Timing of perinatal human immunodeficiency virus type 1 infection and rate of neurodevelopment. The Women and Infant Transmission Study Group

Neurocognitive Lag in School-Aged Children Living With HIV in India and Its Relevance

Objective

Objective assessment of neurocognitive lags in pediatric HIV patients and its correlation with various clinical, social and familial factors.

Methods

Ninety-eight school-aged children living with HIV (CLHIV) (age 7-18 years) attending regional pediatric HIV clinic were observed for neurocognitive lag using Raven’s Standard Progressive Matrices by the same trained instructor. Sociodemographic data, mode of transmission, clinical staging, CD4 count, highly active antiretroviral therapy (HAART) duration were recorded and analyzed in the well-performing group and under-performing group.

Results

29.6% of children had definitive neurocognitive lag. The proportion of older children (11-18 years) in the under-performing group was significantly high (P = 0.007). The mean CD4 counts were low in the under-performing group (P = 0.001). Other socioeconomic factors could not be specifically correlated with neurocognitive lag in either of the groups.

Conclusion

CLHIV has a significant neurocognitive lag, which is accentuated in the upper age group. Findings point toward declining intellectual gains with increasing age in CLHIV.

Propelling the Pediatric HIV Therapeutic Agenda With Science, Innovation, and Collaboration

BACKGROUND

A number of well-described obstacles to the pediatric therapeutic agenda have resulted in substantial delays in the introduction of new medications, formulations, strategies, and approaches to treat infants, children, and adolescents living with HIV.

SETTING

Global landscape.

METHODS

The authors will provide a summary of current and emerging initiatives to accelerate the pediatric therapeutic agenda including illustrative case studies of innovations and scientific discovery in diagnosis and treatment of very young children with HIV infection.

RESULTS

The challenges posed by rapid physiologic and developmental changes that characterize the trajectory of childhood as well as the complex regulatory and fiscal milieu of HIV therapeutics have hampered pediatric HIV therapeutic research. Recent efforts to accelerate this agenda include prioritizing agents and formulations, defining dosing by weight bands, applying innovative study designs, synergizing work across research networks to achieve common goals, and the establishment of a global prioritized research agenda. A case study of initiatives to diagnose and effectively treat newborns and infants will illustrate the critical role of basic science research and novel approaches to study design and implementation that are informing global efforts to end AIDS.

CONCLUSIONS

A pediatric therapeutic agenda informed by basic science and achieved through innovation and global cooperation is essential to achieve an AIDS-free generation.

Neurodevelopmental assessment of HIV-exposed uninfected and early-treated HIV-infected children: study protocol

Objective

Sub-Saharan Africa has the highest prevalence of children at risk of not achieving their developmental potential, attributable largely to the human immunodeficiency virus (HIV) pandemic coupled with negative environmental factors. Childhood developmental stimulation programmes can mitigate adverse outcomes.

Methods

Neonates testing HIV positive at birth will be initiated on antiretroviral treatment (ART) and receive an age-appropriate stimulation program, updated at 3 monthly intervals through the first year of life. Neurodevelopment at 12 months of age will be assessed using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III). Outcomes will be compared with HIV-infected and HIV-exposed uninfected children (HEU) not having received the stimulatory intervention. Associations between neurodevelopmental outcomes, environmental factors, and parental stress will be investigated. The study will take place at a single site in Johannesburg, South Africa. This non-randomised controlled intervention study, with a single non-blinded comparative intervention group, aims to investigate whether an early childhood stimulation programme used in conjunction with ART initiated at birth can positively impact neurodevelopmental outcomes at 1 year of age in children infected with HIV.

Trial registration 15 January 2018, Pan African Clinical Trial Registry PACTR201801002967587

Deformed Subcortical Structures Are Related to Past HIV Disease Severity in Youth With Perinatally Acquired HIV Infection

BACKGROUND

Combination antiretroviral therapy has led to increased survival among youth with perinatally acquired HIV (PHIV). However, cognitive deficits continue to be common. Histopathological studies in adults have found HIV concentrated in subcortical structures, which are involved in sensory processing, movement, and higher-order cognition that emerges with development.

METHODS

We conducted magnetic resonance imaging and cognitive testing in 40 youth with PHIV at one site of the Adolescent Master Protocol of the Pediatric HIV/AIDS Cohort Study. We collected HIV disease-severity measures and substance-use reports. Subcortical volume and shape deformation were generated with FreeSurfer-Initiated Large Deformation Diffeomorphic Metric Mapping. Inward shape deformation was defined as negative displacement. We evaluated associations of subcortical shape deformation with past HIV severity after adjustment for sex, age at neuroimaging, age at HIV severity marker, and substance use. We examined associations between subcortical deformation and cognitive function.

RESULTS

Negative correlations between shape deformation and peak HIV viral load (VL) were found in clusters in the caudate tail, globus pallidus, lateral putamen, and anterior and medial thalamus. Positive correlations between shape deformation and nadir CD4-positive T-lymphocyte percentage (CD4%) were found in clusters in the medial and posterior thalamus. Inward deformation in caudate and thalamic clusters correlated with worse cognition.

CONCLUSIONS

Youth with PHIV have demonstrable subcortical shape deformation related to past HIV severity and cognition; inward deformation was associated with higher peak VL, lower nadir CD4%, and worse cognition. Identifying subcortical deformation may inform clinical practice for early intervention to help improve cognitive outcomes and assess the neuroefficacy of combination antiretroviral therapy in youth with PHIV.

HIV-associated neurodevelopmental delay: prevalence, predictors and persistence in relation to antiretroviral therapy initiation and viral suppression

CONTEXT

HIV infection in infancy may influence the developing brain, leading to adverse neurodevelopmental consequences.

OBJECTIVE

We aim to describe neurodevelopmental characteristics of a cohort of HIV-infected infants and young children prior to antiretroviral therapy (ART) initiation and after achieving viral suppression.

METHODS

As part of the Neverest 2 trial, 195 HIV-infected children under 2 years of age were assessed using the Ages and Stages Questionnaire (ASQ) prior to ART initiation and at subsequent age-appropriate time points after ART had been started. The ASQ is a simple screening questionnaire used to identify children at risk of neurodevelopmental delays. Questionnaires completed by the parent/caregiver assess neurodevelopmental functioning in five domains: communication, gross motor, fine motor, problem solving and personal-social.

RESULTS

Median age pre-ART was 8.8 months (range 2.2-24.9) and 53.9% were male. Mean time to viral suppression was 9.4 months (range 5.9-14.5). Compared with pre-ART better outcomes were reported at time of viral suppression with a lower proportion of children failing the gross motor (31.5% vs. 13%, p = 0.0002), fine motor (21.3% vs. 10.2%, p = 0.017), problem solving (26.9% vs. 9.3%, p = 0.0003) and personal-social (19.6% vs. 7.4%, p = 0.019) domains. However, there was no change in the communication domain (14.8% vs. 12.0%, p = 0.6072).

CONCLUSION

Although achieving viral suppression on ART resulted in significant improvements in markers of neurodevelopmental function of young HIV-infected children, potential neurodevelopmental delays still persisted in a large proportion. Further interventions are needed to limit potential disabilities and maximize developmental outcomes.

Head circumferences of children born to HIV-infected and HIV-uninfected mothers in Zimbabwe during the preantiretroviral therapy era

OBJECTIVES

To describe the head growth of children according to maternal and child HIV infection status.

DESIGN

Longitudinal analysis of head circumference data from 13 647 children followed from birth in the ZVITAMBO trial, undertaken in Harare, Zimbabwe, between 1997 and 2001, prior to availability of antiretroviral therapy (ART) or cotrimoxazole prophylaxis.

METHODS

Head circumference was measured at birth, then at regular intervals through 24 months of age. Mean head circumference-for-age Z-scores (HCZ) and prevalence of microcephaly (HCZ < -2) were compared between HIV-unexposed children, HIV-exposed uninfected (HEU) children and children infected with HIV in utero (IU), intrapartum (IP) and postnatally (PN).

RESULTS

Children infected with HIV in utero had head growth restriction at birth. Head circumference Z-scores remained low throughout follow-up in IP children, whereas they progressively declined in IU children. During the second year of life, HCZ in the PN group declined, reaching a similar mean as IP-infected children by 21 months of age. Microcephaly was more common among IU and IP children than HIV-uninfected children through 24 months. HEU children had significantly lower head circumferences than HIV-unexposed children through 12 months.

CONCLUSION

HIV-infected children had lower head circumferences and more microcephaly than HIV-uninfected children. Timing of HIV acquisition; influenced HCZ, with those infected before birth having particularly poor head growth. HEU children had poorer head growth until 12 months of age. Correlations between head growth and neurodevelopment in the context of maternal/infant HIV infection, and further studies from the current ART era, will help determine the predictive value of routine head circumference measurement.

Developmental status of preschool children receiving cART: a descriptive cohort study

BACKGROUND

HIV is known to cause neurodevelopmental problems in infants and young children. The impact of HIV on the development of preschool-age children has been less well described.

METHOD

The study was conducted at an urban paediatric HIV clinic in Johannesburg, South Africa. A sample of convenience was used. Sixty-eight medically stable children between the ages of 3 and 5 years were assessed with the Griffiths Scales of Mental Development. Children were excluded from the study if they had severe HIV encephalopathy, which made it impossible for them to participate in the items on the Griffiths Scales of Mental Development.

RESULTS

The children had started combination antiretroviral treatment (cART) at a mean age of 8.1 months. The majority of the children were virologically suppressed and did not present with wasting or stunting. Severe overall developmental delay (z-scores < -2SD) was detected in 55.88% of children. Developmental facets related to speech, cognition and perception were the most severely affected. Personal-social development was the least affected with only 13.4% of the children demonstrating severe delay.

CONCLUSION

Despite having early access to cART, children infected with HIV are still at risk for severe developmental delay across a number of facets. Very early initiation of cART may help alleviate this problem. All preschool children infected with HIV should have routine developmental screening.

Correlates of age at attainment of developmental milestones in HIV-infected infants receiving early antiretroviral therapy

BACKGROUND

Infant HIV-1 infection is associated with impaired neurologic and motor development. Antiretroviral therapy (ART) has the potential to improve developmental outcomes but the relative contributions of pre-ART disease status, growth, treatment regimen and ART response during infancy are unknown.

METHODS

Kenyan ART-naive infants <5-months old initiated ART and had monthly assessment of age of full neck control, unsupported walking and monosyllabic speech during 24 months of follow-up. Pre-ART and post-ART correlates of age at milestone attainment were evaluated using t tests or multivariate linear regression.

RESULTS

Among 99 infants, pre-ART correlates of later milestone attainment included: underweight and stunted (neck control, walking and speech, all P values <0.05), missed prevention of mother-to-child transmission (P = 0.04) (neck control), previous hospitalization, World Health Organization (WHO) Stage III/IV, low CD4 count, and wasting (speech and walking, all P values <0.05), and low maternal CD4 (speech, P = 0.04). Infants initiated ART at a median of 14 days following enrollment. Infants receiving nevirapinevs lopinavir/ritonavir-based ART attained later speech (18.1 vs. 15.5 months, P = 0.003) [corrected]. Adjusting for pre-ART level, lower 6-month gain in CD4% was associated with later walking (0.18 months earlier per unit increase in CD4%; P = 0.004) and speech (0.12 months earlier per unit increase in CD4%; P = 0.05), and lower 6-month gains in weight-for-age (P = 0.009), height-for-age (P = 0.03) and weight-for-height (P = 0.02) were associated with later walking.

CONCLUSION

In HIV-infected infants, compromised pre-ART immune and growth status, poor post-ART immune and growth responses, and use of nevirapine- vs. lopinavir/ritonavir-based ART were each associated with later milestone attainment [corrected]. The long-term consequences of these delays are unknown.

Neurologic disease in HIV-infected children and the impact of combination antiretroviral therapy

The prevalence of HIV-associated neurocognitive impairment in perinatally HIV-infected children has declined since the introduction of combination antiretroviral therapy (cART). Early initiation of cART in infancy has been shown to positively impact neurodevelopment; however, children continue to be diagnosed with HIV outside of the early infancy period and can experience subtle to severe neurocognitive deficits despite cART. The causes of these neurocognitive deficits despite effective cART are multifactorial and likely include continued viral replication in the CNS, ongoing neuroinflammation, irreversible CNS injury prior to cART initiation, neurotoxic effects of cART, and socioeconomic and psychosocial effects. Many aspects of our understanding of HIV-associated neurocognitive disorders have emerged from research in adult patients, but perinatally HIV-infected children represent a very different population. These children were exposed to HIV during a period of rapid brain development and have lifelong infection and potential lifelong cART exposure. HIV is no longer a rapidly fatal disease, and most HIV-infected children in resource-rich countries are living into adulthood. It is therefore critical to optimize neurocognitive outcomes of these youth. This review summarizes current understanding of the pathogenesis of HIV-associated CNS infection and the impact of cART on neurocognitive function in children and adolescents and discusses important areas for future research.

Perinatally acquired HIV infection: long-term neuropsychological consequences and challenges ahead

Over the past three decades, perinatal HIV infection in the United States has evolved from a fatal disease to a manageable chronic illness. As the majority of youth with perinatal HIV infection age into adolescence and adulthood, management of this stigmatizing, transmittable disease in the backdrop of a cadre of environmental stressors presents challenges beyond those of other chronic illnesses. The neurologic and neuropsychological consequences of this neurotropic virus have important implications for the successful navigation of responsibilities related to increasingly independent living of this aging population. This article will review the neurologic and neuropsychological consequences of perinatal HIV infection and concomitant factors in the era of highly active antiretroviral therapy and will provide an overview of the neuropathology, pathogenesis, neuroimaging findings, and treatment of perinatal HIV infection, as well as recommendations for service provision and future research.

The impact of HIV on children's education in eastern Zimbabwe

Little is known about how HIV impacts directly and indirectly on receiving, or particularly succeeding in, education in sub-Saharan Africa. To address this gap, we used multivariable logistic regression to determine the correlation between education outcomes in youth (aged 15–24) (being in the correct grade-for-age, primary school completion and having at least five “O” level passes) and being HIV-positive; having an HIV-positive parent; being a young carer; or being a maternal, paternal or double orphan, in five rounds (1998–2011) of a general population survey from eastern Zimbabwe. The fifth survey round (2009–2011) included data on children aged 6–17, which were analysed for the impacts of the above risk factors on regular attendance in primary and secondary schools and being in the correct grade-for-age. For data pooled over all rounds, being HIV-positive had no association with primary school completion, “O” level passes, or being in the correct grade-for-age in adolescents aged 16–17 years. Additionally, HIV status had no significant association with any education outcomes in children aged 6–17 surveyed in 2009–2011. In 2009–2011, being a young carer was associated with lower attendance in secondary school (69% vs. 85%, AOR: 0.44; p = 0.02), whilst being a maternal (75% vs. 83%, AOR: 0.67; p < 0.01), paternal (76% vs. 83%, AOR: 0.67; p = 0.02) or double (75% vs. 83%, AOR: 0.68; p = 0.02) orphan was associated with decreased odds of being in the correct grade-for-age. All forms of orphanhood also significantly decreased the odds of primary school completion in youths surveyed from 1998 to 2011 (all p < 0.01). We found no evidence that HIV status affects education but further evidence that orphans do experience worse education outcomes than other children. Combination approaches that provide incentives for children to attend school and equip schools with tools to support vulnerable children may be most effective in improving education outcomes and should be developed and evaluated.

The burden and predictors of cognitive impairment among 6- to 8-year-old children infected and uninfected with HIV from Harare, Zimbabwe: a cross-sectional study

With long-term survival of children infected with HIV, information on cognitive function at school age is needed. To determine cognitive function among 6- to 8 year-old children exposed to HIV and to assess factors associated with cognitive impairment, we conducted a cross-sectional study from October 2010 to December 2011 among children whose mothers participated in a national HIV prevention program in Harare. Cognitive function was assessed using the McCarthy Scales of Children's Abilities (MSCA). Of the 306 assessed children, 32 (10%) were HIV infected, 121 (40%) exposed uninfected, and 153 (50%) unexposed uninfected. The mean (SD) General Cognitive Index for the whole study group was 82 (15). An overall of 49 (16%) out of the 306 children had cognitive impairment with no difference in general cognitive function among the three groups. Children with HIV infection scored lowest in perceptual performance domain, p = .028. Unemployed caregivers, child orphanhood and undernutrition were associated with impaired cognitive performance in univariate analysis. In multivariate analysis, caregiver unemployment status remained a factor associated with cognitive impairment with an ODDS ratio of 2.1 (95% CI 1.03-3.36). In a cohort of 6- to 8-year-olds, HIV infection did not show evidence of significant difference in general cognitive function. Children infected with HIV had major deficits in perceptive performance. Lower socioeconomic status was associated with cognitive impairment. In resource-constrained settings, strategies aimed at poverty alleviation and good nutritional management should complement early infant diagnosis and treatment of HIV in order to optimize neurocognitive potential.

Motor development of infants exposed to maternal human immunodeficiency virus (HIV) but not infected

BACKGROUND

To assess the motor development of infants exposed to maternal human immunodeficiency virus (HIV).

METHODS

Thirty infants were assessed in the period from November 2009 to March 2010 at the AIDS Reference and Training Centre, in São Paulo, Brazil. The assessment instrument used in the research was the Alberta Infant Motor Scale (AIMS). All 30 infants used the antiretroviral drug properly for 42 consecutive days, in accordance with the protocol of the World Health Organization.

RESULTS

Out of the total number of infants, 27 (90%) had proper motor performance and 3 (10%) presented motor delay, according to the AIMS.

DISCUSSION

This study demonstrated that only 10% of the assessed group had developmental delay and no relation with environmental variables was detected, such as maternal level of education, social and economic issues, maternal practices, attendance at the day care center, and drug use during pregnancy. It is important to emphasize the necessity of studies with a larger number of participants.

Neurocognitive function in HIV-positive children in a developing country

OBJECTIVES

We aimed to characterize neurological outcomes and determine the prevalence of HIV encephalopathy in a cohort of HIV-infected children in Jamaica.

METHODS

Data for 287 HIV-infected children presenting between 2002 and 2008 were reviewed and neurological outcomes characterized. A nested case-control study was conducted between July and September 2009 used 15 randomly selected encephalopathic HIV-infected children aged 7-10 years and 15 matched controls (non-encephalopathic HIV-infected). Their neurocognitive functions were evaluated using clinical assessment and standardized tests for intelligence, short term memory (visuo-spatial and auditory), selective attention, and fine motor and coordination functions. Outcomes were compared using Fisher's exact test and the Mann-Whitney U-test.

RESULTS

Sixty-seven (23.3%) children were encephalopathic. The median age at diagnosis of HIV encephalopathy was 1.6 years (interquartile range (IQR) 1.1-3.4 years). Predominant abnormalities were delayed milestones (59, 88.1%), hyperreflexia (59, 86.5%), spasticity (50, 74.6%), microcephaly (42, 61.7%), and quadriparesis (21, 31.3%). The median age of tested children was 8.7 years (IQR 7.6-10.8 years) in the encephalopathic group and 9 years (IQR 7.4-10.7 years) in the non-encephalopathic group. Encephalopathic children performed worse in all domains of neurocognitive function (p<0.05).

CONCLUSIONS

A high prevalence of HIV encephalopathy was noted, and significant neurocognitive dysfunction identified in encephalopathic children. Optimized management through the early identification of neurological impairment and implementation of appropriate interventions is recommended to improve quality of life.

Neurodevelopment in children born to HIV-infected mothers by infection and treatment status

BACKGROUND

We reviewed the impact of HIV, HIV exposure, and antiretroviral therapy/prophylaxis on neurodevelopmental outcomes of HIV-infected and HIV-exposed-uninfected infants and children.

METHODS

A literature search of Medline, Embase, PsychINFO, Web of Science, PubMed, and conference Web sites (1990-March 2011) using the search terms, infant, child, HIV, neurodevelopment, cognition, language, and antiretroviral therapy, identified 31 studies of HIV/antiretroviral exposure using standardized tools to evaluate infant/child development as the main outcome. Articles were included if results were reported in children <16 years of age who were exposed to HIV and antiretrovirals in fetal/early life, and excluded if children did not acquire HIV from their mothers or were not exposed to antiretrovirals in fetal/early life.

RESULTS

Infants who acquired HIV during fetal and early life tended to display poorer mean developmental scores than HIV-unexposed children. Mean motor and cognitive scores were consistently 1 to 2 SDs below the population mean. Mean scores improved if the infant received treatment before 12 weeks and/or a more complex antiretroviral regimen. Older HIV-infected children treated with highly active antiretroviral therapy demonstrated near normal global mean neurocognitive scores; subtle differences in language, memory, and behavior remained. HIV-exposed-uninfected children treated with antiretrovirals demonstrated subtle speech and language delay, although not universally.

CONCLUSIONS

In comparison with resource-rich settings, HIV-infected and HIV-exposed-uninfected infants/children in resource-poor settings demonstrated greater neurodevelopmental delay compared with HIV-unexposed infants. The effects on neurodevelopment in older HIV-infected children commenced on antiretroviral therapy from an early age and HIV-exposed-uninfected children particularly in resource-poor settings remain unclear.

Impact of HIV severity on cognitive and adaptive functioning during childhood and adolescence

BACKGROUND

The influence of disease severity on cognitive and adaptive functioning in perinatally HIV-infected youth with (PHIV+/C) and without (PHIV+/NoC) a previous AIDS-defining illness (Centers for Disease Control and Prevention Class C event), compared with perinatally HIV-exposed but uninfected youth (PHEU) is not well understood.

METHODS

This was a cross-sectional analysis of cognitive and adaptive functioning in PHIV+/C (n = 88), PHIV+/NoC (n = 270) and PHEU (n = 200) youth aged 7-16 years, from a multisite prospective cohort study. Youth and caregivers completed the Wechsler Intelligence Scale for Children, Fourth Edition and the Adaptive Behavior Assessment System, Second Edition, respectively. We compared means and rates of impairment between groups, and examined associations with other psychosocial factors.

RESULTS

Overall mean scores on measures of cognitive and adaptive functioning were in the low average range for all 3 groups. After adjustment for covariates, mean full-scale intelligence quotient scores were significantly lower for the PHIV+/C group than the PHIV+/NoC and PHEU groups (mean = 77.8 versus 83.4 and 83.3, respectively), whereas no significant differences were observed between the PHEU and PHIV+/NoC groups in any domain. Lower cognitive performance for the PHIV+/C group was primarily attributable to a prior diagnosis of encephalopathy. No significant differences between groups were observed in adaptive functioning.

CONCLUSION

For long-term survivors, youth with HIV infection and a prior Centers for Disease Control and Prevention Class C event have higher risk for cognitive but not adaptive impairment regardless of current health status; this finding appears attributable to a previous diagnosis of encephalopathy. Early preventive therapy may be critical in reducing risk of later neurodevelopmental impairments.

Long-term neurodevelopmental outcomes after intrauterine and neonatal insults: a systematic review

BACKGROUND

Neonatal interventions are largely focused on reduction of mortality and progression towards Millennium Development Goal 4 (child survival). However, little is known about the global burden of long-term consequences of intrauterine and neonatal insults. We did a systematic review to estimate risks of long-term neurocognitive and other sequelae after intrauterine and neonatal insults, especially in low-income and middle-income countries.

METHODS

We searched Medline, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and Embase for studies published between Jan 1, 1966, and June 30, 2011, that reported neurodevelopmental sequelae after preterm or neonatal insult. For unpublished studies and grey literature, we searched Dissertation Abstracts International and the WHO library. We reviewed publications that had data for long-term outcome after defined neonatal insults. We summarised the results with medians and IQRs, and calculated the risk of at least one sequela after insult.

FINDINGS

Of 28,212 studies identified by our search, 153 studies were suitable for inclusion, documenting 22,161 survivors of intrauterine or neonatal insults. The overall median risk of at least one sequela in any domain was 39·4% (IQR 20·0-54·8), with a risk of at least one severe impairment in any insult domain of 18·5% (7·7-33·3), of at least one moderate impairment of 5·0% (0·0-13·3%), and of at least one mild impairment of 10·0% (1·4-17·9%). The pooled risk estimate of at least one sequela (weighted mean) associated with one or more of the insults studied (excluding HIV) was 37·0% (95% CI 27·0-48·0%) and this risk was not significantly affected by region, duration of the follow-up, study design, or period of data collection. The most common sequelae were learning difficulties, cognition, or developmental delay (n=4032; 59%); cerebral palsy (n=1472; 21%); hearing impairment (n=1340; 20%); and visual impairment (n=1228; 18%). Only 40 (26%) studies included data for multidomain impairments. These studies included 2815 individuals, of whom 1048 (37%) had impairments, with 334 (32%) having multiple impairments.

INTERPRETATION

Intrauterine and neonatal insults have a high risk of causing substantial long-term neurological morbidity. Comparable cohort studies in resource-poor regions should be done to properly assess the burden of these conditions, and long-term outcomes, such as chronic disease, and to inform policy and programme investments.

FUNDING

The Bill & Melinda Gates Foundation, Saving Newborn Lives, and the Wellcome Trust.

A prospective study of the onset of sexual behavior and sexual risk in youth perinatally infected with HIV

Perinatally HIV-infected (PHIV+) youth are surviving into adolescence and young adulthood. Understanding the sexual development of PHIV+ youth is vital to providing them with developmentally appropriate HIV-prevention programs. Using pooled data (N = 417) from two longitudinal studies focused on HIV among youth (51% female; 39% HIV+) and their caregivers (92% female; 46% HIV+), the rate of sexual onset during adolescence across four youth-caregiver combinations was compared: PHIV+ youth with HIV+caregivers (12%), PHIV+ youth with HIV- caregivers (27%), HIV- youth with HIV+caregivers (34%), and HIV- youth with HIV- caregivers (27%). Youth with HIV- caregivers were more likely than other youth-caregiver groups to have had their sexual onset. Youth with HIV+ caregivers reported a slower rate of onset of penetrative sex across the adolescent years. Findings are discussed by highlighting the role that both youth and caregiver HIV status play in the onset of sexual behavior across adolescence.

Maternal periodontitis treatment and child neurodevelopment at 24 to 28 months of age

BACKGROUND

Some maternal infections are associated with impaired infant cognitive and motor performance. Periodontitis results in frequent bacteremia and elevated serum inflammatory mediators.

OBJECTIVE

The purpose of this study was to determine if periodontitis treatment in pregnant women affects infant cognitive, motor, or language development.

METHODS

Children born to women who had participated in a previous trial were assessed between 24 and 28 months of age by using the Bayley Scales of Infant and Toddler Development (Third Edition) and the Preschool Language Scale (Fourth Edition). Information about the pregnancy, neonatal period, and home environment was obtained through chart abstractions, laboratory test results, and questionnaires. We compared infants born to women treated for periodontitis before 21 weeks' gestation (treatment group) or after delivery (controls). In unadjusted and adjusted analyses, associations between change in maternal periodontal condition during pregnancy and neurodevelopment scores were tested by using Student's t tests and linear regression.

RESULTS

A total of 411 of 791 eligible mother/caregiver-child pairs participated. Thirty-seven participating children (9.0%) were born at <37 weeks' gestation. Infants in the treatment and control groups did not differ significantly for adjusted mean cognitive (90.7 vs 91.4), motor (96.8 vs 97.2), or language (92.2 vs 92.1) scores (all P > .5). Results were similar in adjusted analyses. Children of women who experienced greater improvements in periodontal health had significantly higher motor and cognitive scores (P = .01 and .02, respectively), although the effect was small (∼1-point increase for each SD increase in the periodontal measure).

CONCLUSION

Nonsurgical periodontitis treatment in pregnant women was not associated with cognitive, motor, or language development in these study children.

Long-term outcome of surgically managed necrotizing enterocolitis in a developing country

Necrotizing enterocolitis (NEC) is a serious condition with a high morbidity and mortality commonly affecting premature babies. Data for the impact of the long-term disease burden in developing countries are limited although poor long-term outcome of surgically managed patients has been shown in terms of increased risk of neurodevelopmental delay, increased infectious disease burden and abnormal neurological outcomes in the developed world.

PURPOSE

To evaluate the long-term outcome of a pre-human immunodeficiency virus pandemic NEC cohort to characterize common risk factors and outcome in a developing world setting.

METHODS

A retrospective review of medical records was carried out on a cohort of 128 premature neonates with surgical NEC (1992-1995). Morbidity, mortality and long-term outcome were evaluated.

RESULTS

Data for 119 of 128 sequentially managed neonates with surgically treated NEC was available. Mean gestational age was 32 weeks and average birth weight was 1,413 g. Early (30-day postoperative) survival was 69% (n = 82) overall and 71% in the <1,500 g birth weight group (n = 68; 53%). Overwhelming sepsis (n = 16) or pan-intestinal necrosis (n = 18) accounted for most of the early deaths. Late deaths (>30 days postoperatively, n = 22) resulted from short bowel syndrome (5), sepsis (9), intraventricular hemorrhage (1) and undetermined causes (7). On follow-up (mean follow-up 39 months, 30 for >2 years), long-term mortality increased to 50%. Late surgical complications included late colonic strictures (9), incisional hernias (2) and adhesive bowel obstruction (3). Fifteen patients had short bowel syndrome, of which 10 (66%) survived. Of the long-term survivors, 8 (20%) had severe neurological deficits and 20 (49%) had significant neurodevelopmental delay. Neurological deficits included severe auditory impairment [5 (12%)] and visual impairment [4 (10%)]. Recurrent infections and gastrointestinal tract complaints requiring hospital admission occurred in 16 (39%) of survivors.

CONCLUSION

Necrotizing enterocolitis in premature infants impacts morbidity and mortality considerably. A number do well in a developing country, but septic complications may be ongoing and recurrent. The high risk of neurodevelopmental and other problems continue beyond the neonatal period and patients should be "flagged" on for careful follow-up.

Neurodevelopmental trajectory of HIV-infected children accessing care in Kinshasa, Democratic Republic of Congo

OBJECTIVE

To assess the effect of HIV care (including highly active antiretroviral therapy if eligible) on neurodevelopment.

DESIGN

Prospective cohort study.

METHODS

Motor and mental development of 35 HIV-infected children (aged 18-71 months) was assessed at entry into care and after 6 and 12 months using age-appropriate tools. Developmental trajectory was compared with 35 HIV-uninfected, affected, and 90 control children using linear mixed-effects models. Effects of age (29 months) and timing of entry into care (before or after highly active antiretroviral therapy eligibility) were explored in secondary analyses.

RESULTS

At baseline, HIV-infected children had the lowest, control children the highest, and HIV-uninfected affected children intermediate mean developmental scores. After 1 year of care, HIV-infected children achieved mean motor and cognitive scores that were similar to HIV uninfected, affected children although lower compared with control children. Overall, HIV-infected children experienced accelerated motor development but similar gains in cognitive development compared with control children. Exploratory analyses suggest that younger children and those presenting early may experience accelerated greater gains in development.

CONCLUSIONS

HIV-infected children accessing care experience improved motor development, and may, if care is initiated at a young age or an early stage of the disease, also experience gains in cognitive development.

Early immunological predictors of neurodevelopmental outcomes in HIV-infected children

BACKGROUND

A previous analysis of children infected with human immunodeficiency virus (HIV) in the Women and Infants Transmission Study showed a strong correlation between low activated CD8(+) T lymphocytes in the first 2 months of life and good immunological prognosis. We sought to extend these observations to neurodevelopmental prognosis.

METHODS

Ninety-eight HIV-infected children born before 1994 with flow cytometric data from the first 2 months of life and adequate neurodevelopmental testing through age 30 months were studied. Children were divided into those with low (<or=5% CD8(+)HLA-DR(+) cells or <or=25% CD8(+)CD38(+) cells) or high (>5% CD8(+)HLA-DR(+) cells or >25% CD8(+)CD38(+) cells) immune activation at 1 and/or 2 months of age. Analysis was performed using survival analysis, Cox's proportional hazard regression, and longitudinal regression models.

RESULTS

Absence of immune activation, measured as <or=5% CD8(+)HLA-DR(+) cells, was strongly associated with better performance on the psychomotor developmental index of the Bayley scales of infant development through the third year of life. This association persisted after adjustment for CD4 cell count, viral load, and progression to acquired immunodeficiency syndrome (P= .005). An association with the mental development index was also present (P= .048). Significant association between neurodevelopmental outcomes and <or=25% CD8(+)CD38(+) cells was not seen.

CONCLUSIONS

In this prospective cohort study of HIV-infected children, there was a significant favorable association of low immune activation in peripheral T cells at age 1 or 2 months, measured by a low percentage of CD8(+)HLA-DR(+) cells, with subsequent psychomotor and mental development. This association was independent of other indices of severity and progression of HIV infection.

Paediatric HIV and neurodevelopment in sub-Saharan Africa: a systematic review

OBJECTIVE

To determine the degree of motor, cognitive, language and social-emotional impairment related to HIV infection in children living in sub-Saharan Africa (SSA).

METHODS

Literature searches using MEDLINE and PsycINFO. Additionally, the reference lists of previous reviews were checked to ensure that all eligible studies were identified. Cohen's d, a measure of effect size, was computed to estimate the level of impairment.

RESULTS

Six reports met the inclusion criteria. In infancy a consistent delay in motor development was observed with a median value of Cohen's d = 0.97 at 18 months, indicating a severe degree of impairment. Mental development showed a moderate delay at 18 months, with a median value d = 0.67. Language delay did not appear until 24 months of age, d = 0.91. Less clear findings occurred in older subjects.

CONCLUSION

Although HIV has been shown to affect all domains of child functioning, motor development is the most apparent in terms of severity, early onset, and persistence across age groups. However, motor development has been the most widely assessed domain while language development has been less vigorously evaluated in SSA, hence an accurate quantitative estimate of the effect cannot yet be made.

Epidemiology and Etiology of Mental Retardation

Mental retardation (MR) is a manifestation of a heterogeneous set of impairments and conditions that result in cognitive limitation. It is a condition of medical, educational, and social importance. Physicians identify profound, severe, and moderate MR but rarely diagnose mild MR unless it is associated with a genetic or medical syndrome. From a medical perspective, the quest for etiology and the possibility of medical or surgical intervention to minimize deterioration are paramount. Educators, on the other hand are less concerned with causation than with academic achievement and school success. The majority of cases of mild MR is identified in school settings. Finally, the public uses the label to describe poor adaptive skills. Adults with MR who hold jobs, live independently, and participate in society are not always described as having MR. Thus some individuals characterized in childhood or adolescence as having mild MR become indistinguishable from the general population in adulthood.

Neurologic and neurodevelopmental manifestations of pediatric HIV/AIDS: a global perspective

Neurodevelopmental abnormalities associated with HIV infection have been described since the first reports of pediatric AIDS in the 1980s. Before antiretroviral therapy (ART) became widely available, progressive HIV-1 encephalopathy (PHE) was reported in the US in 13-35% of children with HIV-1 infection and in 35-50% of children with AIDS. Introduction of ART can prevent PHE and reverse PHE present at ART initiation, but a high prevalence of residual problems has been described. Even though 90% of HIV-infected children live in the developing world, few children have access to ART and little is known regarding the neurological manifestations of perinatal HIV infection in those regions. Mechanisms of pediatric HIV-1 neuropathogenesis and factors associated with neurodevelopmental abnormalities in perinatally infected children are not yet fully understood. Studies have demonstrated that HIV-1 enters the CNS soon after infection and may persist in this compartment over the entire course of HIV-1 infection. The CNS is a distinct viral reservoir, differing from peripheral compartments in target cells and antiretroviral penetration. Neurotropic HIV-1 likely develops distinct genotypic characteristics in response to this unique environment. We reviewed the literature on pediatric neuroAIDS and identified gaps in the current knowledge.

Effects of Polymorphisms of Chemokine Receptors on Neurodevelopment and the Onset of Encephalopathy in Children with Perinatal HIV-1 Infection

This study examined the effects of chemokine receptor polymorphisms on neurodevelopment and the onset of encephalopathy in children with perinatal HIV-1 infection. Infected children (N = 121) between the ages of I and 72 months were categorized into dichotomous groups (heterozygous or homozygous mutant vs. homozygous wild type) for each chemokine receptor 2 (CCR2) and chemokine receptor 5 (CCR5) allele. Neurodevelopmental measures included the Bayley Scales of Infant Development (BSID)for children age < or = 30 months and the McCarthy Scales of Children's Abilities (MSCA) for children aged > 30 months. A basic linear spline was used to model the mean value at each visit for the relevant test index, with determination of the slope between 4-12 months, 12-30 months, and 31-72 months of age. A mixed model analysis of variance was used to compare differences between slopes (AP) and intercepts (AX) according to the presence or absence of the specified CCR2 or CCR5 polymorphism. Survival analyses were used to compare the onset of encephalopathy by chemokine receptor allelic grouping. After adjusting for potential confounds, statistically significant differences emerged in CCR5-39353, 39356, and 39402. Although the protective effects appeared to be discrete and transient, children with mutant CCR5 genotypes exhibited better neurodevelopmental outcomes than children with the wild type alleles. Chemokine polymorphisms did not appear to impact the onset of encephalopathy. Although possibly a temporary effect, HIV-1 infected children with selected mutant chemokine receptor polymorphims CCR5-39353, 39356, and 39402 may exhibit better neurodevelopmental outcome than children with the wild type allele.

Interaction between Plasmodium falciparum and human immunodeficiency virus type 1 on the central nervous system of African children

Plasmodium falciparum and human immunodeficiency virus type 1 (HIV-1) infections are common in children living in sub-Saharan Africa (SSA). Both of these pathogens affect the central nervous system (CNS). Most HIV-1 infection of children in this region is acquired from infected mothers, particularly during breast-feeding and at the time of delivery. Over a third of children infected by birth will have died before their first birthday, before overt CNS manifestations have developed. The most common manifestations of primary CNS infection include neurodevelopmental delay, impaired brain growth, motor deficits, and behavioral problems. These deficits may also result from infections, neoplasm, or stroke. Cognitive impairments become more evident if the child survives for longer, but in Africa, children rarely survive past their fifth birthday. In malaria endemic areas, severe falciparum malaria usually develops after 6 months of age, and most of the CNS manifestations are more common in children over 1 year old. About 11% of children develop neurological deficits following cerebral malaria, most of which improve within 2 years of the insult. However, up to 24% of children may have neurocognitive impairments following severe malaria. The effect of milder malaria and coincidental parasitization on cognitive function is unknown. Other comorbidities that are common in SSA, such as malnutrition or micronutrient deficiencies, may influence children's neurodevelopment. The coinfection of malaria and HIV-1 may aggravate the neurodevelopmental impairments documented in these children. However, to date there are little published data, although it may have a profound effect of children living in SSA.

Health, neurologic, and cognitive status of HIV-infected, long-surviving, and antiretroviral-naive Ugandan children

OBJECTIVE

The purpose of this study was to assess the health status and school-age neurodevelopmental progress of antiretroviral treatment (ARVT)-naive, HIV-infected Ugandan children who had been followed as part of cohorts of children born to HIV-infected and -noninfected mothers between 1989 and 1993.

METHODS

Twenty-eight children, aged 6 to 12 years, vertically infected with HIV-1 and never treated with ARVT were evaluated in terms of health status, neurologic, and psychometric testing. A randomly selected group of 42 seroreverters and 37 HIV-1 negative children who were age- and gender-matched and who had been followed in the same cohorts were evaluated also. The families studied were homogenous in their socioeconomic status. None of the mothers or children had received ARVT or been exposed to illicit drugs.

RESULTS

The HIV-infected children showed significantly more evidence of acute malnutrition. They also had more illness, especially parotitis, otitis media, upper respiratory infections, and lymphadenopathy. However, they did not differ significantly in neurologic and cognitive assessments when compared with age- and gender-matched seroreverter and HIV-negative children. They were in the normal range with respect to neurologic and psychometric development measures.

CONCLUSIONS

These children seem to represent a significant subgroup of HIV-infected child survivors for whom the progress of the disease is less aggressive throughout early life. Given the fact that many infants, especially in developing countries, continue to be born without the benefit of perinatal ARVT, there will likely continue to be many older HIV-infected children in the same situation as those described in this follow-up study. They will not have been recognized as being HIV-infected. It is important that such children be identified and offered access to ARVT and other appropriate support services.

HIV-1 encephalopathy among perinatally infected children: Neuropathogenesis and response to highly active antiretroviral therapy

HIV-1 encephalopathy among perinatally infected children in the United States was initially defined by a classic triad of findings that included: (1) developmental delay, (2) secondary or acquired microcephaly, and (3) pyramidal tract neuromotor deficits. The most severe form of this disorder typically occurred among young children who developed rapidly progressive disease in concert with profound immunosuppression, and Pneumocystis jiroveci pneumonitis (PCP). The neuropathogenesis of this disorder appears to involve a cascade of viral products, various cytokines and chemokines, and neurotransmitters which promote ongoing inflammation, excitation, and overstimualtion of the N-methyl-D-aspartate type receptor (NMDAR) system. These subsequently lead to neuronal injury and death secondary to apoptosis or necrosis, astrocytosis, as well as dentritic and synaptic damage. The frequency of the most severe forms of encephalopathy among children has dropped dramatically since the introduction of highly active antiretroviral therapy (HAART). Of concern, however, is the possibility that a more insidious form of this disorder may be occurring presently among older vertically infected children as a result of inadequate penetration of HAART agents into the cerebrospinal fluid (CSF). This paper will review what published data there is as yet that bears on this question.

The timing of mother-to-child transmission of human immunodeficiency virus infection and the neurodevelopment of children in Tanzania

OBJECTIVE

To determine the association between the timing of mother-to-child transmission of human immunodeficiency virus (HIV)-1 and neurodevelopment among children born to HIV-1 infected mothers in Tanzania.

METHODS

Bayley Scales of Infant Development (2nd edition) were administered at 6, 12 and 18 months to a subset of children (N = 327). Linear regression models and Cox proportional hazard models were separately fitted for the mental development index (MDI) and the psychomotor development index (PDI).

RESULTS

Children who tested HIV-1-positive at birth had significantly higher decreases per month in MDI and PDI than HIV-1-negative children; 1.1 [95% confidence interval (95% CI), 0.4, 1.8] for MDI and 1.4 (95% CI 0.0, 2.7] for PDI. Children who tested HIV-1-positive after birth had an additional 0.6 (95% CI 0.1, 1.1) point decrease in MDI per month and a 0.6 (95% CI 0.0, 1.1) higher decrease in PDI each month than HIV-1-negative children. Testing HIV-1-positive at birth was associated with a 14.9 (95% CI 5.0, 44.7) times higher rate of becoming developmentally delayed in mental function, while testing HIV-1-positive after birth was associated with a 3.2 (95% CI 1.6, 6.4) times higher rate than in uninfected children.

CONCLUSIONS

HIV-1 infected infants performed worse on tests of neurodevelopment and were significantly more likely to be identified as developmentally delayed in the first 18 months of life than HIV-1-negative children. The effect of HIV-1 infection on neurodevelopment scores and the risk of developmental delay may be highest among those who are already HIV-1 infected at birth.

Manifestações neurológicas em crianças e adolecentes infectados e expostos ao HIV-1

O envolvimento do sistema nervoso central SNC na infecção pelo HIV-1 em crianças pode estar evidente desde o início ou demorar muitos anos para se manifestar. Microcefalia, rebaixamento cognitivo, sinais piramidais, distúrbios do humor e do comportamento e complicações pelo uso da terapia antiretroviral são comuns. Este é um trabalho observacional, descritivo e seccional cuja finalidade é descrever as alterações do exame neurológico em um grupo de crianças e adolescentes expostos pelo HIV-1 durante o período perinatal. Foram avaliados 173 pacientes. Muitos pacientes tinham superposição de alterações de exame neurológico e/ou mais de um diagnóstico. As alterações mais comuns foram: retardo do desenvolvimento neuropsicomotor, atraso de linguagem, deficiência mental, síndrome piramidal, hiporreflexia. O exame neurológico foi alterado em 67% dos casos, mesmo naqueles pacientes soro-revertidos. Sugerimos que existe alto risco para doença neurológica nesse grupo de pacientes e que a progressão da infecção pelo HIV-1 acentua o aparecimento de co-morbidades e comprometimento de seu prognóstico.

Cognitive and motor deficits associated with HIV-2(287) infection in infant pigtailed macaques: a nonhuman primate model of pediatric neuro-AIDS

Lentivirus-infected nonhuman primates exhibit behavioral and neurological pathology similar to human immunodeficiency virus (HIV)-infected humans and offer a means to examine the effects of lentivirus infection while controlling for confounding factors inherent in human populations. The purpose of this study was to examine cognitive and motor development in infant macaques vertically infected with HIV-2287. Subjects were 20 infant pigtail macaques (Macaca nemestrina); 8 controls born to uninfected dams, and 12 infants whose dams had been inoculated and infected with HIV-2287 in the third trimester of pregnancy. Eight of these pregnancies had undergone surgical procedures in the form of maternal amniotic catheters or maternal amniotic and fetal carotid artery and jugular vein catheters. Data indicated that catheterization had little or no impact on behavioral development. Seven infants were vertically infected (as measured by polymerase chain reaction (PCR) at birth) and five were not infected (as measured by PCR and coculture on repeated testing). Infected infants attained cognitive and motor milestones at significantly later ages than controls. Uninfected infants, born to infected dams, attained developmental milestones at later ages than controls on all tasks, but this reached statistical significance only for the Fine Motor Task. Attainment of milestones was not correlated with viral dose, maternal CD4+ levels at parturition or infant viral RNA levels at birth. Attainment of milestones was negatively correlated with infants' proportions of CD4+ lymphocytes at birth and significantly correlated with proportions of CD4+ lymphocytes 2 weeks after birth, indicating poorer performance in those infants with a more rapid CD4+ depletion. These cognitive and motor deficits closely resemble those observed in human infants and children infected with HIV and indicate that HIV-2287-infected infant macaques represent an excellent model of pediatric neuro-acquired immunodeficiency syndrome (neuroAIDS).

Differences in neuropsychological performance associated with ethnicity in children with HIV-1 infection: preliminary findings

This study investigated the relationship between ethnicity (African American and European American) and neuropsychological performance in two specific neuropsychological domains (language and speed of information processing) in a group of HIV-1+ children. The Expressive One-Word Picture Vocabulary Test-Revised and the Rapid Color Naming subtest of the Comprehensive Test of Phonological Processing were administered to 5- to 7-year-old children (n = 22) as part of a comprehensive research or clinical protocol. African American children scored lower than European American children (p < .05) on both procedures. The observed performance difference emerged despite the fact that there were no group differences in age, immunologic clinical categories, intellect, level of maternal education, or CD4+ percentage and after using stringent exclusionary criteria, including history of enrollment in special education services and the presence of other chronic medical conditions. The implications of such findings are discussed within biological and demographic frameworks.

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

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

Developmental milestones of vertically HIV infected and seroreverters children: follow up of 83 children

The aim of the study was to detect neurological abnormalities in human immunodeficiency virus (HIV) infected children. This was achieved by a prospective evaluation, from November/1995 to April/2000, of 43 HIV infected children (group I) and 40 HIV seroreverters children (group II) through neurological exam and neurodevelopmental tests: Denver Developmental Screening Test (DDST) and Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS). A control group (III), of 67 children, were evaluated by CAT/CLAMS. Hyperactivity, irritability and hypotonia were the findings on neurological examination, without statistical differences between group I and II. On CAT/CLAMS, the group I developmental quotient (DQ) was significantly lower than the other groups. The same occurred in DDST, with group I presenting significantly more failures than group II. Nineteen HIV children of group I had brain computed tomographic scan, with abnormalities in three of them (basal ganglia calcification, white matter hypodensity and asymmetry of lateral ventricles). We conclude that in HIV infected children a neurodevelopment delay occur early in the disease, and it can be detected by screening tests.