1
|
Faris JG, Orbidan D, Wells C, Petersen BK, Sprenger KG. Moving the needle: Employing deep reinforcement learning to push the boundaries of coarse-grained vaccine models. Front Immunol 2022; 13:1029167. [PMID: 36405722 PMCID: PMC9670804 DOI: 10.3389/fimmu.2022.1029167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Highly mutable infectious disease pathogens (hm-IDPs) such as HIV and influenza evolve faster than the human immune system can contain them, allowing them to circumvent traditional vaccination approaches and causing over one million deaths annually. Agent-based models can be used to simulate the complex interactions that occur between immune cells and hm-IDP-like proteins (antigens) during affinity maturation-the process by which antibodies evolve. Compared to existing experimental approaches, agent-based models offer a safe, low-cost, and rapid route to study the immune response to vaccines spanning a wide range of design variables. However, the highly stochastic nature of affinity maturation and vast sequence space of hm-IDPs render brute force searches intractable for exploring all pertinent vaccine design variables and the subset of immunization protocols encompassed therein. To address this challenge, we employed deep reinforcement learning to drive a recently developed agent-based model of affinity maturation to focus sampling on immunization protocols with greater potential to improve the chosen metrics of protection, namely the broadly neutralizing antibody (bnAb) titers or fraction of bnAbs produced. Using this approach, we were able to coarse-grain a wide range of vaccine design variables and explore the relevant design space. Our work offers new testable insights into how vaccines should be formulated to maximize protective immune responses to hm-IDPs and how they can be minimally tailored to account for major sources of heterogeneity in human immune responses and various socioeconomic factors. Our results indicate that the first 3 to 5 immunizations, depending on the metric of protection, should be specially tailored to achieve a robust protective immune response, but that beyond this point further immunizations require only subtle changes in formulation to sustain a durable bnAb response.
Collapse
Affiliation(s)
- Jonathan G. Faris
- Department of Chemical and Biological Engineering, University of Colorado Boulder, Boulder, CO, United States
| | - Daniel Orbidan
- Department of Chemical and Biological Engineering, University of Colorado Boulder, Boulder, CO, United States
| | - Charles Wells
- Department of Computer Science, Rice University, TX, Houston, United States
| | - Brenden K. Petersen
- Computational Engineering Division, Lawrence Livermore National Laboratory, Livermore, CA, United States
| | - Kayla G. Sprenger
- Department of Chemical and Biological Engineering, University of Colorado Boulder, Boulder, CO, United States
| |
Collapse
|
2
|
Kohns Vasconcelos M, Laws H, Borkhardt A, Neubert J. Medical history and clinical examinations are insufficient to exclude vertical human immunodeficiency virus transmission in healthy, at-risk adolescents. Acta Paediatr 2019; 108:994-997. [PMID: 30901119 DOI: 10.1111/apa.14793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Malte Kohns Vasconcelos
- Paediatric Infectious Diseases Research Group Institute for Infection and Immunity St George's University of London London UK
| | - Hans‐Jürgen Laws
- Department of Pediatric Oncology, Hematology and Clinical Immunology Center for Child and Adolescent Health Medical Faculty Heinrich‐Heine‐University Düsseldorf Germany
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology and Clinical Immunology Center for Child and Adolescent Health Medical Faculty Heinrich‐Heine‐University Düsseldorf Germany
| | - Jennifer Neubert
- Department of Pediatric Oncology, Hematology and Clinical Immunology Center for Child and Adolescent Health Medical Faculty Heinrich‐Heine‐University Düsseldorf Germany
| |
Collapse
|
3
|
HIV-1 Subtype C-Infected Children with Exceptional Neutralization Breadth Exhibit Polyclonal Responses Targeting Known Epitopes. J Virol 2018; 92:JVI.00878-18. [PMID: 29950423 PMCID: PMC6096808 DOI: 10.1128/jvi.00878-18] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 06/14/2018] [Indexed: 02/01/2023] Open
Abstract
An HIV vaccine is likely to require bNAbs, which have been shown to prevent HIV acquisition in nonhuman primates. Recent evidence suggests that HIV-infected children are inherently better at generating bNAbs than adults. Here, we show that exceptional neutralization breadth in a group of viremic HIV-1 subtype C-infected children was due to the presence of polyclonal bNAb responses. These bNAbs targeted multiple epitopes on the HIV envelope glycoprotein previously defined in adult infection, suggesting that the immature immune system recognizes HIV antigens similarly. Since elicitation of a polyclonal bNAb response is the basis of next-generation HIV envelope vaccines, further studies of how bNAb lineages are stimulated in children is warranted. Furthermore, our findings suggest that children may respond particularly well to vaccines designed to elicit antibodies to multiple bNAb epitopes. We have previously shown that HIV-1-infected children develop broader and more potent neutralizing antibody responses than adults. This study aimed to determine the antibody specificities in 16 HIV-1 subtype C-infected children who displayed exceptional neutralization breadth on a 22-multisubtype virus panel. All children were antiretroviral treatment (ART) naive with normal CD4 counts despite being infected for a median of 10.1 years with high viral loads. The specificity of broadly neutralizing antibodies (bNAbs) was determined using epitope-ablating mutants, chimeric constructs, and depletion or inhibition of activity with peptides and glycoproteins. We found that bNAbs in children largely targeted previously defined epitopes, including the V2-glycan, V3-glycan, CD4bs, and gp120-gp41 interface. Remarkably, 63% of children had antibodies targeting 2 or 3 and, in one case, 4 of these bNAb epitopes. Longitudinal analysis of plasma from a mother-child pair over 9 years showed that while they both had similar neutralization profiles, the antibody specificities differed. The mother developed antibodies targeting the V2-glycan and CD4bs, whereas bNAb specificities in the child could not be mapped until 6 years, when a minor V2-glycan response appeared. The child also developed high-titer membrane-proximal external region (MPER) binding antibodies not seen in the mother, although these were not a major bNAb specificity. Overall, exceptional neutralization breadth in this group of children may be the result of extended exposure to high antigenic load in the context of an intact immune system, which allowed for the activation of multiple B cell lineages and the generation of polyclonal responses targeting several bNAb epitopes. IMPORTANCE An HIV vaccine is likely to require bNAbs, which have been shown to prevent HIV acquisition in nonhuman primates. Recent evidence suggests that HIV-infected children are inherently better at generating bNAbs than adults. Here, we show that exceptional neutralization breadth in a group of viremic HIV-1 subtype C-infected children was due to the presence of polyclonal bNAb responses. These bNAbs targeted multiple epitopes on the HIV envelope glycoprotein previously defined in adult infection, suggesting that the immature immune system recognizes HIV antigens similarly. Since elicitation of a polyclonal bNAb response is the basis of next-generation HIV envelope vaccines, further studies of how bNAb lineages are stimulated in children is warranted. Furthermore, our findings suggest that children may respond particularly well to vaccines designed to elicit antibodies to multiple bNAb epitopes.
Collapse
|
4
|
Balasubramanian R, Fowler MG, Dominguez K, Lockman S, Tookey PA, Huong NNG, Nesheim S, Hughes MD, Lallemant M, Tosswill J, Shaffer N, Sherman G, Palumbo P, Shapiro DE. Time to first positive HIV-1 DNA PCR may differ with antiretroviral regimen in infants infected with non-B subtype HIV-1. AIDS 2017; 31:2465-2474. [PMID: 28926397 PMCID: PMC5710822 DOI: 10.1097/qad.0000000000001640] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the association of type and timing of prophylactic maternal and infant antiretroviral regimen with time to first positive HIV-1 DNA PCR test, in nonbreastfed HIV-infected infants, from populations infected predominantly with HIV-1 non-B subtype virus. DESIGN Analysis of combined data on nonbreastfed HIV-infected infants from prospective cohorts in Botswana, Thailand, and the United Kingdom (N = 405). METHODS Parametric models appropriate for interval-censored outcomes estimated the time to first positive PCR according to maternal or infant antiretroviral regimen category and timing of maternal antiretroviral initiation, with adjustment for covariates. RESULTS Maternal antiretroviral regimens included: no antiretrovirals (n = 138), single-nucleoside analog reverse transcriptase inhibitor (n = 165), single-dose nevirapine with zidovudine (n = 66), and combination prophylaxis with 3 or more antiretrovirals [combination antiretroviral therapy (cART), n = 36]. Type of maternal/infant antiretroviral regimen and timing of maternal antiretroviral initiation were each significantly associated with time to first positive PCR (multivariate P < 0.0001). The probability of a positive test with no antiretrovirals compared with the other regimen/timing groups was significantly lower at 1 day after birth, but did not differ significantly after age 14 days. In a subgroup of 143 infants testing negative at birth, infant cART was significantly associated with longer time to first positive test (multivariate P = 0.04). CONCLUSION Time to first positive HIV-1 DNA PCR in HIV-1-infected nonbreastfed infants (non-B HIV subtype) may differ according to maternal/infant antiretroviral regimen and may be longer with infant cART, which may have implications for scheduling infant HIV PCR-diagnostic testing and confirming final infant HIV status.
Collapse
Affiliation(s)
- Raji Balasubramanian
- aDepartment of Biostatistics and Epidemiology, University of Massachusetts-Amherst, Amherst, Massachusetts bDepartment of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland cDivision of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia dDivision of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston eDepartment of Immunology and Infectious Diseases, Harvard University, T. H. Chan School of Public Health, Boston, Massachusetts, USA fBotswana Harvard AIDS Institute Partnership, Gaborone, Botswana gUniversity College Institute of Child Health, London, UK hInstitut de recherche pour le développement (IRD) UMI 174-PHPT, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand iDepartment of Biostatistics, Harvard University T. H. Chan School of Public Health, Boston, Massachusetts, USA jVirus Reference Department, National Infection Service, Public Health England, London, UK kDepartment of HIV/AIDS, World Health Organization, Geneva, Switzerland lDepartment of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand and National Institute for Communicable Diseases, Johannesburg, South Africa mSection of Infectious Diseases and International Health, Geisel School of Medicine at Dartmouth, 1 Medical Center Dr, Lebanon, New Hampshire nCenter for Biostatistics in AIDS Research, Harvard University T. H. Chan School of Public Health. Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Williams EF, Ferrer K, Lee MA, Bright K, Williams K, Rakhmanina NY. Growing up with perinatal human immunodeficiency virus-A life not expected. J Clin Nurs 2017; 26:4734-4744. [PMID: 28334487 DOI: 10.1111/jocn.13826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2017] [Indexed: 12/24/2022]
Abstract
AIM AND OBJECTIVES To describe the lived experience of young adults with perinatally acquired HIV (PaHIV). BACKGROUND With the advancement of the highly active antiretroviral treatment, PaHIV infection has transformed into a chronic lifelong illness that is faced by young adults who grew up with HIV. The known challenges that are associated with HIV are poverty, stigma and social and emotional isolation. DESIGN This was a qualitative single-interview study of a convenience sample of PaHIV-infected young adults receiving care at a large metropolitan pediatric hospital. METHODS The participants had individual face-to-face interviews which were audio-taped and transcribed verbatim. Themes were developed to describe their living space, and Max Van Manen's lifeworld guide was used to describe their lived experience. FINDINGS Seventeen participants (eight males/nine females) were enrolled. Four major themes emerged: (i) limited social capital, especially when orphaned participants reflected on a life void of parental guidance; (ii) incomplete education and unemployment, participants described an idle existence; (iii) a harsh life, described as participants facing difficulties meeting their life's milestones; (iv) unanticipated adult issues, where participants described their limited ability to care for themselves and their children. Van Manen lifeworld themes also described the space they occupied, their memories growing up with PaHIV, their health care and relationships. CONCLUSION Our study provides a valuable insight into the social and emotional difficulties faced by youth with PaHIV. The findings underscore the importance of extensive support and coordination of services between adult and pediatric providers to optimize long-term outcomes among young adults with PaHIV. RELEVANCE TO CLINICAL PRACTICE The young adults with PaHIV require close attention and support from the healthcare providers, who can offer them a safe space to discuss lived experiences and support their ability to achieve full lives.
Collapse
Affiliation(s)
- Elaine Fay Williams
- Children's National Health System, Pharmacology and Therapeutics, Washington, DC, USA
| | - Kathleen Ferrer
- Children's National Health System, Special Immunology, Infectious Diseases, Washington, DC, USA.,School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Marlene A Lee
- Children's National Health System, Clinical Resource Management, Revenue Cycle, Washington, DC, USA
| | - Kimberly Bright
- Children's National Health System, Special Immunology, Infectious Diseases, Washington, DC, USA
| | - Keetra Williams
- Children's National Health System, Special Immunology, Infectious Diseases, Washington, DC, USA
| | - Natella Y Rakhmanina
- Children's National Health System, Special Immunology, Infectious Diseases, Washington, DC, USA.,School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA.,Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| |
Collapse
|
6
|
Judd A, Lodwick R, Noguera‐Julian A, Gibb DM, Butler K, Costagliola D, Sabin C, van Sighem A, Ledergerber B, Torti C, Mocroft A, Podzamczer D, Dorrucci M, De Wit S, Obel N, Dabis F, Cozzi‐Lepri A, García F, Brockmeyer NH, Warszawski J, Gonzalez‐Tome MI, Mussini C, Touloumi G, Zangerle R, Ghosn J, Castagna A, Fätkenheuer G, Stephan C, Meyer L, Campbell MA, Chene G, Phillips A. Higher rates of triple-class virological failure in perinatally HIV-infected teenagers compared with heterosexually infected young adults in Europe. HIV Med 2017; 18:171-180. [PMID: 27625109 PMCID: PMC5298034 DOI: 10.1111/hiv.12411] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The aim of the study was to determine the time to, and risk factors for, triple-class virological failure (TCVF) across age groups for children and adolescents with perinatally acquired HIV infection and older adolescents and adults with heterosexually acquired HIV infection. METHODS We analysed individual patient data from cohorts in the Collaboration of Observational HIV Epidemiological Research Europe (COHERE). A total of 5972 participants starting antiretroviral therapy (ART) from 1998, aged < 20 years at the start of ART for those with perinatal infection and 15-29 years for those with heterosexual infection, with ART containing at least two nucleoside reverse transcriptase inhibitors (NRTIs) and a nonnucleoside reverse transcriptase inhibitor (NNRTI) or a boosted protease inhibitor (bPI), were followed from ART initiation until the most recent viral load (VL) measurement. Virological failure of a drug was defined as VL > 500 HIV-1 RNA copies/mL despite ≥ 4 months of use. TCVF was defined as cumulative failure of two NRTIs, an NNRTI and a bPI. RESULTS The median number of weeks between diagnosis and the start of ART was higher in participants with perinatal HIV infection compared with participants with heterosexually acquired HIV infection overall [17 (interquartile range (IQR) 4-111) vs. 8 (IQR 2-38) weeks, respectively], and highest in perinatally infected participants aged 10-14 years [49 (IQR 9-267) weeks]. The cumulative proportion with TCVF 5 years after starting ART was 9.6% [95% confidence interval (CI) 7.0-12.3%] in participants with perinatally acquired infection and 4.7% (95% CI 3.9-5.5%) in participants with heterosexually acquired infection, and highest in perinatally infected participants aged 10-14 years when starting ART (27.7%; 95% CI 13.2-42.1%). Across all participants, significant predictors of TCVF were those with perinatal HIV aged 10-14 years, African origin, pre-ART AIDS, NNRTI-based initial regimens, higher pre-ART viral load and lower pre-ART CD4. CONCLUSIONS The results suggest a beneficial effect of starting ART before adolescence, and starting young people on boosted PIs, to maximize treatment response during this transitional stage of development.
Collapse
Affiliation(s)
- A Judd
- MRC Clinical Trials UnitUniversity College LondonLondonUK
| | - R Lodwick
- Department of Infection and Population HealthUniversity College LondonLondonUK
| | - A Noguera‐Julian
- Institut de Recerca Pediàtrica Hospital Sant Joan de DéuBarcelonaSpain
- Departament de PediatriaUniversitat de BarcelonaBarcelonaSpain
- CIBER de Epidemiología y Salud Pública CiberespBarcelonaSpain
| | - DM Gibb
- MRC Clinical Trials UnitUniversity College LondonLondonUK
| | - K Butler
- Department of Infectious Diseases and ImmunologyOur Lady's Children's HospitalCrumlin, DublinIreland
| | - D Costagliola
- INSERM, UPMC Univ Paris 06, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136)Sorbonne UniversitésParisFrance
| | - C Sabin
- Department of Infection and Population HealthUniversity College LondonLondonUK
| | - A van Sighem
- Stichting HIV MonitoringAmsterdamThe Netherlands
| | - B Ledergerber
- Division of Infectious Diseases and Hospital EpidemiologyUniversity of ZurichZurichSwitzerland
| | - C Torti
- Unit of Infectious and Tropical Diseases, Department of Medical and Surgical SciencesUniversity “Magna Graecia”CatanzaroItaly
| | - A Mocroft
- Department of Infection and Population HealthUniversity College LondonLondonUK
| | - D Podzamczer
- HIV and STD Unit, Infectious Disease ServiceHospital Universitari de Bellvitge. L'HospitaletBarcelonaSpain
| | | | - S De Wit
- Département of Infectious Diseases, Centre Hospitalier Saint‐PierreUniversité Libre de BruxellesBrusselsBelgium
| | - N Obel
- Department of Infectious DiseasesCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - F Dabis
- INSERM U1219 – Centre Inserm Bordeaux Population HealthUniversité de BordeauxBordeauxFrance
- ISPED, Centre INSERM U1219‐Bordeaux Population HealthUniversité de BordeauxBordeauxFrance
| | - A Cozzi‐Lepri
- Department of Infection and Population HealthUniversity College LondonLondonUK
| | - F García
- Clinical Microbiology Department, Complejo Hospitalario Universitario GranadaInstituto de Investigación Biosanitaria ibs.GranadaGranadaSpain
| | - NH Brockmeyer
- Department of Dermatology, Venerology and Allergology, Center for Sexual Health and Medicine, St. Josef HospitalRuhr‐Universität BochumBochumGermany
| | - J Warszawski
- INSERM CESP U1018, AP‐HP Public Health DepartmentUniversité Paris‐Sud, Université Paris‐SaclayLe Kremlin‐Bicêtre ParisFrance
| | - MI Gonzalez‐Tome
- HIV and Paeds Infectious Diseases DepartmentHospital 12 de OctubreMadridSpain
| | - C Mussini
- Infectious Diseases ClinicsUniversity HospitalModenaItaly
| | - G Touloumi
- Department Hygiene, Epidemiology & Medical Statistics, Medical SchoolNational & Kapodistrian University of AthensAthensGreece
| | - R Zangerle
- Medical University InnsbruckInnsbruckAustria
| | - J Ghosn
- EA 7327, Faculté de Médecine site NeckerUniversité Paris Descartes, Sorbonne Paris CitéParisFrance
- APHP, Unité Fonctionnelle de Thérapeutique en Immuno‐InfectiologieHôpitaux Universitaires Paris Centre site Hôtel DieuParisFrance
| | - A Castagna
- San Raffaele Scientific InstituteVita‐SaLute UniversityMilanItaly
| | - G Fätkenheuer
- Department I of Internal MedicineUniversity Hospital of CologneCologneGermany
| | - C Stephan
- Second Medical Department, Infectious Diseases UnitGoethe‐University HospitalFrankfurtGermany
| | - L Meyer
- INSERM CESP U1018Université Paris‐Sud, Université Paris‐SaclayParisFrance
- AP‐HP Public Health DepartmentLe Kremlin‐BicêtreParisFrance
| | - MA Campbell
- Centre for Health and Infectious Disease ResearchUniversity of CopenhagenCopenhagenDenmark
| | - G Chene
- INSERM U1219 – Centre Inserm Bordeaux Population HealthUniversité de BordeauxBordeauxFrance
- ISPED, Centre INSERM U1219‐Bordeaux Population HealthUniversité de BordeauxBordeauxFrance
- CHU de Bordeaux, Pole de sante publique, Service d'information medicaleBordeauxFrance
| | - A Phillips
- Department of Infection and Population HealthUniversity College LondonLondonUK
| | | |
Collapse
|
7
|
Harris R. Complexities and challenges of transition to adult services in adolescents with vertically transmitted HIV infection. ACTA ACUST UNITED AC 2016; 41:64-7. [PMID: 25512353 DOI: 10.1136/jfprhc-2014-100996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Ruth Harris
- Medical Student, MBBS Year 5, King's College London, London, UK
| |
Collapse
|
8
|
Abstract
Recent anecdotal reports of HIV-infected children who received early antiretroviral therapy (ART) and showed sustained control of viral replication even after ART discontinuation have raised the question of whether there is greater intrinsic potential for HIV remission, or even eradication ('cure'), in paediatric infection than in adult infection. This Review describes the influence of early initiation of ART, of immune ontogeny and of maternal factors on the potential for HIV cure in children and discusses the unique immunotherapeutic opportunities and obstacles that paediatric infection may present.
Collapse
Affiliation(s)
- Philip J Goulder
- Department of Paediatrics, University of Oxford, Oxford OX1 3SY, UK
| | - Sharon R Lewin
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne 3000, Australia
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne 3004, Australia
| | - Ellen M Leitman
- Department of Paediatrics, University of Oxford, Oxford OX1 3SY, UK
| |
Collapse
|
9
|
Abstract
Adolescence is a time of sexual risk-taking and experimentation but also vulnerability. Young people may present to general physicians with systemic symptoms of sexually transmitted infections (STIs), such as arthritis, hepatitis or rash, but may not necessarily volunteer information about sexual activity. It is important for physicians to ask directly about sexual risks and if appropriate test for STIs and pregnancy. Knowing how to take a sexual history and consent a patient for an HIV test are core medical skills that all physicians should be trained to competently perform. Safeguarding young people is the responsibility of all healthcare professionals who come into contact with them, and young victims of abuse may present with physical symptoms such as abdominal pain or deliberate self-harm. We must all be aware of indicators of both child sexual exploitation and HIV infection and not be afraid to ask potentially awkward questions. If we don't we may miss vital opportunities to prevent or minimise harm to young people.
Collapse
Affiliation(s)
- Sophie Forsyth
- Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | | |
Collapse
|
10
|
Muthusamy K, Yoganathan S, Thomas MM, Alexander M, Verghese VP. Subacute sclerosing panencephalitis in a child with human immunodeficiency virus (HIV) infection on antiretroviral therapy. Ann Indian Acad Neurol 2015; 18:96-8. [PMID: 25745323 PMCID: PMC4350227 DOI: 10.4103/0972-2327.144299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 07/06/2014] [Accepted: 08/14/2014] [Indexed: 11/30/2022] Open
Abstract
Subacute Sclerosing Panencephalitis (SSPE) in HIV-infected children is a scarcely reported entity with previous reports describing fulminant course. The impact of highly active antiretroviral therapy (HAART) in altering its course remains unknown. We describe a child with HIV infection, who developed measles at 5 months of age and later developed SSPE at 14 years of age, remaining stable at 7 month follow-up, while on HAART for WHO (World Health Organisation) stage IV disease. The dynamics of HIV-related immunosuppression has an impact on the clinical course of SSPE. Contrary to reported cases of fulminant progression, a classic presentation with slow progression can be expected in children on HAART. We reemphasize the recommendation of “early measles vaccination” to prevent measles infection and subsequent SSPE in these children with an increasingly good life expectancy in the era of HAART.
Collapse
Affiliation(s)
- Karthik Muthusamy
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sangeetha Yoganathan
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Maya Mary Thomas
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | |
Collapse
|
11
|
Bamford A, Turkova A, Lyall H, Foster C, Klein N, Bastiaans D, Burger D, Bernadi S, Butler K, Chiappini E, Clayden P, Della Negra M, Giacomet V, Giaquinto C, Gibb D, Galli L, Hainaut M, Koros M, Marques L, Nastouli E, Niehues T, Noguera-Julian A, Rojo P, Rudin C, Scherpbier HJ, Tudor-Williams G, Welch SB. Paediatric European Network for Treatment of AIDS (PENTA) guidelines for treatment of paediatric HIV-1 infection 2015: optimizing health in preparation for adult life. HIV Med 2015; 19:e1-e42. [PMID: 25649230 PMCID: PMC5724658 DOI: 10.1111/hiv.12217] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2014] [Indexed: 02/06/2023]
Abstract
The 2015 Paediatric European Network for Treatment of AIDS (PENTA) guidelines provide practical recommendations on the management of HIV‐1 infection in children in Europe and are an update to those published in 2009. Aims of treatment have progressed significantly over the last decade, moving far beyond limitation of short‐term morbidity and mortality to optimizing health status for adult life and minimizing the impact of chronic HIV infection on immune system development and health in general. Additionally, there is a greater need for increased awareness and minimization of long‐term drug toxicity. The main updates to the previous guidelines include: an increase in the number of indications for antiretroviral therapy (ART) at all ages (higher CD4 thresholds for consideration of ART initiation and additional clinical indications), revised guidance on first‐ and second‐line ART recommendations, including more recently available drug classes, expanded guidance on management of coinfections (including tuberculosis, hepatitis B and hepatitis C) and additional emphasis on the needs of adolescents as they approach transition to adult services. There is a new section on the current ART ‘pipeline’ of drug development, a comprehensive summary table of currently recommended ART with dosing recommendations. Differences between PENTA and current US and World Health Organization guidelines are highlighted and explained.
Collapse
Affiliation(s)
- A Bamford
- Department of Paediatric Infectious Diseases and Immunology, Great Ormond Street Hospital NHS Trust, London, UK
| | - A Turkova
- Medical Research Council Clinical Trials Unit, London, UK
| | - H Lyall
- Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
| | - C Foster
- Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
| | - N Klein
- Institute of Child Health, University College London, London, UK
| | - D Bastiaans
- Radboud University Medical Center, Nijmegan, The Netherlands
| | - D Burger
- Radboud University Medical Center, Nijmegan, The Netherlands
| | - S Bernadi
- University Department of Immunology and Infectious Disease, Bambino Gesù Children's Hospital, Rome, Italy
| | - K Butler
- Our Lady's Children's Hospital Crumlin & University College Dublin, Dublin, Ireland
| | - E Chiappini
- Meyer University Hospital, Florence University, Florence, Italy
| | | | - M Della Negra
- Emilio Ribas Institute of Infectious Diseases, Sao Paulo, Brazil
| | - V Giacomet
- Paediatric Infectious Disease Unit, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - C Giaquinto
- Department of Paediatrics, University of Padua, Padua, Italy
| | - D Gibb
- Medical Research Council Clinical Trials Unit, London, UK
| | - L Galli
- Department of Health Sciences, Pediatric Unit, University of Florence, Florence, Italy
| | - M Hainaut
- Department of Pediatrics, CHU Saint-Pierre, Free University of Brussels, Brussels, Belgium
| | - M Koros
- Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - L Marques
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Pediatric Department, Porto Central Hospital, Porto, Portugal
| | - E Nastouli
- Department of Clinical Microbiology and Virology, University College London Hospitals, London, UK
| | - T Niehues
- Centre for Pediatric and Adolescent Medicine, HELIOS Hospital Krefeld, Krefeld, Germany
| | - A Noguera-Julian
- Infectious Diseases Unit, Pediatrics Department, Sant Joan de Déu Hospital, University of Barcelona, Barcelona, Spain
| | - P Rojo
- 12th of October Hospital, Madrid, Spain
| | - C Rudin
- University Children's Hospital, Basel, Switzerland
| | - H J Scherpbier
- Department of Paediatric Immunology and Infectious Diseases, Emma Children's Hospital Academic Medical Centre, Amsterdam, The Netherlands
| | | | | | | |
Collapse
|
12
|
Abstract
This review is an update focusing on the current status of paediatric HIV in the UK and Ireland. Successes in prevention of mother to child transmission are highlighted. The changing epidemiology of the UK cohort is summarised and the shift in emphasis of treatment guidelines beyond limiting short-term morbidity and mortality to ensuring optimal health status in adult life is discussed. Current and future challenges relating to an aging cohort, successful transition to adult services and the prospect of a lifetime on antiretroviral therapy (ART), as well as the possibility of ART-free survival are also considered. While numbers of HIV-infected children in the UK are now decreasing, lessons we have learned in the last 30 years from this relatively small cohort are increasingly applicable to the global paediatric HIV population.
Collapse
Affiliation(s)
- Alasdair Bamford
- Department of Paediatric Infectious Diseases and Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Hermione Lyall
- Department Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| |
Collapse
|
13
|
Hegazi A, Forsyth S, Prime K. Testing the children of HIV-infected parents: 6 years on from 'Don't forget the children'. Sex Transm Infect 2014; 91:76-7. [PMID: 25316913 DOI: 10.1136/sextrans-2014-051817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Aseel Hegazi
- Department of Genitourinary Medicine, St George's University Hospital, London, UK
| | - Sophie Forsyth
- Department of Genitourinary Medicine, Great Western Hospital, Swindon, UK
| | - Katia Prime
- Department of Genitourinary Medicine, St George's University Hospital, London, UK
| | | |
Collapse
|
14
|
de Jose MI, Jiménez de Ory S, Espiau M, Fortuny C, Navarro ML, Soler-Palacín P, Muñoz-Fernandez MA. A new tool for the paediatric HIV research: general data from the Cohort of the Spanish Paediatric HIV Network (CoRISpe). BMC Infect Dis 2013; 13:2. [PMID: 23282073 PMCID: PMC3544738 DOI: 10.1186/1471-2334-13-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 12/18/2012] [Indexed: 12/20/2022] Open
Abstract
There are approximately from 1,100 to 1,200 HIV-infected children in a follow-up in Spain. In 2008 an open, multicentral, retrospective and prospective Cohort of the Spanish Paediatric HIV Network (CoRISpe) was founded. The CoRISpe is divided into the node 1 and node 2 representing geographically almost the whole territory of Spain. Since 2008 seventy-five hospitals have been participating in the CoRISpe. All the retrospective data of the HIV-infected children have been kept in the CoRISpe since 1995 and prospective data since 2008. In this article we are going to present the notion of CoRISpe, its role, the structure, how the CoRISpe works and the process how a child is transferred from Paediatric to Adults Units. The main objective of the CoRISpe is to contribute to furthering scientific knowledge on paediatric HIV infection by providing demographic, sociopsychological, clinical and laboratory data from HIV-infected paediatric patients. Its aim is to enable high-quality research studies on HIV-infected children.
Collapse
Affiliation(s)
- Ma Isabel de Jose
- Servicio Infecciosas Infantil, Hospital Universitario “La Paz”, Paseo de la Castellana 26, Madrid, 128046, Spain
| | - Santiago Jiménez de Ory
- Laboratorio de Inmuno-Biología Molecular. Spanish HIV HGM BioBank. Hospital General Universitario “Gregorio Marañón” and Instituto de Investigación Sanitaria Gregorio Marañón, C/Dr. Esquerdo 46, Madrid, 28007, Spain
| | - Maria Espiau
- Unitat de Patologia Infecciosa i Immunodeficiències de Pediatria, Hospital Universitari Vall d` Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Claudia Fortuny
- Servicio Infecciosas Infantil, Hospital Sant Joan de Dèu, Esplugues de Llobregat, Barcelona, Spain
| | - Ma Luisa Navarro
- Sección de Enfermedades Infecciosas. Servicio de Pediatría. Hospital General Universitario “Gregorio Marañón”, Madrid, Spain
| | - Pere Soler-Palacín
- Unitat de Patologia Infecciosa i Immunodeficiències de Pediatria, Hospital Universitari Vall d` Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ma Angeles Muñoz-Fernandez
- Laboratorio de Inmuno-Biología Molecular. Spanish HIV HGM BioBank. Hospital General Universitario “Gregorio Marañón” and Instituto de Investigación Sanitaria Gregorio Marañón, C/Dr. Esquerdo 46, Madrid, 28007, Spain
| |
Collapse
|
15
|
Remembering the Children: Implementation and Success of a Robust Method for Identifying and Testing Children of HIV Patients. JOURNAL OF SEXUALLY TRANSMITTED DISEASES 2013; 2013:828024. [PMID: 26316965 PMCID: PMC4437414 DOI: 10.1155/2013/828024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 09/23/2013] [Indexed: 11/17/2022]
Abstract
Background. Children of HIV patients are a historically neglected demographic by HIV services. It has been recommended by CHIVA that HIV services have a robust method of detecting and testing untested children. We note that no such method is either in widespread use or in the literature. Method. In December 2011, a one-page proforma to identify HIV untested children and a clear multidisciplinary pathway to test them were implemented. Twelve months later the uptake of the proforma and pathway, the numbers of patients and children identified for testing, and their outcomes were audited. Results. The proforma was completed in 192/203 (94.6%) eligible patients. Twenty-five (21.5%) of 118 identified offspring had not been tested. Ten (8.5%) of these were <18 years old. All were reported to be clinically well. Ten children were referred for testing, seven were tested immediately, and three were tested within 18 months of identification. All children were tested HIV negative. Discussion. We have identified a method of identification that is easy and robust and provides a user-friendly safety net to empower healthcare providers to identify and test children at risk. We recommend the implementation of such strategies nationwide to prevent death due to undiagnosed HIV in children.
Collapse
|
16
|
de Mulder M, Yebra G, Navas A, de José MI, Gurbindo MD, González-Tomé MI, Mellado MJ, Saavedra-Lozano J, Muñoz-Fernández MÁ, de Ory SJ, Ramos JT, Holguín Á. High drug resistance prevalence among vertically HIV-infected patients transferred from pediatric care to adult units in Spain. PLoS One 2012; 7:e52155. [PMID: 23284913 PMCID: PMC3524105 DOI: 10.1371/journal.pone.0052155] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 11/09/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Antiretroviral treatment (ART) has contributed to increased life expectancy of HIV-1 infected children. In developed countries, an increasing number of children reaching adulthood are transferred to adult units. The objectives were to describe the demographic and clinical features, ART history, antiviral drug resistance and drug susceptibility in HIV-1 perinatally infected adolescents transferred to adult care units in Spain from the Madrid Cohort of HIV-1 infected children. METHODS Clinical, virological and immunological features of HIV-1 vertically infected patients in the Madrid Cohort of HIV-infected children were analyzed at the time of transfer. Pol sequences from each patient were recovered before transfer. Resistance mutations according to the InternationaI AIDS Society 2011 list were identified and interpreted using the Stanford algorithm. Results were compared to the non-transferred HIV-1 infected pediatric cohort from Madrid. RESULTS One hundred twelve infected patients were transferred to adult units between 1997 and 2011. They were mainly perinatally infected (93.7%), with a mean nadir CD4+-T-cells count of 10% and presented moderate or severe clinical symptoms (75%). By the time of transfer, the mean age was 18.9 years, the mean CD4+T-cells count was 627.5 cells/ml, 64.2% presented more than 350 CD4+T-cells/ml and 47.3% had ≤ 200 RNA-copies/ml. Most (97.3%) were ART experienced receiving Highly Active ART (HAART) (84.8%). Resistance prevalence among pretreated was 50.9%, 76.9% and 36.5% for Protease Inhibitors (PI), Nucleoside Reverse Transcriptase Inhibitors (NRTI) and Non-NRTI (NNRTI), respectively. Resistance mutations were significantly higher among transferred patients compared to non-transferred for the PI+NRTI combination (19% vs. 8.4%). Triple resistance was similar to non-transferred pediatric patients (17.3% vs. 17.6%). CONCLUSION Despite a good immunological and virological control before transfer, we found high levels of resistance to PI, NRTI and triple drug resistance in HIV-1 infected adolescents transferred to adult units.
Collapse
Affiliation(s)
- Miguel de Mulder
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, Hospital Universitario Ramón y Cajal, IRYCIS and CIBER-ESP, Madrid, Spain
| | - Gonzalo Yebra
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, Hospital Universitario Ramón y Cajal, IRYCIS and CIBER-ESP, Madrid, Spain
| | - Adriana Navas
- Pediatrics Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | | | | | | | - Jesús Saavedra-Lozano
- Pediatrics Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Santiago Jiménez de Ory
- Molecular Immunobiology Laboratory, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Tomás Ramos
- Pediatrics Department, Hospital Universitario de Getafe, Madrid, Spain
| | - África Holguín
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, Hospital Universitario Ramón y Cajal, IRYCIS and CIBER-ESP, Madrid, Spain
| | | |
Collapse
|
17
|
Kenny J, Williams B, Prime K, Tookey P, Foster C. Pregnancy outcomes in adolescents in the UK and Ireland growing up with HIV. HIV Med 2011; 13:304-8. [PMID: 22136754 DOI: 10.1111/j.1468-1293.2011.00967.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2011] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Adolescents with HIV infection acquired perinatally or in early childhood are becoming sexually active, but little is known about fertility and pregnancy outcomes. Multicentre data on pregnancy outcomes in this population are described here. METHODS A retrospective case note review of pregnant women with perinatal/early acquired HIV infection, conceiving before 1 September 2009 and attending participating centres in the UK and Ireland, was carried out. RESULTS Among 252 women with perinatal/early acquired infection aged 12 years and older under follow-up in 21 centres, 42 pregnancies were reported in 30 women (19 women with a single pregnancy, 10 women with two pregnancies, and one woman with three pregnancies). Fifteen women (50%) had previous AIDS-defining diagnoses. The median age at first reported pregnancy was 18 years (range 14-22 years). Of the 42 pregnancies, 34 (81%) were reportedly unplanned, 31 (74%) involved regular partners, and in 21 (50%) of the 42 pregnancies the partners were reported to be unaware of maternal HIV status. Fifteen of the 42 pregnancies (36%) were electively terminated, six of the 42 (14%) resulted in first-trimester miscarriages and 21 of the 42 (50%) resulted in live births. Maternal viral load was detectable close to delivery in seven of 21 pregnancies (33%). Four infants required neonatal intensive care, three of whom were delivered preterm. One infant is HIV infected, there are ongoing concerns about the development of three of 21 infants (14%), and two of 21 (10%) have been fostered. CONCLUSIONS Despite access to ongoing sexual health and contraceptive services, unplanned pregnancies are occurring in young women growing up with HIV. Pregnancy care and prevention of onward transmission require complex case management for this emerging population.
Collapse
Affiliation(s)
- J Kenny
- HIV in Young People Network (HYPNet), London, UK.
| | | | | | | | | |
Collapse
|
18
|
Kneen R, Michael BD, Menson E, Mehta B, Easton A, Hemingway C, Klapper PE, Vincent A, Lim M, Carrol E, Solomon T. Management of suspected viral encephalitis in children - Association of British Neurologists and British Paediatric Allergy, Immunology and Infection Group national guidelines. J Infect 2011; 64:449-77. [PMID: 22120594 DOI: 10.1016/j.jinf.2011.11.013] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 11/13/2011] [Indexed: 12/25/2022]
Abstract
In the 1980s the outcome of patients with herpes simplex encephalitis was shown to be dramatically improved with aciclovir treatment. Delays in starting treatment, particularly beyond 48 h after hospital admission, are associated with a worse prognosis. Several comprehensive reviews of the investigation and management of encephalitis have been published. However, their impact on day-to-day clinical practice appears to be limited. The emergency management of meningitis in children and adults was revolutionised by the introduction of a simple algorithm as part of management guidelines. In February 2008 a group of clinicians met in Liverpool to begin the development process for clinical care guidelines based around a similar simple algorithm, supported by an evidence base, whose implementation is hoped would improve the management of patients with suspected encephalitis.
Collapse
Affiliation(s)
- R Kneen
- Alder Hey Children's NHS Foundation Trust, West Derby, Liverpool L12 2AP, UK.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Whitfield CA, Kingston M, Fothergill H, Thng C. Are we forgetting the children? Testing the children of HIV-positive parents. Int J STD AIDS 2011; 22:177-8. [PMID: 21464458 DOI: 10.1258/ijsa.2010.010351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Undiagnosed HIV infection in children carries significant risks and national guidelines recommend that children of HIV-positive parents be tested. We reviewed the testing of HIV-positive patients' children in those new to our service from April 2008 to December 2009. Of the 86 women, 95% were asked about children. Of the 243 men, 53 were heterosexual or bisexual, and 190 identified themselves as men who have sex with men (MSM). Parental status was determined in 37 (70%) of heterosexual and bisexual men and in 14 (17%) of 84 MSM with a history of previous female partners. All untested children apart from one lived in their country of origin. In MSM, recording of parental status was uncommon. Following this audit, clinic proformas were changed to document the parental status of men of all sexual orientations, and the HIV status of all children.
Collapse
Affiliation(s)
- C A Whitfield
- Manchester Centre for Sexual Health, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | | | | | | |
Collapse
|
20
|
Cohen D, Lungu M, van Oosterhout JJ. HIV testing coverage of family members of adult antiretroviral therapy patients in Malawi. AIDS Care 2011; 22:1346-9. [PMID: 20635242 DOI: 10.1080/09540121003720986] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Many children in sub-Saharan Africa die from AIDS, not having accessed HIV testing and care. Children of adult antiretroviral therapy (ART) patients are a target group for HIV testing in order to increase access to care, but the HIV test coverage of this group in Malawi is unknown. In a cross-sectional survey of 832 patients at a large urban ART clinic in Blantyre, we found that 81.2% of 1223 children and 37.7% of 488 spouses of adult ART patients were reportedly not HIV tested. Wives of male patients were significantly less frequently HIV tested than husbands of female patients (53.0% vs. 72.4%, p<0.0001). Children under the age of 8 years (adjusted odds ratios [aOR] 2.76), children of female patients (aOR 2.53) and of patients whose partner had been HIV tested (aOR 2.87) were significantly more likely to have been tested for HIV. More attention needs to be given to provider initiated testing of children and spouses of ART patients.
Collapse
Affiliation(s)
- D Cohen
- Department of Medicine, University of Malawi, Blantyre, Malawi
| | | | | |
Collapse
|
21
|
Ferrand RA, Weiss HA, Nathoo K, Ndhlovu CE, Mungofa S, Munyati S, Bandason T, Gibb DM, Corbett EL. A primary care level algorithm for identifying HIV-infected adolescents in populations at high risk through mother-to-child transmission. Trop Med Int Health 2010; 16:349-55. [PMID: 21176006 PMCID: PMC3132444 DOI: 10.1111/j.1365-3156.2010.02708.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To present an algorithm for primary-care health workers for identifying HIV-infected adolescents in populations at high risk through mother-to-child transmission. Methods Five hundred and six adolescent (10–18 years) attendees to two primary care clinics in Harare, Zimbabwe, were recruited. A randomly extracted ‘training’ data set (n = 251) was used to generate an algorithm using variables identified as associated with HIV through multivariable logistic regression. Performance characteristics of the algorithm were evaluated in the remaining (‘test’) records (n = 255) at different HIV prevalence rates. Results HIV prevalence was 17%, and infection was independently associated with client-reported orphanhood, past hospitalization, skin problems, presenting with sexually transmitted infection and poor functional ability. Classifying adolescents as requiring HIV testing if they reported >1 of these five criteria had 74% sensitivity and 80% specificity for HIV, with the algorithm correctly predicting the HIV status of 79% of participants. In low-HIV-prevalence settings (<2%), the algorithm would have a high negative predictive value (≥99.5%) and result in an estimated 60% decrease in the number of people needing to test to identify one HIV-infected individual, compared with universal testing. Conclusions Our simple algorithm can identify which individuals are likely to be HIV infected with sufficient accuracy to provide a screening tool for use in settings not already implementing universal testing policies among this age-group, for example immigrants to low-HIV-prevalence countries.
Collapse
Affiliation(s)
- Rashida A Ferrand
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Skin disease among human immunodeficiency virus-infected adolescents in Zimbabwe: a strong indicator of underlying HIV infection. Pediatr Infect Dis J 2010; 29:346-51. [PMID: 19940800 PMCID: PMC3428906 DOI: 10.1097/inf.0b013e3181c15da4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Southern Africa is witnessing the emergence of an epidemic of long-term survivors of vertically acquired human immunodeficiency virus (HIV) infection presenting with untreated HIV as adolescents. Dermatologic conditions, common in both HIV-infected adults and children, have not been described in this age-group. We investigated the prevalence and spectrum of skin conditions in adolescents admitted to hospitals in Zimbabwe. METHODS A total of 301 consecutive adolescents admitted to 2 central Harare hospitals, underwent a dermatologic examination. Clinical history, HIV serology, and CD4 lymphocyte counts were obtained. Herpes simplex virus-2 serology was used as a surrogate marker for sexual activity. RESULTS : A total of 139 (46%) patients were HIV-1 antibody positive, of whom only 2 (1.4%) were herpes simplex virus-2 antibody positive. The prevalence of any skin complaint among HIV-infected and uninfected participants was 88% and 14%, respectively (odds ratio: 37.7, 95% confidence interval: 19.4-72). The most common HIV-related conditions were pruritic papular eruptions (42%) and plane warts >5% of body area (24%). Having 3 or more skin conditions, a history of recurrent skin rashes and angular cheilitis were each associated with CD4 counts <200 cells/microL (P < 0.03, P < 0.01, and P < 0.05, respectively). CONCLUSIONS Skin disease was a common and striking feature of underlying HIV-infection in hospitalized HIV-infected adolescents in Zimbabwe. In resource-poor settings with maturing epidemics, the presence of skin disease should be regarded as a strong indication for HIV testing and especially as it may reflect advanced immunosuppression. The high frequency of multiple plane warts has not previously been described, and may be a feature that distinguishes vertically-infected from horizontally-infected adolescents.
Collapse
|