Evaluation of the WHO clinical case definition for pediatric HIV infection in Bloemfontein, South Africa

Addition of Questions on Parental Factors to the WHO (Integrated Management of Childhood Illnesses) IMCI-HIV Algorithm Improves the Utility of the Algorithm for Diagnosis of HIV Infection in Children

The WHO Integrated Management of Childhood Illnesses-HIV (IMCI-HIV) algorithm and its regional adaptation have shown variable performance in clinically identifying HIV-infected children with lack of validation in low prevalence areas. Addition of certain 'parental factors' (proxy indicators of parental HIV) may improve its utility. In this study, children aged 2 months to 5 years were enrolled into Group A (n = 1000, 'suspected symptomatic HIV infected' children as per the IMNCI-HIV algorithm) and group B (n = 50, children newly diagnosed with HIV infection). Parental factors were asked and HIV infection was tested for in Group A. For Group B, retrospective data were collected regarding IMNCI-HIV algorithm signs and parental factors. Utility of individual and various combinations of IMNCI-HIV signs and parental factors to predict HIV status was evaluated. Results showed that incorporating parental factors to IMNCI-HIV algorithm improved its sensitivity and positive predictive value in identifying HIV-infected children while maintaining the same sensitivity.

Human immunodeficiency virus status in malnourished children seen at Lagos

Introduction

Human immunodeficiency virus and protein energy malnutrition are still prevalent in Nigeria and the occurrence of the two conditions together confers a poor prognosis. The aim of this study was to determine the current categories of malnutrition amongst under-5 children in Lagos, document their HIV status and determine any peculiarities in the clinical features, haematological and some biochemical profile in these children.

Methods

The study was a cross-sectional study conducted at the Paediatric departments of the Lagos University Teaching Hospital and the Massey Street Children’s Hospital, both in Lagos, over a 6-month period. All the subjects had anthropometry, HIV testing, full blood count and serum proteins done. The factors associated with HIV status were determined with the logistic regression analysis.

Results

Two hundred and fourteen (214) malnourished children ≤5 years, including 25 (11.7%) with HIV were recruited in the study. Among the study participants, 150 (70.1%) and 54 (29.9%) had moderate and severe malnutrition, respectively. Fever, cough and diarrhea were the most common symptoms in the study participants. The haematological indices were comparable in the two groups, the serum globulin levels though higher in the HIV infected group was not statistically significantly different from the non-infected group.(p = 0.66). None of the factors explored on multivariate analysis was able to predict the occurrence of the infection in this cohort.

Conclusion

Malnourished children remain a high risk group for HIV infection and the prevalence of the infection obtained in this group of children is still unacceptably high. Discriminatory features between malnutrition and HIV remains difficult. The presence of hyperglobulinaemia on laboratory analysis in a malnourished child may heighten the suspicion of possible underlying associated HIV infection. Screening of malnourished children for HIV infection and further longitudinal studies on malnourished children with HIV is advocated

Clinical Findings of Pediatric HIV Infection in a Tertiary Center in Turkey

Background:

Paediatric HIV infection is different from the adult type of disease in many ways, including transmission routes, clinical findings and treatment strategies.

Aims:

To evaluate clinical data of paediatric patients with HIV disease.

Study Design:

Retrospective cross-sectional study.

Methods:

The charts of 22 paediatric patients diagnosed with HIV infection in our clinic during a 14 year period through 2001-2015 were retrospectively analysed. Clinical data, laboratory findings, treatment modalities and outcomes were recorded.

Results:

The mean age of diagnosis 61.9±49.2 months and the mean follow-up period was 60.3±37.5 months. Seven patients (31.8%) were foreigners and the most common transmission route was vertical transmission (n=16, 72.7%). The most common presenting symptom and the sign were history of recurrent upper respiratory tract infections (n=8, 36.4%) and lymphadenopathy (n=12, 54.5%), respectively. Recurrent pneumonia (n=6, 27.3%), prolonged fever (n=5, 22.7%), recurrent otitis media (n=4, 18.2%), and gastroenteritis (n=4, 18.2%) were other clinical symptoms. Other than bacterial sinopulmonary infections, tuberculosis was the most frequent opportunistic infection (n=3, 13.6%). Mortality occurred in two patients (9.1%).

Conclusion:

Although mostly vertically transmitted, HIV infection may be diagnosed throughout the childhood. Frequently encountered signs and symptoms may be the reason for doctor admission. High clinical suspicion together with detailed anamnestic data and physical findings constitute the basis for pediatric HIV diagnosis.

Prevalence of oral candidiasis in HIV/AIDS children in highly active antiretroviral therapy era. A literature analysis

SummaryHighly active antiretroviral therapy has decreased the morbidity and mortality related to HIV infection, including oral opportunistic infections. This paper offers an analysis of the scientific literature on the epidemiological aspects of oral candidiasis in HIV-positive children in the combination antiretroviral therapy era. An electronic databases search was made covering the highly active antiretroviral therapy era (1998 onwards). The terms used were oral lesions, oral candidiasis and their combination with highly active antiretroviral therapy and HIV/AIDS children. The following data were collected from each paper: year and country in which the investigation was conducted, antiretroviral treatment, oral candidiasis prevalence and diagnostic parameters (clinical or microbiological). Prevalence of oral candidiasis varied from 2.9% in American HIV-positive children undergoing highly active antiretroviral therapy to 88% in Chilean HIV-positive children without antiretroviral therapy. With respect to geographical location and antiretroviral treatment, higher oral candidiasis prevalence in HIV-positive children on combination antiretroviral therapy/antiretroviral therapy was reported in African children (79.1%) followed by 45.9% reported in Hindu children. In HIV-positive Chilean children on no antiretroviral therapy, high oral candidiasis prevalence was reported (88%) followed by Nigerian children (80%). Oral candidiasis is still frequent in HIV-positive children in the highly active antiretroviral therapy era irrespective of geographical location, race and use of antiretroviral therapy.

Improving survival of children with severe acute malnutrition in HIV-prevalent settings

The care of severely malnourished children in sub-Saharan Africa is challenging, especially in HIV-prevalent settings. Recent improvements to facility-based individual case management, and increased community-based management focusing on early identification and high programme coverage have led to reductions in mortality. Further interventions are urgently needed to address resistant mortality, mostly attributable to HIV. This paper explores strategies in three main areas to improve survival for children with severe acute malnutrition (SAM): identifying HIV and improving case management for HIV-infected children; strengthening existing strategies to improve outcomes for all children with SAM, regardless of HIV status; and improving early identification and increasing programme coverage. Although interventions to further improve survival among children with SAM in sub-Saharan Africa must firstly ensure best care for all children, HIV-infected children are at particular risks for mortality. Integration of specific interventions for HIV testing and treatment into SAM care is essential. International guidelines should reflect best evidence, and are in urgent need of updating and adapting to local country context. Effective interventions already exist that can improve survival in children with SAM in HIV-prevalent settings. The challenge is to implement what we know and to research what we do not.

Performance of the integrated management of childhood illness algorithm for diagnosis of HIV-1 infection among African infants

OBJECTIVES

Early infant HIV-1 diagnosis and treatment substantially improve survival. Where virologic HIV-1 testing is unavailable, integrated management of childhood illness (IMCI) clinical algorithms may be used for infant HIV-1 screening. We evaluated the performance of the 2008 WHO IMCI HIV algorithm in a cohort of HIV-exposed Kenyan infants.

METHODS

From 1999 to 2003, 444 infants had monthly clinical assessments and quarterly virologic HIV-1 testing. Using archived clinical data, IMCI sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated using virologic testing as a gold standard. Linear regression and survival analyses were used to determine the effect of age on IMCI performance and timing of diagnosis.

RESULTS

Overall IMCI sensitivity, specificity, PPV, and NPV value were 58, 87, 52, and 90%, respectively. Sensitivity (1.4%) and PPV (14%) were lowest at 1 month of age, when 81% of HIV infections already had occurred. Sensitivity increased with age (P < 0.0001), but remained low throughout infancy (range 1.4-35%). Specificity (range 97-100%) was high at each time point and was not associated with age. Fifty-eight percent of HIV-1-infected infants (50 of 86) were eventually diagnosed by IMCI, and use of IMCI was estimated to delay diagnosis in HIV-infected infants by a median of 5.9 months (P < 0.0001).

CONCLUSION

IMCI had low sensitivity during the first month of life, when the majority of HIV-1 infections had already occurred and initiation of treatment is most critical. Although sensitivity increased with age, the substantial delay in HIV-1 diagnosis using IMCI limits its utility in early infant HIV-1 diagnosis.

Presumptive diagnosis of severe HIV infection to determine the need for antiretroviral therapy in children less than 18 months of age

OBJECTIVE

To develop a new algorithm for the presumptive diagnosis of severe disease associated with human immunodeficiency virus (HIV) infection in children less than 18 months of age for the purpose of identifying children who require antiretroviral therapy (ART).

METHODS

A conditional probability model was constructed and non-virologic parameters in various combinations were tested in a hypothetical cohort of 1000 children aged 6 weeks, 6 months and 12 months to assess the sensitivity, specificity, and positive and negative predictive values of these algorithms for identifying children in need of ART. The modelled parameters consisted of clinical criteria, rapid HIV antibody testing and CD4+ T-lymphocyte (CD4) count.

FINDINGS

In children younger than 18 months, the best-performing screening algorithm, consisting of clinical symptoms plus antibody testing plus CD4 count, showed a sensitivity ranging from 71% to 80% and a specificity ranging from 92% to 99%. Positive and negative predictive values were between 61% and 97% and between 95% and 96%, respectively. In the absence of virologic tests, this alternate algorithm for the presumptive diagnosis of severe HIV disease makes it possible to correctly initiate ART in 91% to 98% of HIV-positive children who are at highest risk of dying.

CONCLUSION

The algorithms presented in this paper have better sensitivity and specificity than clinical parameters, with or without rapid HIV testing, for the presumptive diagnosis of severe disease in HIV-positive children less than 18 months of age. If implemented, they can increase the number of HIV-positive children successfully initiated on ART.

Impact of HIV/Aids on Child Mortality before the Highly Active Antiretroviral Therapy Era: A Study in Pointe-Noire, Republic of Congo

Few studies have documented the contribution of HIV/AIDS to mortality among children under 15 years. From June 30 to October 19, 2001, all child deaths (n = 588) registered to the morgue and/or hospitals of the city of Pointe-Noire, Congo, were investigated using a combined approach including an interview of relatives and postmortem clinical and biological HIV diagnosis. Twenty-one percent of children were HIV positive, while 10.5% of deaths were attributed to AIDS. The most common causes of death in HIV-infected children were pneumonia (30%), pyrexia (22%), diarrhoea (16%) and wasting syndrome (16%). Infant mortality rate was estimated 6.3 times higher in children born to HIV-infected mothers compared to HIV-uninfected mothers. This study provides a direct measure of HIV/AIDS as impact on child mortality using a rapid and reliable method. A significant number of deaths could be prevented if HIV infection was diagnosed earlier and infants were provided with antiretroviral treatments.

Paediatric HIV in central Sudan: high sero-prevalence and poor performance of clinical case definitions

BACKGROUND

Paediatric clinical case definitions (CCDs) for the human immunodeficiency virus (HIV) have been proposed as screening tools in resource-limited countries.

OBJECTIVES

We assessed the performance of the World Health Organisation CCD (WHO-CCD), the Bloemfontein CCD (B-CCD) and a locally modified version of the Bloemfontein CCD (MB-CCD) in comparison with HIV serology in acutely hospitalised children aged 1.5-14 years. We also determined the HIV sero-prevalence among this group of children.

STUDY DESIGN

A cohort of 106 consecutive acute paediatric admissions to a major teaching hospital in central Sudan was recruited over a 3-month period.

RESULTS

The WHO-CCD, B-CCD, and MB-CCD were relatively specific with estimates of 96.0% (95% confidence interval [CI] 90.1-98.9), 88.0% (95% CI 80.0-93.6), and 74.0% (95% CI 64.3-82.3), respectively. However, corresponding sensitivities were poor with estimates of 16.7% (95% CI 0.4-64.1), 33.3% (95% CI 4.3-77.7), and 66.7% (95% CI 22.3-95.7), respectively. The HIV sero-prevalence was high at 5.7% (95% CI 2.1-11.9).

CONCLUSIONS

CCDs performed poorly against HIV serology in acutely hospitalised children aged 1.5-14 years in central Sudan and, therefore, we advocate improving access to serological diagnostic tools. The high HIV sero-prevalence rate among this group of children poses serious challenges to policy makers and warrants further research.

Sensitivity of paediatric AIDS score vs. WHO case classification in Indian children--a retrospective study

This study was conducted at the Department of Paediatrics, Dr Ram Manohar Lohia Hospital, to test the statistical significance of existing World Health Organization (WHO) clinical case definition (CCD) for diagnosis of AIDS in areas where diagnostic resources are limited. A total of 360 cases between 18 months and 12 years of age satisfying WHO case definitions of AIDS were included in study group. Our study detected 16.66% (60) of HIV incidence in children visiting the paediatrics outpatient clinic. Twenty percent of cases manifested three major and two minor signs, which had sensitivity of 73.33%; specificity, 90.66% and positive predictive value (PPV), 61.11%. Stepwise logistic analysis identified weight loss, chronic fever >1 month and total lymphocyte count <1500 cells mm(-3) as important predictors. Eighty-six cases (23.89%) showed two major and two minor signs with sensitivity and specificity of 86.66 and 88.66%, respectively. Thus a CCD based on 13 clinical signs/symptoms was proposed for paediatric AIDS with better sensitivity and PPV than the WHO case definition but with almost similar specificity.

Effect of ocular surface reconstruction by using amniotic membrane transplant for symptomatic conjunctivochalasis on fluorescein clearance test results

PURPOSE

To evaluate the hypothesis that the therapeutic effect of amniotic membrane transplantation (AMT) ocular surface reconstruction in the setting of symptomatic temporal conjunctivochalasis is through improved tear clearance.

METHODS

Twelve eyes with delayed tear clearance by the fluorescein clearance test in the setting of symptomatic temporal conjunctivochalasis were subjected to surface reconstruction by using AMT and evaluated for the effect on delayed tear clearance, symptoms, surface erosions, artificial tear use, visual acuity, and tear strip wetness.

RESULTS

AMT of temporal symptomatic conjunctivochalasis did not improve tear clearance; however, it significantly improved symptoms (Fisher exact test, P = 0.001), surface erosions (Fisher exact test, P = 0.008), and log minimal angle resolution visual acuity (Fisher exact test, P = 0.007) and reduced artificial tear use (Fisher exact test, P = 0.015). There was also an improvement in tear strip wetting, but this did not reach statistical significance.

CONCLUSIONS

Relief of symptoms and improvement in clinical signs after AMT for symptomatic temporal conjunctivochalasis was not caused by improved tear clearance.

Management of oral lesions in HIV-positive patients

HIV/AIDS is currently the leading cause of death in Africa and the fourth leading cause of death worldwide. This systematic review of the literature was conducted to evaluate the evidence for treatment of the most common oral lesions associated with HIV: oral candidiasis with or without oropharyngeal involvement (OPC), oral hairy leukoplakia (OHL), recurrent aphthous-like ulcerations (RAU), oral Kaposi's sarcoma (OKS), orolabial herpes simplex infection (HSV), oral herpes zoster infection (VZV), intraoral or perioral warts (HPV), and HIV-associated periodontal diseases. Treatment of HIV-associated salivary gland disease is addressed in a different section of this World Workshop. We found the largest body of evidence for treatment of OPC in HIV patients. Future trials will be needed to test drugs currently in development for treatment of Candida strains that are resistant to existing therapies. There were no double blind, placebo-controlled randomized clinical trials (RCT) for topical treatment of OHL, and only one RCT for systemic treatment of the lesion with desciclovir. Systemic thalidomide was the only drug tested in RCT for treatment or prevention of RAU. Only 1 double-blind RCT comparing vinblastine and sodium tetradecyl sulfate was identified for localized treatment of OKS. Three drugs (famciclovir, acyclovir, and valaciclovir) were shown to be effective in randomized, double-blind trials for treatment or suppression of mucocutaneous HSV lesions in HIV patients. In all 3 trials, the effects of these medications on orolabial HSV lesions were not reported separately. There were no double-blind, placebo-controlled RCT testing topical treatments for orolabial HSV lesions in HIV patients. No trials testing treatments of oral VZV were identified. There were no double-blind, placebo-controlled RCT for treatment of HIV-associated intraoral or perioral warts or periodontal diseases. In conclusion, there is a need for well-designed RCTs to assess the safety and efficacy of topical and systemic treatments of most oral mucosal and perioral lesions in HIV patients. There is also a need to develop newer drugs for treatment of resistant fungal and viral microorganisms. Finally, standardized outcome measures should be developed for future clinical trials to allow comparisons of studies using different populations.

Care and treatment of HIV-infected children in Africa: issues and challenges at the district hospital level

More than 90% of pediatric HIV infection occurs in sub-Saharan Africa and 75% of these children currently die before their fifth birthday. Most HIV-infected children in Africa rely on district hospitals for HIV treatment, but insufficient attention has been paid to improving HIV/AIDS care at this level. Considerable confusion exists about optimal use of combination antiretroviral treatment, prophylaxis for opportunistic infections and other rational healthcare interventions that can greatly improve the quality of life for these children. A simple and inexpensive infant HIV diagnostic assay and alternative laboratory markers of pediatric HIV disease progression would be highly beneficial. Routine anthropometric and neurodevelopmental assessments could help guide initiation and monitoring of antiretroviral therapy. Even in the absence of antiretroviral therapy, interventions such as immunizations, provision of micronutrients and nutrition counseling, prevention and treatment of opportunistic as well as endemic infections (such as helminths and malaria) can substantially reduce pediatric HIV-related morbidity and mortality. The need for pain relief, palliative care, counseling and emotional support is often underestimated. Surmounting the sense of hopelessness by providing district healthcare workers with training in basic pediatric HIV/AIDS care is an urgent priority.

The first 5 years of the family clinic for HIV at Tygerberg Hospital: family demographics, survival of children and early impact of antiretroviral therapy

BACKGROUND

Family clinics address the problems of HIV-infected children and their families. The aims were to document demographics of the children and caregivers attending the Family Clinic for HIV at Tygerberg Academic Hospital (TAH) and to investigate factors affecting disease progression in children.

METHODS

A retrospective folder review of children and parents attending the Family Clinic at TAH between January 1997 and December 2001, a period noted for its lack of antiretroviral treatment.

RESULTS

Of 432 children seen for testing, 274 children, median age 16.9 months, were HIV-infected. During follow-up, 46 children died (median age 23 months) and 113 were lost to follow-up. The majority of children were malnourished. Those <2 years of age had lower weight for age Z-scores (WAZ) than older children (p<0.001). At presentation, 47 per cent were in clinical stage B and two-thirds had moderate or severe CD4+ T cell depletion. Seventeen children had received highly active antiretroviral therapy (HAART), 12 dual and 31 monotherapy. HAART was associated with improved survival compared to dual or monotherapy. Risk of death was reduced from eleven-fold for a WAZ <-4 to four-fold between -2 and -3. There was no association with immunological and clinical classification at entry and risk of mortality. Only 18 per cent of parents were evaluated in the clinic. Non-parental care was documented for 25 per cent of families.

CONCLUSIONS

A low WAZ is associated with poor survival in children. Nutritional status should receive more attention in HIV disease classification in children. Parent utilization of the clinic was inadequate. Even in the absence of HAART, extended survival in children is possible.

Clinical profile of pediatric HIV infection from India

BACKGROUND

Our aim was to study the clinical profile of pediatric patients admitted with HIV infection.

METHODS

The prospective study was conducted from January 2000 to October 2001 at a tertiary care referral teaching hospital in Mumbai, India. Admitted in-patients (aged 1 month to 12 years) detected to be HIV-positive (on triple ELISA test) were enrolled in the study. HIV status of patients < 18 months of age was confirmed by DNA-PCR testing. Demographic data, clinical features, investigations and outcome were recorded in a pre-designed proforma.

RESULTS

Fifty HIV-positive children (31 males and 19 females; M:F = 1.6:1) were enrolled. Thirty cases were completely immunized, 9 were partially immunized while 11 were not immunized. Forty-two were perinatally infected, while eight cases were infected via blood transfusion (patients with thalassemia major on chronic transfusion therapy). Clinical features at presentation in 42 symptomatic cases included protein-energy malnutrition (90%), fever > 1 month (50%), weight loss > 1 month (50%), persistent generalized lymphadenopathy (24%) and skin manifestations (79%). The gastrointestinal (62%) and respiratory (52%) were the most commonly involved organ systems. Opportunistic infections noted included tuberculosis (19 cases), candidiasis (6 cases), Pneumocystis carinii pneumonia (4 cases), herpes zoster (3 cases) and giardiasis (1 case). Six patients died (mortality, 14%).

CONCLUSIONS

Perinatal transmission is the most common mode of acquiring HIV in the pediatric age group. Most patients have protein-energy malnutrition. Tuberculosis is common in HIV-infected Indian children. Patients with HIV-encephalopathy have a poor outcome.