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Magondo N, Meintjes EM, Warton FL, Little F, van der Kouwe AJW, Laughton B, Jankiewicz M, Holmes MJ. Distinct alterations in white matter properties and organization related to maternal treatment initiation in neonates exposed to HIV but uninfected. Sci Rep 2024; 14:8822. [PMID: 38627570 PMCID: PMC11021525 DOI: 10.1038/s41598-024-58339-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 03/27/2024] [Indexed: 04/19/2024] Open
Abstract
HIV exposed-uninfected (HEU) infants and children are at risk of developmental delays as compared to HIV uninfected unexposed (HUU) populations. The effects of exposure to in utero HIV and ART regimens on the HEU the developing brain are not well understood. In a cohort of 2-week-old newborns, we used diffusion tensor imaging (DTI) tractography and graph theory to examine the influence of HIV and ART exposure in utero on neonate white matter integrity and organisation. The cohort included HEU infants born to mothers who started ART before conception (HEUpre) and after conception (HEUpost), as well as HUU infants from the same community. We investigated HIV exposure and ART duration group differences in DTI metrics (fractional anisotropy (FA) and mean diffusivity (MD)) and graph measures across white matter. We found increased MD in white matter connections involving the thalamus and limbic system in the HEUpre group compared to HUU. We further identified reduced nodal efficiency in the basal ganglia. Within the HEUpost group, we observed reduced FA in cortical-subcortical and cerebellar connections as well as decreased transitivity in the hindbrain area compared to HUU. Overall, our analysis demonstrated distinct alterations in white matter integrity related to the timing of maternal ART initiation that influence regional brain network properties.
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Affiliation(s)
- Ndivhuwo Magondo
- Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, Biomedical Engineering Research Centre, University of Cape Town, Cape Town, South Africa.
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa.
| | - Ernesta M Meintjes
- Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, Biomedical Engineering Research Centre, University of Cape Town, Cape Town, South Africa.
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa.
- Cape Universities Body Imaging Centre, University of Cape Town, Cape Town, South Africa.
| | - Fleur L Warton
- Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, Biomedical Engineering Research Centre, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Andre J W van der Kouwe
- Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, Biomedical Engineering Research Centre, University of Cape Town, Cape Town, South Africa
- A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MI, USA
| | - Barbara Laughton
- Department of Paediatrics and Child Health and Tygerberg Children's Hospital, Faculty of Medicine and Health Sciences, Family Centre for Research with Ubuntu, Stellenbosch University, Stellenbosch, South Africa
| | - Marcin Jankiewicz
- Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, Biomedical Engineering Research Centre, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Cape Universities Body Imaging Centre, University of Cape Town, Cape Town, South Africa
- ImageTech, Simon Fraser University, Surrey, BC, Canada
| | - Martha J Holmes
- Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, Biomedical Engineering Research Centre, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
- ImageTech, Simon Fraser University, Surrey, BC, Canada
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Green F, du Plooy C, Rehman AM, Nhapi RT, Lake MT, Barnett W, Hoffman N, Zar HJ, Donald KA, Stein DJ, Wedderburn CJ. Language outcomes of preschool children who are HIV-exposed uninfected: An analysis of a South African cohort. PLoS One 2024; 19:e0297471. [PMID: 38598467 PMCID: PMC11006185 DOI: 10.1371/journal.pone.0297471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/05/2024] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION There are approximately 16 million children who are HIV-exposed and uninfected (CHEU) worldwide. Studies suggest that CHEU are at risk for developmental impairment in infancy, particularly in language domains. However, there is limited research examining neurocognitive function in CHEU older than 2 years, including important pre-school years. This study aimed to investigate associations between HIV exposure without infection and neurocognitive outcomes and to determine risk factors for neurodevelopment in CHEU at age 3-4 years. METHODS The Drakenstein Child Health Study is a South African population-based birth cohort which enrolled women in pregnancy with ongoing follow up. Neurocognitive outcomes were assessed in children at 3.5 years by trained assessors blinded to HIV status including general cognitive function, language, and memory, measured using the Kaufmann Assessment Battery for Children, Second Edition (KABC-II). Data were compared between CHEU and children who were HIV-unexposed uninfected (CHUU) using multivariable logistic and linear regression, including testing for effect modification; sex-stratified risk factor analyses were performed. RESULTS A total of 497 children were included (97 [20%] CHEU; 400 [80%] CHUU; 50% male), with a mean age of 3.5 years (range 3.4-3.6). Groups had similar birth and household characteristics, although mothers of CHEU were older, on average. Overall, CHEU had lower expressive language scores compared to CHUU on unadjusted and adjusted analyses (effect size: -0.23 [95% CI -0.45, -0.01]). There were no group differences in general cognitive or memory function (p>0.05). On sex-stratified analyses, male CHEU were found to have higher odds of suboptimal cognitive development compared to male CHUU (aOR 2.28 [95% CI 1.06, 4.87], p = 0.034). Several other factors including birthweight, maternal education, maternal ART duration and HIV viral load during pregnancy were associated with cognition, memory, or expressive language outcomes in CHEU, dependent on child sex. INTERPRETATION The findings suggest that perinatal HIV exposure continues to be associated with impaired language development across the preschool years, highlighting the importance of targeting early interventions to optimise language outcomes. Further, the results suggest the importance of demographic, biological and HIV-related variables influencing developmental outcomes in CHEU. The greater risk of suboptimal cognitive development in male CHEU requires investigation around sex-specific mechanisms.
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Affiliation(s)
- Freddy Green
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Christopher du Plooy
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrea M. Rehman
- MRC International Statistics & Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Raymond T. Nhapi
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Marilyn T. Lake
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council (SAMRC), Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Whitney Barnett
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Nadia Hoffman
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
| | - Heather J. Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council (SAMRC), Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Kirsten A. Donald
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Dan J. Stein
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- SAMRC, Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Catherine J. Wedderburn
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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Wedderburn CJ, Yeung S, Subramoney S, Fouche JP, Joshi SH, Narr KL, Rehman AM, Roos A, Gibb DM, Zar HJ, Stein DJ, Donald KA. Association of in utero HIV exposure with child brain structure and language development: a South African birth cohort study. BMC Med 2024; 22:129. [PMID: 38519887 PMCID: PMC10960435 DOI: 10.1186/s12916-024-03282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 02/01/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND There is a growing population of children with in utero HIV exposure who are at risk of poor neurodevelopmental outcomes despite avoiding HIV infection. However, the underlying neurobiological pathways are not understood and neuroimaging studies are lacking. We aimed to investigate the cortical brain structure of children who are HIV-exposed and uninfected (HEU) compared to HIV-unexposed (HU) children and to examine the relationship with neurodevelopment. METHODS The Drakenstein Child Health birth cohort study enrolled pregnant women from a high HIV prevalence area in South Africa with longitudinal follow-up of mother-child pairs. High-resolution magnetic resonance imaging scans from 162 children (70 HEU; 92 HU) were acquired at 2-3 years of age. All HEU children were born to mothers taking antiretroviral therapy. Measures of brain structure (cortical thickness and surface area) in the prefrontal cortex regions were extracted from T1-weighted images and compared between groups using multivariate analysis of variance and linear regression. Child development, assessed using the Bayley Scales of Infant and Toddler Development-III, was correlated with cortical structure, and mediation analyses were performed. RESULTS Analyses demonstrated an association between HIV exposure and cortical thickness across the prefrontal cortex (p = 0.035). Children who were HEU had thicker cortices in prefrontal regions, with significantly greater cortical thickness in the medial orbitofrontal cortex (mOFC) bilaterally compared to HU children (3.21 mm versus 3.14 mm, p = 0.009, adjusted effect size 0.44 [95% CI 0.12 to 0.75]). Estimates held across multiple sensitivity analyses. There were no group differences in cortical surface area. Language scores, which were lower in HEU versus HU children (81.82 versus 86.25, p = 0.011, effect size - 0.44 [95% CI - 0.78 to - 0.09]), negatively correlated with prefrontal cortical thickness in both groups. Cortical thickness in the mOFC mediated the relationship between HIV exposure and poor language outcomes (Sobel test p = 0.032). CONCLUSIONS In this cohort study, exposure to HIV during pregnancy was associated with altered cortical structure in early life. Our findings indicate that differences in cortical thickness development in the prefrontal region in children who are HEU may be a pathway leading to language impairment. Longitudinal studies are needed to determine the lasting impact.
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Affiliation(s)
- Catherine J Wedderburn
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.
- The Neuroscience Institute, University of Cape Town, Cape Town, South Africa.
| | - Shunmay Yeung
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Sivenesi Subramoney
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Jean-Paul Fouche
- The Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
| | - Shantanu H Joshi
- Departments of Neurology, Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA, USA
| | - Katherine L Narr
- Departments of Neurology, Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Andrea M Rehman
- MRC International Statistics & Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Annerine Roos
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
- The Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- SA MRC Unit On Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Diana M Gibb
- MRC Clinical Trials Unit, University College London, London, UK
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
- SA MRC Unit On Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- The Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
- SA MRC Unit On Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Kirsten A Donald
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
- The Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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Magondo N, Meintjes EM, Warton FL, Little F, van der Kouwe AJ, Laughton B, Jankiewicz M, Holmes MJ. Distinct alterations in white matter properties and organization related to maternal treatment initiation in neonates exposed to HIV but uninfected. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.11.575169. [PMID: 38260347 PMCID: PMC10802593 DOI: 10.1101/2024.01.11.575169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
HIV exposed-uninfected (HEU) infants and children are at risk of developmental delays as compared to uninfected unexposed (HUU) populations. The effects of exposure to in utero HIV and ART regimens on the HEU the developing brain are not well understood. In a cohort of 2-week-old newborns, we used diffusion tensor imaging (DTI) tractography and graph theory to examine the influence of HIV and ART exposure in utero on neonate white matter integrity and organisation. The cohort included HEU infants born to mothers who started ART before conception (HEUpre) and after conception (HEUpost), as well as HUU infants from the same community. We investigated HIV exposure and ART duration group differences in DTI metrics (fractional anisotropy (FA) and mean diffusivity (MD)) and graph measures across white matter. We found increased MD in white matter connections involving the thalamus and limbic system in the HEUpre group compared to HUU. We further identified reduced nodal efficiency in the basal ganglia. Within the HEUpost group, we observed reduced FA in cortical-subcortical and cerebellar connections as well as decreased transitivity in the hindbrain area compared to HUU. Overall, our analysis demonstrated distinct alterations in white matter integrity related to the timing of maternal ART initiation that influence regional brain network properties.
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Affiliation(s)
- Ndivhuwo Magondo
- Biomedical Engineering Research Centre, Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Ernesta M. Meintjes
- Biomedical Engineering Research Centre, Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Cape Universities Body Imaging Centre, University of Cape Town, Cape Town, South Africa
| | - Fleur L. Warton
- Biomedical Engineering Research Centre, Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Andre J.W. van der Kouwe
- Biomedical Engineering Research Centre, Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA,USA
- Department of Radiology, Harvard Medical School, Boston, MI, USA
| | - Barbara Laughton
- Family Centre for Research with Ubuntu, Department of Paediatrics and Child Health and Tygerberg Children’s Hospital, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch,South Africa
| | - Marcin Jankiewicz
- Biomedical Engineering Research Centre, Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Cape Universities Body Imaging Centre, University of Cape Town, Cape Town, South Africa
- ImageTech, Simon Fraser University, Surrey, BC, Canada
| | - Martha J. Holmes
- Biomedical Engineering Research Centre, Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
- ImageTech, Simon Fraser University, Surrey, BC, Canada
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Bulterys MA, Njuguna I, Mahy M, Gulaid LA, Powis KM, Wedderburn CJ, John-Stewart G. Neurodevelopment among children exposed to HIV and uninfected in sub-Saharan Africa. J Int AIDS Soc 2023; 26 Suppl 4:e26159. [PMID: 37909232 PMCID: PMC10618877 DOI: 10.1002/jia2.26159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 08/21/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION The population of 16 million children exposed to HIV and uninfected (CHEU) under 15 years of age continues to expand rapidly, and the estimated prevalence of CHEU exceeds 20% in several countries in sub-Saharan Africa with high HIV prevalence. Some evidence suggests that CHEU experience suboptimal neurodevelopmental outcomes compared to children born to women without HIV. In this commentary, we discuss the latest research on biologic and socio-behavioural factors associated with neurodevelopmental outcomes among CHEU. DISCUSSION Some but not all studies have noted that CHEU are at risk of poorer neurodevelopment across multiple cognitive domains, most notably in language and motor skills, in diverse settings, ages and using varied assessment tools. Foetal HIV exposure can adversely influence infant immune function, structural brain integrity and growth trajectories. Foetal exposure to antiretrovirals may also influence outcomes. Moreover, general, non-CHEU-specific risk factors for poor neurodevelopment, such as preterm birth, food insecurity, growth faltering and household violence, are amplified among CHEU; addressing these factors will require multi-factorial solutions. There is a need for rigorous harmonised approaches to identify children at the highest risk of delay. In high-burden HIV settings, existing maternal child health programmes serving the general population could adopt structured early child development programmes that educate healthcare workers on CHEU-specific risk factors and train them to conduct rapid neurodevelopmental screening tests. Community-based interventions targeting parent knowledge of optimal caregiving practices have shown to be successful in improving neurodevelopmental outcomes in children and should be adapted for CHEU. CONCLUSIONS CHEU in sub-Saharan Africa have biologic and socio-behavioural factors that may influence their neurodevelopment, brain maturation, immune system and overall health and wellbeing. Multidisciplinary research is needed to disentangle complex interactions between contributing factors. Common environmental and social risk factors for suboptimal neurodevelopment in the general population are disproportionately magnified within the CHEU population, and it is, therefore, important to draw on existing knowledge when considering the socio-behavioural pathways through which HIV exposure could impact CHEU neurodevelopment. Approaches to identify children at greatest risk for poor outcomes and multisectoral interventions are needed to ensure optimal outcomes for CHEU in sub-Saharan Africa.
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Affiliation(s)
- Michelle A Bulterys
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Irene Njuguna
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Kenyatta National Hospital, Nairobi, Kenya
| | | | - Laurie A Gulaid
- UNICEF, eastern and southern Africa Regional Office, Nairobi, Kenya
| | - Katheen M Powis
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Catherine J Wedderburn
- Department of Pediatrics and Child Health and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- School of Medicine, University of Washington, Seattle, Washington, USA
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