HIV-associated changes in adaptive, emotional, and behavioral functioning in children and adolescents with hemophilia: results from the Hemophilia Growth and Development Study

OBJECTIVE

To assess changes in adaptive, emotional, and behavioral functioning over four years in children and adolescents with hemophilia and with or without HIV infection and to evaluate the relationship of these changes to immune status.

METHODS

Participants were 277 HIV-seropositive and 126 HIV-seronegative boys with hemophilia. Participants with HIV infection were divided into three groups based on trajectory of immune functioning (CD4+ cell counts) over the course of the study. Caregivers completed the Vineland Adaptive Behavior Scales and Pediatric Behavior Scale (PBS).

RESULTS

Results showed declining Vineland Communication scores for participants with consistently poor immune functioning. These participants also started with more PBS Attention Deficit and Deviation symptoms, which then decreased more sharply than for other groups. Low CD4+ counts were consistently associated with more Health and Depression-Anxiety symptoms on the PBS. However, with few exceptions, group means remained within normal limits.

CONCLUSIONS

According to their caregivers, boys with hemophilia and HIV infection showed considerable resilience with regard to adaptive behavior and emotional and behavioral problems. However, over time changes occurred in these areas that appear to be related to immune functioning.

Declining immune function in children and adolescents with hemophilia and HIV infection: effects on neuropsychological performance. Hemophilia Growth and Development Study

OBJECTIVE

To determine whether declines in immune functioning are associated with changes in neuropsychological performance in children and adolescents with hemophilia who are infected with the human immunodeficiency virus (HIV).

METHODS

Participants were 333 males with hemophilia, ages 6-19 years at entry. A baseline and four annual neuropsychological evaluations were given. A longitudinal growth curves analysis of data was performed to detect changes associated with declining immune function. The cohort was stratified into four groups: (1) HIV- (n = 126); (2) HIV+, average of first two and last two CD4 counts > or = 200, (n = 106; High CD4 group); (3) HIV+, average first two counts > or = 200, average last two counts < 200 (n = 41; CD4 Drop group); and (4) HIV+, average first two and last two counts < 200 (n = 60; Low CD4 group).

RESULTS

There were significant differences among the four groups over time in nonverbal intelligence, perceptual/performance skills, nonverbal memory, academic achievement, and language. The Low CD4 group consistently showed the greatest decrement in performance. On measures showing a practice effect for repeated measurements, the Low CD4 group participants' scores remained stable over time, suggesting opposing effects of practice and HIV-related declines. Lowered academic performance relative to IQ was found in all groups.

CONCLUSIONS

Declines in neuropsychological functioning are directly related to declines in immune functioning in HIV+ children, adolescents, and young adults with hemophilia. Hemophilia itself may be a risk factor for academic underachievement.

Hemophilia morbidity, cognitive functioning, and academic achievement

Data from the Hemophilia Growth and Development Study (HGDS) were used to evaluate the association between hemophilia morbidity, measured by abnormalities in coordination and gait (CG), and intellectual ability and academic achievement. The CG abnormalities observed in the HGDS participants (n = 333) were primarily due to hemophilia-related morbidity. Although HGDS participants performed within the average range for age on measures of intellectual ability, there were meaningful differences between CG outcomes at baseline and throughout the 4 years of study. Participants without CG abnormalities consistently achieved higher scores than those with CG abnormalities on Reading, Spelling, and Arithmetic subtests of the Wide Range Achievement Test-Revised. Our findings suggest that lowered achievement is related to the functional severity of hemophilia.

Comparability of absolute/percent CD4+ T-lymphocytes completed locally and centrally. Hemophilia Growth and Development Study

The Hemophilia Growth and Development Study (HGDS) is a multicenter longitudinal study of 333 male children and adolescents with moderate or severe hemophilia, ranging in age from 6 to 19 at entry. Sixty-two percent of the cohort was infected with human immunodeficiency virus (HIV) in the late 1970s and early 1980s through exposure to contaminated clotting factor concentrates. The HGDS has followed this cohort since 1989. HGDS subjects have blood drawn twice each year for t-lymphocyte subsets, with fresh blood shipped overnight to a central laboratory. T-lymphocyte subsets from the same blood draw are often determined locally as well. To evaluate interlaboratory variation, we examined the comparability of pairs of local and central results for CD4+ absolute counts and percents. Ninety-four pairs of absolute counts and 73 pairs of percent CD4 + results were available. We calculated concordance correlation coefficients, which evaluate the agreement between two readings from the sample by measuring the variation from the 45 degrees line through the origin. Absolute counts were square root transformed. Comparability of the pairs was high for both absolute counts and percents (0.93 and 0.92, respectively). Agreement was high whether we determined the CD4+ counts and percents centrally, using fresh samples received the day after the examination (0.95, 0.95), or from specimens that were frozen upon receipt and batched for later testing (0.90, 0.87). We conclude that when a centrally processed CD4+ result is unavailable because of shipping problems or loss of specimens, a study may reasonably accept a CD4+ result completed locally, if validity checks indicate good comparability. In the HGDS, the data provided by the local laboratories were of comparable quality to those provided by the central laboratories.

Hemophilia growth and development study: relationships between neuropsychological, neurological, and MRI findings at baseline

OBJECTIVE

To determine the effects of human immunodeficiency virus (HIV) infection on children's development by identifying neurological and environmental variables associated with neuropsychological measures of cognitive development in HIV-seronegative (HIV-) and HIV-seropositive (HIV+)children and adolescents with hemophilia.

METHODS

Participants (N = 298; 60% HIV+) were males ages 7-19 years enrolled in the Hemophilia Growth and Development Study (HGDS). Least squares modeling was used to determine whether there was a difference at baseline in mean neuropsychological test scores by HIV status, age, and neurological baseline findings, adjusting for selected environmental and medical history variables.

RESULTS

The participants were within age expectations for general intelligence. Variables associated with lowered neuropsychological performance included academic problems, coordination and/or gait abnormalities, parents' education, and previous head trauma.

CONCLUSIONS

Hemophilia-related morbidity has a subtle adverse influence on cognitive performance. HIV infection was not associated with neuropsychological dysfunction in this group even when MRI abnormalities were present.

Changes in smoking behavior and body weight after implementation of a no-smoking policy in the workplace

There is little information on the long-term consequences for employees when no-smoking policies are established in the workplace. Our study was designed to assess changes in employee health and smoking behavior. Of the original 60 subjects, 40 employees (18 smokers, 22 nonsmokers) completed this study, which was conducted in a major medical institution. Nonsmokers were recruited as part of the study to determine whether they showed evidence of workplace carbon monoxide associated with passive smoke, potentially inhaled at the work site. Baseline measurements of smoking frequency, carbon monoxide, and weight were obtained during the month preceding the smoking restrictions and at 6 and 18 months afterward. Smokers made significant reductions in daily smoking during the first 6 months but gradually returned to prepolicy levels over the following year. Smokers, in particular, showed increases in weight. Smokers gained 4.93 lb after 18 months, whereas nonsmokers gained 2.25 lb in the same period. Nonsmoker employees showed no evidence of workplace carbon monoxide exposure associated with passive smoke. We discuss the implications of the findings for no-smoking policies in the workplace.