnoea. Other heart abnormalities presented with non-specific clinical features.

CONCLUSION

Heart abnormalities were common especially in children with symptomatic HIV disease and included sinus tachycardia, left ventricular systolic dysfunction and right ventricular dilatation. The detected heart abnormalities, except left ventricular systolic dysfunction, had non-specific clinical features.

The feasibility of preventing mother-to-child transmission of HIV using peer counselors in Zimbabwe

Background

Prevention of mother-to-child transmission of HIV (PMTCT) is a major public health challenge in Zimbabwe.

Methods

Using trained peer counselors, a nevirapine (NVP)-based PMTCT program was implemented as part of routine care in urban antenatal clinics.

Results

Between October 2002 and December 2004, a total of 19,279 women presented for antenatal care. Of these, 18,817 (98%) underwent pre-test counseling; 10,513 (56%) accepted HIV testing, of whom 1986 (19%) were HIV-infected. Overall, 9696 (92%) of women collected results and received individual post-test counseling. Only 288 men opted for HIV testing. Of the 1807 HIV-infected women who received posttest counseling, 1387 (77%) collected NVP tablet and 727 (40%) delivered at the clinics. Of the 1986 HIV-infected women, 691 (35%) received NVPsd at onset of labor, and 615 (31%) infants received NVPsd. Of the 727 HIV-infected women who delivered in the clinics, only 396 women returned to the clinic with their infants for the 6-week follow-up visit; of these mothers, 258 (59%) joined support groups and 234 (53%) opted for contraception. By the end of the study period, 209 (53%) of mother-infant pairs (n = 396) came to the clinic for at least 3 follow-up visits.

Conclusion

Despite considerable challenges and limited resources, it was feasible to implement a PMTCT program using peer counselors in urban clinics in Zimbabwe.

Maternal disease stage and child undernutrition in relation to mortality among children born to HIV-infected women in Tanzania

OBJECTIVE

To examine whether maternal HIV disease stage during pregnancy and child malnutrition are associated with child mortality.

DESIGN

Prospective cohort study in Tanzania.

METHODS

Indicators of disease stage were assessed for 939 HIV-infected women during pregnancy and at delivery, and children's anthropometric status was obtained at scheduled monthly clinic visits after delivery. Children were followed up for survival status until 24 months after birth.

RESULTS

Advanced maternal HIV disease during pregnancy (CD4 count <350 vs. >or=350 cells/mm) was associated with increased risk of child mortality through 24 months of age (hazard ratio [HR] = 1.74, 95% confidence interval [CI]: 1.32 to 2.30). CD4 count <350 cells/mm was also associated with an increased risk of death among children who remained HIV-negative during follow-up (HR = 2.00, 95% CI: 1.36 to 2.94). Low maternal hemoglobin concentration and child undernutrition were related to an increased risk of mortality in this cohort of children.

CONCLUSIONS

Low maternal CD4 cell count during pregnancy is related to increased risk of mortality in children born to HIV-infected women. Care and treatment for HIV disease, including highly active antiretroviral therapy to pregnant women, could improve child survival. Prevention and treatment of undernutrition in children remain critical interventions in settings with high HIV prevalence.

Growth of human immunodeficiency virus-uninfected children exposed to perinatal zidovudine for the prevention of mother-to-child human immunodeficiency virus transmission

BACKGROUND

Perinatal human immunodeficiency virus (HIV) prevention programs have been implemented in several countries, and many children have been or will be exposed to antiretrovirals in utero and during their first weeks of life. Although reducing substantially the number of infected children, the potential adverse consequences of these treatments on the health of HIV-uninfected children need to be assessed.

OBJECTIVE

To investigate the impact of in utero and postnatal zidovudine exposure on the growth of HIV-uninfected children born to HIV-infected women.

METHODS

We used data prospectively collected in 1408 live born children participating in a clinical trial comparing zidovudine regimens of different durations to prevent perinatal transmission in Thailand (PHPT-1). We used a linear mixed model to analyze the anthropometric measurements (weight for age, height for age and weight for height Z-scores) until 18 months of age according to zidovudine treatment duration (mothers, <7.5 weeks versus more; infants, 3 days versus >4 weeks).

RESULTS

Children exposed in utero for >7.5 weeks had a slightly lower birth weight (Z-score difference, 0.08; P = 0.003). However, zidovudine exposure had no effect on the evolution of Z-scores from 6 weeks to 18 months of age.

CONCLUSIONS

Although a longer in utero zidovudine exposure may have had a negative impact on birth weight, the magnitude of this effect was small and faded over time. Neither the total nor the postnatal duration of exposure was associated with changes in infant Z-scores from 6 weeks to 18 months of age.

Dried blood spots improve access to HIV diagnosis and care for infants in low-resource settings

Effective health care delivery to the majority of perinatally exposed infants worldwide, including those enrolled in prevention of mother-to-child transmission programs, is hampered by lack of access to an HIV diagnosis in infancy. Dried blood spot collection from young infants for centralized HIV polymerase chain reaction (PCR) testing is attainable in low-resource settings, provided PCR methodology suitable for routine laboratory service is available. The accuracy of the Roche Amplicor HIV-1 DNA test version 1.5 (Branchburg, NJ) performed on dried blood spots collected prospectively on ordinary Whatman filter paper from a cohort of 300 6-week-old infants born to HIV-infected women in Johannesburg, South Africa, was assessed. Anonymous analysis of the blood spots using a unique DNA extraction procedure was performed in a routine diagnostic laboratory and the results compared with HIV DNA and RNA PCR liquid blood tests at age 6 weeks, and the HIV status of the infant. Dried blood spots were available for 288 infants (96%) of whom 25 (8.7%) were HIV infected. The Roche Amplicor assay yielded a sensitivity of 100% and a specificity of 99.6%. HIV DNA PCR tests on dried blood spots have the potential to improve health care delivery to HIV-affected children in low-resource settings right now.

Quantitative and qualitative antibody response to pneumococcal conjugate vaccine among African human immunodeficiency virus-infected and uninfected children

OBJECTIVE

To determine the quantitative and qualitative antibody responses to a pneumococcal conjugate vaccine (PnCV) in human immunodeficiency virus (HIV)-exposed infected and uninfected children.

METHODS

Children were randomized to receive either a PnCV or placebo at 6, 10 and 14 weeks of age. PnCV serotype-specific antibody concentrations were measured by a standard enzyme immunoassay (EIA) and a 22F modified EIA (22F EIA) on single serum samples drawn at 21-42 days post-dose 3. Functional activities of the serotype-specific antibody to serotypes 6B, 19F and 23F were measured with an opsonophagocytic assay (OPA).

RESULTS

The geometric mean antibody concentrations (GMC) were similar in HIV-infected and HIV-uninfected PnCV recipients for 7 of the 9 vaccine serotypes. In placebo recipients, the GMCs were significantly higher in HIV-infected than in uninfected children for 7 of the serotypes. In HIV-infected PnCV recipients, the GMCs were lower for 5 of the serotypes in children with severe acquired immunodeficiency syndrome than in children who were asymptomatic or mildly symptomatic with acquired immunodeficiency syndrome. HIV-infected PnCV recipients were less likely to have measurable functional antibody (OPA titer > or =1/8) to all 3 studied serotypes (6B, 19F and 23F) than in HIV-uninfected children. HIV-infected children required a higher concentration of anticapsular antibody to achieve 50% of the maximum uptake of labeled Streptococcus pneumoniae in the OPA assay than HIV-uninfected children for 2 of the 3 serotypes, although this was significant only for serotype 6B (P = 0.0005).

CONCLUSION

HIV-infected children have similar quantitative antibody responses but poorer qualitative antibody responses to the PnCV.

Making the choice: the translation of global HIV and infant feeding policy to local practice among mothers in Pune, India

In 2003, India had over 5.1 million infected individuals living with HIV/AIDS. The percentage of all HIV cases attributed to perinatal transmission has been increasing steadily from 0.33% of total cases in 1999 to 2.80% in 2004. Recent statistics indicate that over 130,000 infants have been infected through this route. Despite recent advances in reducing in utero and interpartum transmission with the use of antiretrovirals, there is a critical need to make infant feeding safer. Current UNAIDS/WHO/UNICEF recommendations stress avoidance of all breast-feeding if replacement feeding fulfills the key requirements of being affordable, feasible, acceptable, sustainable, and safe. In this paper, we examine how the UNAIDS/WHO/UNICEF recommendations have been actualized within the context of an urban government hospital in India. The documented patterns of infant feeding by HIV-positive mothers in Pune, India, from 2000 to 2004, highlight the complexities of making an informed and healthy choice under suboptimal conditions. The data indicate that interpersonal variations in the key requirements greatly influence the optimal practice to minimize mortality risks. Moreover, local information on health outcomes is crucial to tailoring policy recommendations to save lives. We propose the development of a decision-making algorithm that includes factors affecting mother-to-infant transmission, including site-specific data on health risks to the mother and the child. Such an algorithm would allow identification of the healthiest feeding choice and would minimize the pitfalls of promoting homogeneous practices lacking site-specific evidence-based evaluation.

Estimating the net effect of HIV on child mortality in African populations affected by generalized HIV epidemics

For a given prevalence, HIV has a relatively higher impact on child mortality when mortality from other causes is low. To project the effect of the epidemic on child mortality, it is necessary to estimate a realistic schedule of "net" age-specific mortality rates that would operate if HIV were the only cause of child death observable. We assume that this net pattern would be independent of mortality from other causes. We used African studies that measured the survival of HIV-infected children (direct data) or survival of children of HIV-infected mothers (indirect data). We developed a mathematic procedure to estimate the mortality of infected children from indirect data sources and obtained net HIV mortality patterns for each study population. The net age-specific HIV mortality pattern for infected children can be described by a double Weibull curve fitted to empiric data; this gives a functional representation of age-specific mortality rates that decline after infancy and rise in the preteens. The fitted curve that we would expect if HIV were the only effective cause of death shows 67% net survival at 1 year and 39% at 5 years. The curve also predicts 13% net survival at 10 years using constraints based on survival of infected adults.

Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis

BACKGROUND

HIV contributes substantially to child mortality, but factors underlying these deaths are inadequately described. With individual data from seven randomised mother-to-child transmission (MTCT) intervention trials, we estimate mortality in African children born to HIV-infected mothers and analyse selected risk factors.

METHODS

Early HIV infection was defined as a positive HIV-PCR test before 4 weeks of age; and late infection by a negative PCR test at or after 4 weeks of age, followed by a positive test. Mortality rate was expressed per 1000 child-years. We investigated the effect of maternal health, infant HIV infection, feeding practices, and age at acquisition of infection on mortality assessed with Cox proportional hazards models, and allowed for random effects for trials grouped geographically.

FINDINGS

378 (11%) of 3468 children died. By age 1 year, an estimated 35.2% infected and 4.9% uninfected children will have died; by 2 years of age, 52.5% and 7.6% will have died, respectively. Mortality varied by geographical region, and was associated with maternal death (adjusted odds ratio 2.27, 95% CI 1.62-3.19), CD4+ cell counts <200 per microL (1.91, 1.39-2.62), and infant HIV infection (8.16, 6.43-10.33). Mortality was not associated with either ever breastfeeding and never breastfeeding in either infected or uninfected children. In infected children, mortality was significantly lower for those with late infection than those with early infection (0.52, 0.39-0.70). This effect was also seen in analyses of survival from the age at infection (0.74, 0.55-0.99).

INTERPRETATION

These findings highlight the necessity for timely antiretroviral care, for support for HIV-infected women and children in developing countries, and for assessment of prophylactic programmes to prevent MTCT, including child mortality and infection averted.

Child mortality and HIV infection in Africa: a review

OBJECTIVES

To review the available data relating to child mortality in Africa by the HIV infection status of mothers and children.

RESULTS

Child survival is influenced by the HIV epidemic through several mechanisms. Mother-to-child transmission of HIV ranges from 15 to 45%, with up to 15-20% resulting from breastfeeding. HIV-infected children have high mortality rates. For example, a recent community-based study in Rakai, Uganda, showed 2-year mortality rates of 547, 166 and 128 per thousand among HIV-infected children, HIV-negative children of HIV-positive mothers, and HIV-negative children of HIV-negative women, respectively. Child mortality estimates from community-based cohorts demonstrate that the children of HIV-infected mothers have higher mortality rates than the children of uninfected mothers, and that child mortality is closely linked with maternal health status, but because the proportion of vertically infected children is unknown, the value of these studies is limited. Models that use HIV surveillance data together with a set of assumptions indicate that child mortality caused by HIV/AIDS has increased throughout the 1990s to reach close to 10% by 2002.

CONCLUSION

Both disparate trends in HIV prevalence and varying levels of non-HIV-associated child mortality will ensure very different impacts in different countries. To improve the projections of the overall effect that the HIV epidemic will have on child mortality at the population level in countries with generalized epidemics, reliable age-specific mortality rates in infected and uninfected children are needed.

Affordable diagnosis of human immunodeficiency virus infection in infants by p24 antigen detection

The expense of PCR testing limits diagnosis of HIV infection in infancy in low resource settings. The ultrasensitive p24 antigen assay has been proposed as an accurate substitute; however, its ability to detect different HIV viral subtypes remains to be determined. A sensitivity of 98.1% and specificity of 98.7% was obtained testing 203 samples from 24 HIV-infected and 66 uninfected infants born to HIV subtype C-infected women.

Survival of HIV-1 and HIV-2 perinatally infected children in The Gambia

BACKGROUND

The risk of mother-to-child transmission (MTCT) of HIV-2 is much lower than that of HIV-1, but the long-term prognosis of perinatally infected HIV-2 children is unknown. We re-visited children who were part of a large MTCT study in The Gambia (conducted during 1993-1997), in order to compare the long-term survival of children perinatally infected with HIV-2 with that of seronegative and of HIV-1 infected children.

METHODS

Five to eight years' follow-up of a cohort of children born to HIV-negative, HIV-1 positive, and HIV-2 positive mothers.

RESULTS

Seven hundred and seventy-four children were followed up for a median of 6.6 years. Of 17 perinatally HIV-1 infected children, three were still alive on 1 July 2001, two had been lost to follow-up, and 12 had died. The median survival was 2.5 years. Of eight HIV-2 infected children five were still alive, none were lost to follow-up and three had died. The mortality hazards ratio of both HIV-1 [9.9; 95% confidence interval (CI), 5.2-19], and of HIV-2 infected children (3.9; CI, 1.2-12) was significantly increased compared with children of seronegative mothers. The mortality hazards ratio of HIV uninfected children of HIV-1 or HIV-2 infected mothers was not significantly increased compared to that of children of seronegative mothers (P = 0.17 and P = 0.5 respectively).

CONCLUSIONS

Children with perinatally acquired HIV-2 infection have a higher mortality than children of seronegative mothers. Guidelines for treatment of HIV-1 infected children should be used for treatment of HIV-2 infected children.

The long-term impact of HIV and orphanhood on the mortality and physical well-being of children in rural Malawi

OBJECTIVE

To assess the influence of maternal HIV status and orphanhood on child mortality and physical well-being.

DESIGN

Retrospective cohort study with > 10 years of follow-up.

METHODS

From population-based surveys in Karonga District, Malawi in the 1980s, 197 individuals were identified as HIV-positive. These individuals and 396 HIV-negative individuals matched for age and sex, and their spouses and offspring, were sought in 1998-2000.

RESULTS

All but 11 of the index individuals were traced, identifying 2520 offspring; of these, 1106 offspring were included in analyses. Among those with HIV-positive mothers, mortality was 27% [95% confidence interval (CI), 17-38] in infants (1-30 days), 46% (95% CI, 34-58) in those under 5 years and 49% (95% CI, 38-61) in those under 10 years. The corresponding figures for those with HIV-negative mothers were 11% (95% CI, 8-13), 16% (95% CI, 13-19) and 17% (95% CI, 14-20). Death of HIV-positive mothers, but not of HIV-negative mothers or of fathers, was associated with increased child mortality. Among survivors who were still resident in the district, neither maternal HIV status nor orphanhood was associated with stunting, being wasted, or reported ill-health.

CONCLUSIONS

Mortality in children under 5 years is much higher in children born to HIV-positive mothers than in those born to HIV-negative mothers. With 10% of pregnant women HIV-positive, we estimate that approximately 18% of under-5 deaths in this population are attributable to HIV. Most of the excess is attributable to vertical transmission of HIV. Our findings suggest that, in terms of physical well-being, the extended family in this society has not discriminated against surviving children whose parents have been ill or have died as a result of HIV/AIDS.

Impact of human immunodeficiency virus 1 infection on clinical presentation, treatment outcome and survival in a cohort of Ethiopian children with tuberculosis

BACKGROUND

Childhood tuberculosis (TB) is difficult to diagnose reliably because signs and symptoms are nonspecific and sputum for direct microscopy is difficult to obtain, especially in very young children. This diagnostic dilemma is thought to have increased with the HIV pandemic. Few studies on treatment outcome of dually infected children in high endemic countries have been reported. This study examines the impact of HIV infection on clinical presentation, diagnostic criteria and treatment outcome of TB in Ethiopian children.

METHODS

A prospective cohort study of children with TB diagnosed in Addis Ababa from December 1995 to January 1997 in which HIV-positive children were compared with HIV-negative children with regard to medical history, signs and symptoms, nutritional status, chest radiography, tuberculin skin test, response to TB treatment and final outcome. Mycobacterium tuberculosis was cultured in children with pulmonary manifestations.

RESULTS

HIV-positive children were younger, were underweight and had a 6-fold higher mortality than HIV-negative children. The tuberculin skin test was less sensitive and chest radiography was less specific in HIV-infected patients. Adherence to treatment was high (96%), and the cure rate was 58% for HIV-positive and 89% for HIV-negative TB patients.

CONCLUSION

HIV-positive children are at risk of diagnostic error as well as delayed diagnosis of TB. TB manifestations are more severe and progression to death is more rapid than in HIV-negative children. Weight for age may be used to identify children at high risk of a fatal outcome.

Impact of human immunodeficiency virus type 1 infection on the epidemiology and outcome of bacterial meningitis in South African children

OBJECTIVE

To define the impact that the human immunodeficiency virus type 1 (HIV-1) epidemic has had on the burden and outcome of bacterial meningitis in an area with a high prevalence of pediatric HIV-1 infection.

METHODS

Children less than 12 years of age with proven or suspected bacterial meningitis were enrolled in this study between March 1997 and February 1999, and their hospital records were retrospectively reviewed for clinical data.

RESULTS

Sixty-two (42.2%) of the 147 children tested for HIV-1 infection were infected. Streptococcus pneumoniae (Pnc) exceeded Haemophilus influenzae type b (Hib) as the most important cause of meningitis in HIV-1-infected (74.2% vs. 12.9%, respectively) compared with uninfected children (29.4% vs. 42.3%, respectively, P less than 10(-5)). The estimated relative risk of Pnc meningitis was greater in HIV-1-infected than in uninfected children under 2 years of age (relative risk [RR] = 40.4; 95% confidence intervals [CI] = 17.7-92.2). Overall, HIV-1-infected children had a higher rate of mortality than uninfected children (30.6% vs. 11.8%, respectively, P = 0.01), and in particular, HIV-1-infected children with Pnc meningitis (60.8% vs. 36.0%, respectively, P = 0.04) had a poorer outcome.

CONCLUSIONS

Streptococcus pneumoniae has exceeded Hib as the most important pathogen causing bacterial meningitis in HIV-1-infected compared with uninfected children. Effective vaccination against Hib and Pnc should be evaluated to reduce the overall burden of bacterial meningitis in HIV-1-infected children.

Efficacy of a less-sensitive enzyme immunoassay (3A11-LS) for early diagnosis of human immunodeficiency virus Type 1 infection in infants

We evaluated a less-sensitive enzyme immunoassay (3A11-LS) for its possible use for early diagnosis of human immunodeficiency virus type 1 (HIV-1) infection in infants. The results were compared with those from the immunoglobulin G-capture enzyme immunoassay. A total of 239 sera from 77 infants were tested. All 25 sera from the 10 infants born to seronegative mothers were found to be negative by both assays. Forty-one seroreverting infants showed a complete decay of maternal antibodies by 4 months by the 3A11-LS assay. However, the assay detected HIV antibodies in only 9 (36%) of 25 sera collected from infected infants between 4 and 6 months and in 27 (63%) of 43 sera collected after 6 months of age. Further analysis with alternative cutoff values indicated that the 3A11-LS had a sensitivity of 12 to 44% and a specificity of 90 to 100% for infants between 4-6 months of age. This data suggest that a diagnosis of HIV infection in some of the infants could be made after 4 months of age by the 3A11-LS assay, although a negative 3A11-LS test result may not rule out infection and may require a further followup.

Genetic diversity and molecular epidemiology of respiratory syncytial virus over four consecutive seasons in South Africa: identification of new subgroup A and B genotypes

The molecular epidemiology of respiratory syncytial virus (RSV) was studied over four consecutive seasons (1997-2000) in a single tertiary hospital in South Africa: 225 isolates were subgrouped by RT-PCR and the resulting products sequenced. Subgroup A predominated in two seasons, while A and B co-circulated approximately equally in the other seasons. The nucleotide sequences of the C-terminal of the G-protein were compared to sequences representative of previously defined RSV genotypes. South African subgroup A and subgroup B isolates clustered into four and five genotypes respectively. One new subgroup A and three new subgroup B genotypes were identified. Different genotypes co-circulated in every season. Different circulation patterns were identified for group A and B isolates. Subgroup A revealed more variability and displacement of genotypes while subgroup B remained more consistent.

Epidemiologic and clinical features of HIV-infected and HIV-uninfected Ugandan children younger than 18 months

METHODS

Groups of HIV-infected and HIV-uninfected infants younger than 18 months (mainly younger than 6 months) were compared to identify clinical features that could differentiate the two groups. The HIV-infected group also was compared with HIV-infected children older than 18 months. Recruitment was as follows for the group younger than 18 months: 708 children admitted with sepsis and clinical features suggestive of HIV infection were screened for HIV1 and HIV2 by HIV enzyme-linked immunosorbent assay (ELISA), and polymerase chain reaction (PCR) was undertaken on all ELISA-seropositive blood samples (270). HIV infection was confirmed in 136 (19.2%), 438 (61.9%) were HIV-seronegative, 27 (3.8%) were HIV seroreverters, 36 (5.1%) were HIV-seropositive but PCR negative (uninfected), and 71 (10.0%) were indeterminate. One hundred thirty-six HIV-infected children were compared with 501 uninfected children. Confirmed HIV-infected children older than 18 months attending the pediatric HIV clinic were compared with the 136 HIV-infected children younger than 18 months.

RESULTS

Under 18 months, the median age of HIV-infected children (n = 136) was 4.0 months (range, 3 d -18 mo ) and the median age of the uninfected children (n = 501) was 1.0 month (range, 3 d -18 mo ). HIV-infected children were more likely to have had injections, chloroquine, and nystatin, and to have attended a health center or hospital (p <.001). In the HIV-infected group, the Z score for weight-for-age was -1.75, length-for-age -0.78, and weight-for-length 1.86, significantly lower scores than those of the uninfected group, which were -0.60, -0.23, and 3.05, respectively (p <.05). The mean head circumference was below the third percentile in 40% of HIV-infected compared with 22% of uninfected children (p <.001). Overall, 56 (8%) children had marasmus, 6 (0.8%) kwashiorkor, and 3 (0.4%) marasmic kwashiorkor. Sixteen percent of the HIV-infected and 7% of uninfected children had marasmus (p <.05). The 1989 revised World Health Organization clinical criteria for diagnosis of AIDS had sensitivity, specificity, and positive predictive values of 28%, 98%, and 93%, respectively. Older than 18 months (n = 109), the median age was 24 months (range, 18-60 mo ). The following were significantly more common in HIV-infected children older than 18 months than in those younger than 18 months: bacille Calmette-Guérin vaccination scar, parotid enlargement, nonspecific generalized dermatitis, and chronic diarrhea ( p <.001). Oral candidiasis was more common in the group younger than 18 months (p <.001). In infants examined in the hospital for infective conditions, oropharyngeal candidiasis, ear discharge, dermatologic disorders, generalized lymphadenopathy, lobar consolidation, hepatosplenomegaly, and failure to thrive, especially marasmus, were important indicators of HIV infection.

18-Month mortality and perinatal exposure to zidovudine in West Africa

OBJECTIVES

To study mortality in African children born to HIV-1-infected mothers exposed peripartum to zidovudine.

METHODS

A randomized placebo-controlled trial in Abidjan and Bobo-Dioulasso. Pregnant women received either 300 mg zidovudine twice daily from 36-38 weeks' gestation, 600 mg during labour, and 300 mg twice daily for 7 days post-partum or a matching placebo. Determinants of mortality were studied up to 18 months, overall and among the infected children: treatment, centre, timing of infection, mother and child HIV disease.

RESULTS

There were 75 infant deaths among 407 live births. The risk of death at 18 months was 176/1000 in the zidovudine arm and 221 for placebo. Relative hazard (RH, zidovudine versus placebo) was 0.47 [95% confidence interval (CI) 0.2-1.0] up to 230 days of life. Maternal CD4 lymphocyte count < 200/mm3 (RH 2.92; CI 1.4-6.1) and child HIV-1 infection (RH 12.6; CI 6.6-24.3) increased mortality of all children born to HIV-1-infected mothers. There were 101 children infected (40 in the zidovudine group), and 51 died. Their 18 month probability of death was 590/1000 in the zidovudine group and 510 in the placebo group. Among infected children, maternal zidovudine reduced the risk of death on or before day 230 (RH 0.18; CI 0.1-0.5). Maternal CD4 lymphocyte count < 200/mm3 (RH 3.25; CI 1.3-8.4), maternal death (RH 9.65; CI 1.7-56.0), diagnosis of paediatric infection on or before day 12 (RH 18.1; CI 4.8-69.0) and between days 13 and 45 (RH 7.63; CI 2.0-29.5), clinical paediatric AIDS (RH 5.37; CI 2.3-12.7) were risk factors for death in HIV-1-infected children.

CONCLUSION

Mother-to-child transmission reduction by zidovudine is safe and beneficial to African children. The mortality of HIV-1-infected children is high. Peripartum maternal zidovudine exerts a protective effect for at least 8 months.

Expedited human immunodeficiency virus testing of mothers and newborns with unknown HIV status at time of labor and delivery

New York State introduced the first statewide program in the U.S. of expedited HIV testing (48-hour turn-around results) of mothers with unknown HIV status at the time of labor or delivery and their newborns on August 1, 1999. We evaluated the results of this program during its first 5 months at Lincoln Medical and Mental Health Center (Lincoln Hospital) in the Bronx, New York. There were 1,274 total live birth deliveries between August 1 and December 31, 1999. The HIV infection status of 539 mothers (42.3%) was unknown to medical providers in the labor-delivery suite, either due to lack of testing during the current pregnancy or unavailability of HIV documentation at the time of delivery. During labor and delivery, a total of 462 (85.7%) mothers with unknown HIV status consented to expedited HIV testing (Single Use Diagnostic System for HIV-1 antibody or SUDS). The newborns of 77 mothers (14.3%) who did not consent were tested immediately after birth. Seventeen tested positive for HIV-1 antibody by the SUDS test. The results of 10 of these infants (58.8%) were subsequently confirmed positive for HIV-1 antibody by Western Blot analysis. This new rapid HIV testing program facilitated early diagnosis of these previously unknown HIV-exposed infants, although the low positive predictive value of the test in our community calls for careful communication of these results pending confirmation.

Differing manifestations of respiratory syncytial virus-associated severe lower respiratory tract infections in human immunodeficiency virus type 1-infected and uninfected children

BACKGROUND

Respiratory syncytial virus (RSV) causes increased morbidity and mortality in immunocompromised children. The outcome of RSV-associated lower respiratory tract infections (LRTI) in HIV-infected children, is less well described.

METHODS

Children from a prospective study evaluating the etiology of

Morbidity among human immunodeficiency virus-1-infected and -uninfected African children

OBJECTIVE

To assess patterns of morbidity and associated factors in late infancy and early childhood among human immunodeficiency virus (HIV)-infected and -uninfected African children.

DESIGN

Prospective study.

SETTING

The Queen Elizabeth Central Hospital, Blantyre, Malawi.

PARTICIPANTS

Children with known HIV status from an earlier perinatal intervention trial were enrolled during the first year of life and followed to approximately 36 months of age.

OUTCOME MEASURES

Morbidity and mortality information was collected every 3 months by a questionnaire. A physical examination was conducted every 6 months. Blood to determine CD4(+) values was also collected. Age-adjusted and Kaplan-Meier analyses were performed to compare rates of morbidity and mortality among infected and uninfected children.

RESULTS

Overall, 808 children (190 HIV-infected, 499 HIV-uninfected but born to infected mothers, and 119 born to HIV-uninfected mothers) were included in this study. Of these, 109 died during a median follow-up of 18 months. Rates of childhood immunizations were high among all children (eg, lowest was measles vaccination [87%] among HIV-infected children). Age-adjusted morbidity rates were significantly higher among HIV-infected than among HIV-uninfected children. HIV-infected children were more immunosuppressed than were uninfected children. By 3 years of age, 89% of the infected children died, 10% were in HIV disease category B or C, and only approximately 1% were without HIV symptoms. Among HIV-infected children, median survival after the first occurrence of acquired immunodeficiency syndrome-related conditions, such as splenomegaly, oral thrush, and developmental delay, was <10 months. These same conditions, in addition to frequent bouts of fever, were the main morbidity predictors of mortality.

CONCLUSIONS

The frequency of diseases was high, and progression from asymptomatic or symptomatic HIV disease to death was rapid. Management strategies that effectively reduce morbidity for HIV-infected children are needed.

Impact of human immunodeficiency virus type 1 on the disease spectrum of Streptococcus pneumoniae in South African children

BACKGROUND

HIV-infected children are at increased risk of developing invasive Streptococcus pneumoniae disease.

OBJECTIVE

To determine the impact of the HIV epidemic on the epidemiology of invasive pneumococcal disease in hospitalized African children.

METHODS

Children <12 years of age with invasive pneumococcal disease were enrolled between March, 1997, and February, 1999.

RESULTS

The seroprevalence of HIV was 64.9% (146 of 225). In children with pneumococcal isolates from serogroups 6, 9, 14, 19 or 23 (pediatric serogroups), pneumonia and pneumonia with concurrent meningitis was more common in HIV-infected children (P = 0.03 and P = 0.003, respectively), whereas septic shock occurred more often in HIV-uninfected children (P = 0.0003). The overall burden of severe invasive pneumococcal disease was 41.7 (95% confidence interval, 26.5 to 65.6) fold increased in HIV-infected compared with HIV-uninfected children. Reduced susceptibility to penicillin (45.91% vs. 27.9%, P = 0.009), trimethoprim-sulfamethoxazole (44.5% vs. 19.0%, P = 0.0002) and multiple drug resistance was more common in HIV-infected than in HIV-uninfected children (24.0% vs. 6.4%, P = 0.01), respectively. The increased burden of disease and reduced antibiotic susceptibility of pneumococcal isolates in HIV-infected children was because of a heightened susceptibility to disease caused by pediatric serogroups in these children than in HIV-uninfected children (P = 0.01). Although the case fatality rates did not differ between HIV-infected and -uninfected children, mortality in HIV-infected children with advanced AIDS (Stage C, 22 of 61; 36.1%) was greater than that in children with moderate AIDS (Stage B, 12 of 85; 14.1%, P = 0.002).

CONCLUSIONS

In children with invasive pneumococcal disease caused by the pediatric serogroups, HIV-infected children have more antibiotic-resistant isolates and have a different clinical presentation than do HIV-uninfected children.

HIV infection and in-hospital mortality at an academic hospital in South Africa

AIM

To document the impact that rapid increases in HIV infection in hospitalised children at Chris Hani Baragwanath Hospital has had on in-hospital mortality.

METHODS

Hospital discharge summaries from January 1992 to the end of 1996 were reviewed.

RESULTS

There were 20 733 admissions in the five year period; 7985 (39%) were tested for HIV. In tested admissions above 15 months of age, 4.9% were HIV infected in 1992, increasing to 35% in 1996. Under 15 months of age, 9% of tested admissions were positive in 1992, increasing to 46% in 1996. The proportion of all hospital deaths occurring in children considered HIV infected (ELISA testing together with clinical features if 15 months or younger) increased from 6.7% in 1992 to 46. 1% in 1996 (p < 0.001). In-hospital mortality for all children increased by 21% from 4.3% in 1992 to 5.2% in 1996. Mortality rates declined in uninfected children from 5.4% in 1992 to 4.5% in 1996 (chi(2) trend 3.3; p = 0.06).

CONCLUSION

The mortality rate of children has increased at Chris Hani Baragwanath Hospital as a result of HIV infection. Almost half the deaths were HIV related in 1996. HIV infection is threatening the advances that have been made on child survival in South Africa over the last few decades.

Increased burden of respiratory viral associated severe lower respiratory tract infections in children infected with human immunodeficiency virus type-1

OBJECTIVES

To determine the burden of viral associated severe lower respiratory tract infections (SLRTI) in human immunodeficiency virus-infected (HIV+) and HIV-uninfected (HIV-) urban black South African children.

METHODS

Children with SLRTI aged 2 to 60 months were enrolled between March 1997 and March 1998. Monoclonal antibody immunofluorescent testing was performed on nasopharyngeal aspirates to detect respiratory syncytial virus (RSV), influenza A and B, parainfluenza 1-3, and adenovirus-specific antigens.

RESULTS

Of the 990 children studied, 44.6% were HIV+. The estimated burden of disease of viral associated SLRTI in children under 2 years was increased for RSV, influenza A/B viruses, parainfluenza 1-3 viruses, and adenovirus in children who were HIV+ compared with children who were HIV- (P <.001). Viral pathogens, however, were identified less frequently (15.7% vs 34.8%, P < 10(-5)) and bacterial pathogens more frequently (12.5% vs 5.8%, P <.0001) in children who were HIV+ than in children who were HIV- and had SLRTI. The seasonal peak for RSV in late summer-early autumn observed in children who were HIV- was less evident in children who were HIV+ (P =.02). Children who were HIV+ and had virus-associated SLRTI had a higher mortality rate (7. 5%) than did children who were HIV- (0%, P < 10(-3)).

CONCLUSIONS

The contribution of viral associated SLRTI differs between HIV+ and HIV- children. In HIV+ children in South Africa, RSV isolation is not limited by season.

Increased disease burden and antibiotic resistance of bacteria causing severe community-acquired lower respiratory tract infections in human immunodeficiency virus type 1-infected children

To improve the management of lower respiratory tract infections (LRTI) in human immunodeficiency virus type 1 (HIV-1)-infected children, we assessed the burden of disease, clinical outcome and antibiotic susceptibility of bacteria causing severe community-acquired LRTI in children. A prospective, descriptive study was performed in the pediatric wards at a secondary and tertiary care hospital in South Africa. Urban black children aged 2-60 months admitted with severe acute LRTI from March 1997 through February 1998 were enrolled. HIV-1 infection was present in 45.1% of 1215 cases of severe LRTI. Bacteremia occurred in 14.9% of HIV-1-infected and in 6.5% of HIV-1-uninfected children (P<.00001). The estimated relative incidence of bacteremic severe LRTI in children aged from 2 to 24 months were greater in HIV-1-infected than in -uninfected children for Streptococcus pneumoniae (risk ratio [RR], 42.9; 95% confidence interval [CI], 20.7-90.2), Haemophilus influenzae type b (RR, 21.4; 95% CI, 9.4-48.4), Staphylococcus aureus (RR, 97.9; 95% CI, 11.4-838.2) and Escherichia coli (RR, 49.0; 95% CI, 15.4-156). Isolation of Mycobacterium tuberculosis was also more common in HIV-1-infected than in -uninfected children (RR, 22.5; 95% CI, 13.4-37.6). In HIV-1-infected children, 60% of S. aureus and 85.7% of E. coli isolates were resistant to methicillin and trimethoprim-sulfamethoxazole, respectively. The case-fatality rates among HIV-1-infected children was 13.1%, and among HIV-1-uninfected children, 2.1% (adjusted odds ratio [AOR]; 6.52, 95% CI, 3.53-12.05; P<.00001). The changing spectrum of bacteria and antibiotic susceptibility patterns in HIV-1-infected children requires a reevaluation of the empirical treatment of community-acquired severe LRTI in children from developing countries with a high prevalence of childhood HIV-1 infection.

Prevention and treatment of perinatal HIV-1 infection in the developing world

Measures to reduce mother-to-child transmission of HIV-1 are discussed according to the presumed timing of transmission. Long course antiretrovirals can substantially decrease intrauterine transmission. Antiretrovirals and caesarean section reduce vertical transmission by preventing intrapartum transmission; but caesarean section is unsuitable for most developing countries. Short and very short course antiretrovirals have an efficacy rate of about 50% in non-breastfeeding populations compared with just under 40% at 6 months and between 23 and 30% at 15-24 months in breastfeeding women. The latter is due to the fact that postnatal transmission occurs as long as breastfeeding continues. Breastfeeding accounts for a third to a half of overall transmission. Exclusive rather than mixed breastfeeding appears to diminish the risk of transmission, and HIV-infected women who choose to breastfeed should be advised to give breastmilk exclusively for a maximum of 5-6 months.

Preventing mother-to-child transmission of HIV-1 in Africa in the year 2000

OBJECTIVES

Various approaches to preventing mother-to-child transmission (MTCT) of HIV have recently been, or are being, evaluated in developing countries, especially in Africa. New findings from these trials are now becoming available, the implications of which, for population-based intervention programmes, need urgent consideration.

METHOD

A critical review of 18 randomized trials and other relevant studies from developing and industrialized countries.

RESULTS

Most African results relate to trials of antiretroviral agents (ARV). They demonstrate efficacy in reducing transmission in the first 6 months of life with short regimens of zidovudine (ZDV), with or without lamivudine (3TC), and nevirapine (NVP) alone. Preliminary results suggest the long-term efficacy of zidovudine. Antiseptic and nutritional interventions have been shown to reduce maternal and infant mortality and morbidity but not MTCT of HIV. HIV confidential voluntary counselling and testing for pregnant women, a short regimen of peripartum ARV with alternatives to breastfeeding such as early weaning or breast milk substitutes from birth currently represent the best option to reduce MTCTof HIV in Africa. However, the prevention of postnatal transmission requires further research, particularly in view of the consequences of different feeding options and the possibility of post-perinatal exposure prophylaxis of newborns with ARV. Issues relating to the implementation of currently validated strategies are discussed.

Immunopathological factors for vertical transmission of HIV-1

With the global rise in human immunodeficiency virus-1 (HIV-1) infection in women of childbearing age, there has also been an alarming rise in the number of mother-to-child transmissions of HIV-1. Although drug therapies such as zidovudine as well as nevirapine have been demonstrated to significantly decrease the incidence of vertical transmission of HIV-1, these therapeutic regimens are still not widely available in some developing countries where maternal-to-child transmission of HIV-1 continues to occur at an alarming rate. Therefore, the continued studies of mechanisms and correlates of vertical transmission of HIV-1 are warranted. The current status of immunological and virological correlates of vertical transmission are summarized in this review. In addition, information concerning recent therapeutic agents for the prevention of HIV-1 vertical transmission is presented.

Caring for the child and family with HIV disease

Caring for children with HIV infection is a much more optimistic process than in the beginning of the epidemic. Antiretroviral therapies are available, and additional drugs are receiving approval from the US Food and Drug Administration. Cautious optimism must be tempered with an understanding that living with the disease is a complicated and daunting process for these children and their families. Although scientific knowledge and medical treatments are moving forward, the social and environmental uncertainties remain for families. Comprehensive care is a balance of health care services and supportive, community-based services offered in a compassionate manner.

Clinical presentation and outcome of Pneumocystis carinii pneumonia in Malawian children

BACKGROUND

Necropsy studies from Africa have shown that Pneumocystis carinii pneumonia (PCP) is common in infants with HIV infection. We aimed to describe the rate, clinical presentation, and outcome of PCP in young Malawian children with acute severe pneumonia.

METHODS

Children aged between 2 months and 5 years who were in hospital with a diagnosis of severe pneumonia were admitted to a study ward for clinical monitoring. We carried out blood culture, immunofluorescence on nasopharyngeal aspirate samples to test for PCP, polymerase chain reaction to detect HIV, and chest radiography.

FINDINGS

16 cases of PCP were identified among 150 children with radiologically confirmed severe pneumonia. All were HIV-positive and younger than 6 months. 21 children had bacterial pneumonia (including one who was also PCP positive) and 114 were not confirmed. The most common bacterial pathogens among children without PCP were Streptococcus pneumoniae (eight) and non-typhoidal salmonellae (seven). On admission, children with confirmed PCP had a lower mean age, body temperature, and oxygen saturation than children with bacterial pneumonia and were less likely to have a focal abnormality on auscultation. Oxygen requirements were much greater in children with PCP than those with bacterial pneumonias (96 of 105 hospital days vs 15 of 94, p<0.0001). Ten of 16 children with PCP and six of 21 with bacterial pneumonia died (relative risk 2.19 [95% CI 1.0-4.7]). The overall case-fatality rate of severe pneumonia was 22%. In addition to a strong association with PCP, a fatal outcome was significantly and independently associated with HIV infection (2.98 [1.1-7.9]) and with age under 6 months (2.76 [1.0-5.2]).

INTERPRETATION

PCP is common and contributes to the high mortality from pneumonia in Malawian infants. Clinical features are helpful in diagnosis. The study highlights the impact of HIV infection and difficult issues of management in countries with few resources.

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.

Pulmonary manifestations of pediatric HIV infection

Vertically acquired HIV infection is becoming increasingly common in India. The main clinical manifestations of HIV in childhood are growth failure, lymphadenopathy, chronic cough and fever, recurrent pulmonary infections, and persistent diarrhoea. Pulmonary disease is the major cause of morbidity and mortality in pediatric AIDS, manifesting itself in more than 80% of cases. The most common causes are Pneumocystis carinii pneumonia (PCP), lymphocytic interstitial pneumonitis (LIP), recurrent bacterial infections which include bacterial pneumonia and tuberculosis. The commonest AIDS diagnosis in infancy is PCP, presenting in infancy with tachypnea, hypoxia, and bilateral opacification on chest-X-ray (CXR). Treatment is with cotrimoxazole. LIP presents with bilateral reticulonodular shadows on CXR. It may be asymptomatic in the earlier stages, but children develop recurrent bacterial super infections, and can progress to bronchiectasis. LIP is a good prognostic sign in children with HIV infection in comparison to PCP. HIV should be considered in children with recurrent bacterial pneumonia, particularly with a prolonged or atypical course, or a recurrence after standard treatment. Pulmonary TB is common in children with HIV, but little data is available to guide treatment decisions. Much can be done to prevent PCP and bacterial infections with cotrimoxazole prophylaxis and appropriate immunisations, which may reduce hospital admissions and health care costs.

Natural history of human immunodeficiency virus type 1 infection in children: a five-year prospective study in Rwanda. Mother-to-Child HIV-1 Transmission Study Group

OBJECTIVE

To compare morbidity and mortality of human immunodeficiency virus type 1 (HIV-1)-infected and HIV-1-uninfected children and to identify predictors of acquired immunodeficiency syndrome (AIDS) and death among HIV-1-infected children in the context of a developing country.

DESIGN

Prospective cohort study.

SETTING

Maternal and child health clinic of the Centre Hospitalier de Kigali, Rwanda.

PARTICIPANTS

Two hundred eighteen children born to HIV-1-seropositive mothers and 218 born to seronegative mothers of the same age and parity were enrolled at birth.

OUTCOME MEASURES

Deaths, clinical AIDS, nonspecific HIV-related manifestations, and use of health care services.

RESULTS

Fifty-four infected and 347 uninfected children were followed up for a median of 27 and 51 months, respectively. With the exception of chronic cough, the risk of occurrence of nonspecific HIV-related conditions was 3 to 13 times higher in infected than in uninfected children. The recurrence rate and severity of these findings were increased systematically in infected infants. Estimated cumulative risk of developing AIDS was 28% and 35% at 2 and 5 years of age, respectively. Estimated risk of death among infected children at 2 and 5 years of age was 45% and 62%, respectively, a rate 21 times higher than in uninfected children. Median survival time after estimated infection was 12.4 months. Early infection, early onset of HIV-related conditions, failure to thrive, and generalized lymphadenopathy were associated with subsequent risk of death and/or AIDS, whereas lymphoid interstitial pneumonitis was predictive of a milder disease.

CONCLUSIONS

In Africa, HIV-1-infected children develop disease manifestations early in life. Specific clinical findings are predictive of HIV-1 disease, AIDS stage, and death. Bimodal expression of HIV-1 pediatric disease is encountered in Africa, as in industrialized countries, but prognosis is poorer. human immunodeficiency virus infection, children, vertical transmission, natural history, Africa.

Mortality after the first year of life among human immunodeficiency virus type 1-infected and uninfected children

BACKGROUND

HIV-infected and uninfected children who survived their first year of life were prospectively followed in Malawi to assess levels of mortality and related risk factors during the second and third years of life.

METHODS

Children with known HIV status from an earlier perinatal intervention trial were enrolled. These children [HIV-infected (Group A); HIV-uninfected but born to HIV-seropositive mothers (Group B); and children born to HIV-seronegative mothers (Group C)] were followed every 3 months until age 36 months. Mortality data were collected at each visit. Immunologic data (CD4+ percent) were collected at or immediately after enrollment.

RESULTS

Overall 702 children were enrolled and 83 children died during follow-up. The mortality rate per 1000 person years of observation was 339.3 among Group A children, 46.3 among Group B children and 35.7 among Group C children. Among HIV-infected children the cumulative proportion surviving to age 24 months was 70% and those surviving to age 36 months was 55%. By age 32 months none of the severely immunosuppressed (CD4% < 15%) children had survived. The mortality differentials between HIV-infected and uninfected children persisted after adjusting for several risk factors. The major causes of death among infected children (n = 52) were wasting and respiratory conditions.

CONCLUSIONS

Although all HIV-infected children had received childhood immunizations, mortality was high. Management of these children should include aggressive antimicrobial treatment, and evaluation of prophylactic regimens should be considered.

The return of tuberculosis

At the end of the 20th century, tuberculosis remains a major public health issue. In developing countries tuberculosis is a leading cause of morbidity and mortality, and the spread of the HIV epidemic contributes significantly to the worsening of the situation. Coinfection with tuberculosis and HIV results in special diagnostic and therapeutic problems and uses up larger amounts of medical resources in developing countries. Outbreaks of multidrug resistant tuberculosis (MDR-TB) were first reported from US-American centers caring for HIV patients, but have now been observed in many other countries. In Western Europe the tuberculosis epidemic is under control, but increasing incidence rates in migrants raise new problems in these countries. Tuberculosis is uncontrolled in large parts of the former Soviet Union due to the socio-economic break-down in these countries. Only rigorous infection control measures on a world-wide scale will prevent further detoriation of this situation. Therefore, the extension of surveillance systems, and sufficient funding for the prevention, diagnosis, and treatment of tuberculosis by national governments and international organizations are all urgently needed.