Community action to end paediatric HIV infections

Virtual prevention of HIV transmission from parents to children is possible. This is cause for hope and renewed energy for prevention in general. The Global Plan is the most concerted and ambitious plan to date to protect children and to promote their care. But the inspiring and much appreciated global targets cannot be achieved, nor will they be realized in spirit in addition to form, without joint action between health services, affected women, their partners, families and communities and the wider society. In turn, this engagement is only possible under enabling political, legal, material and social conditions. Much has already been achieved, and community engagement can everywhere be seen in efforts to increase demand, to supply services and to create and improve enabling environments. Some of these initiatives are highly organized and expansive, with demonstrated success. Others are local but essential adjuncts to health services. The nature of this engagement varies because the challenges are different across countries and parts of countries. To be sustained and effective, community action must simultaneously be inclusive and supportive for those people who are affected, it must be appreciated and assigned a place within the broad systemic response, and it must promote and defend social justice.     

Undiagnosed HIV infections among gay and bisexual men increasingly contribute to new infections in Australia

Introduction

We determined the contribution of undiagnosed HIV to new infections among gay and bisexual men (GBM) over a 12‐year period in Australia where there has been increasing focus on improving testing and HIV treatment coverage.

Methods

We generated annual estimates for each step of the HIV cascade and the number of new HIV infections for GBM in Australia over 2004 to 2015 using relevant national data. Using Bayesian melding we then fitted a quantitative model to the cascade and incidence estimates to infer relative transmission coefficients associated with being undiagnosed, diagnosed and not on ART, on ART with unsuppressed virus, or on ART with suppressed virus.

Results

Between 2004 and 2015, we estimated the percentage of GBM with HIV in Australia who were unaware of their status to have decreased from 14.5% to 7.5%. During the same period, there was a substantial increase in the number and proportion of GBM living with HIV on treatment and with suppressed virus, with the number of virally suppressed GBM increasing from around 3900 (30.2% of all GBM living with HIV) in 2004 to around 14,000 (73.7% of all GBM living with HIV) in 2015. Despite the increase in viral suppression, the annual number of new infections rose from around 660 to around 760 over this period. Our results have a wide range due to the uncertainty in the cascade estimates and transmission coefficients. Nevertheless, undiagnosed GBM increasingly appear to contribute to new infections. The proportion of new infections attributable to undiagnosed GBM almost doubled from 33% in 2004 to 59% in 2015. Only a small proportion (<7%) originated from GBM with suppressed virus.

Discussion

Our study suggests that an increase in HIV treatment coverage in Australia has reduced the overall risk of HIV transmission from people living with HIV. However, the proportion of infections and the rate of transmission from undiagnosed GBM has increased substantially. These findings highlight the importance of HIV testing and intensified prevention for Australian GBM at high risk of HIV.

     

Eliminating paediatric infections and keeping mothers alive

The global plan of reducing the number of new child HIV infections and a reduction in the number of HIV‐related maternal deaths by 2015 will require inordinate political commitment and strengthening of health systems in Sub‐Saharan Africa where the burden of HIV infections in pregnant women is the highest. Preventing HIV infection in women of child‐bearing age and unwanted pregnancies in HIV‐positive women forms the cornerstone of long‐term control of paediatric HIV infections. To achieve the goal of eliminating paediatric HIV infection by 2015, health systems strengthening to address prevention of mother‐to‐child HIV transmission cascade attrition and focusing on the elimination of breastmilk transmission is critical. Understanding the pathogenesis of breastmilk transmission and the mechanisms by which antiretroviral therapy impacts on transmission through this compartment will drive future interventions. Identifying and retaining HIV‐positive pregnant women in care and committed to long‐term antiretroviral therapy will improve maternal outcomes and concomitant reductions in maternal mortality. Research assessing the natural history of HIV infection and long‐term outcomes in women who interrupt antiretroviral therapy post‐weaning is urgently required. Data on the outcome of women who opt to continue the long‐term use of antiretroviral therapy after initiating therapy during pregnancy will determine future policy in countries considering option B+. The prevalence of antiretroviral resistance and impact on survival in infants who sero‐convert whilst receiving neonatal prophylaxis, or are exposed to maternal HAART through breastmilk at a population level, are currently unknown. In addition to the provision of biomedical interventions, healthcare workers and policy makers must address the structural, cultural and community issues that impact on treatment uptake, adherence to medication and retention in care.     

Achieving universal access and moving towards elimination of new HIV infections in Cambodia

Introduction

In the mid-1990s, Cambodia faced one of the fastest growing HIV epidemics in Asia. For its achievement in reversing this trend, and achieving universal access to HIV treatment, the country received a United Nations millennium development goal award in 2010. This article reviews Cambodia’s response to HIV over the past two decades and discusses its current efforts towards elimination of new HIV infections.

Methods

A literature review of published and unpublished documents, including programme data and presentations, was conducted.

Results and discussion

Cambodia classifies its response to one of the most serious HIV epidemics in Asia into three phases. In Phase I (1991–2000), when adult HIV prevalence peaked at 1.7% and incidence exceeded 20,000 cases, a nationwide HIV prevention programme targeted brothel-based sex work. Voluntary confidential counselling and testing and home-based care were introduced, and peer support groups of people living with HIV emerged. Phase II (2001–2011) observed a steady decline in adult prevalence to 0.8% and incidence to 1600 cases by 2011, and was characterized by: expanding antiretroviral treatment (coverage reaching more than 80%) and continuum of care; linking with tuberculosis and maternal and child health services; accelerated prevention among key populations, including entertainment establishment-based sex workers, men having sex with men, transgender persons, and people who inject drugs; engagement of health workers to deliver quality services; and strengthening health service delivery systems. The third phase (2012–2020) aims to attain zero new infections by 2020 through: sharpening responses to key populations at higher risk; maximizing access to community and facility-based testing and retention in prevention and care; and accelerating the transition from vertical approaches to linked/integrated approaches.

Conclusions

Cambodia has tailored its prevention strategy to its own epidemic, established systematic linkages across different services and communities, and achieved nearly universal coverage of HIV services nationwide. Still, the programme must continually (re)prioritize the most effective and efficient interventions, strengthen synergies between programmes, contribute to health system strengthening, and increase domestic funding so that the gains of the previous two decades are sustained, and the goal of zero new infections is reached.     

Management of paediatric retropharyngeal infections: non-surgical versus surgical

BACKGROUND: Paediatric retropharyngeal infections are a serious infection associated with morbidity. The relative role of medical versus surgical treatment for these infections is debated. The aims of this study were to analyse the management of retropharyngeal infections with respect to radiological assessment and treatment. METHODS: Medical records from January 1999 to June 2005 were reviewed and analysed. RESULTS: Twenty-four children with retropharyngeal infections were included in the study. Computed tomography had a 75% accuracy of correctly identifying an abscess and 36% of the retropharyngeal abscesses resolved with medical treatment alone, with no difference in duration of hospital stay or morbidity. CONCLUSION: Medical treatment of retropharyngeal abscesses has been successful in selected cases. We can recommend this as a viable alternative to surgery and would suggest a 48-h inpatient i.v. antibiotic trial in selected children before considering surgery.     

Incidence of HIV seroconversion in paediatric burn patients.

A retrospective review of paediatric patients treated for acute burn injuries and receiving blood/blood products between 1978 and 1985, identified 52 patients at risk for HIV infection. Over 50 per cent of the identified population had received 3 or more units of blood/blood products during their acute hospital stay. A total of 214 patients (36.8 per cent) have been tested for HIV seroconversions: five tested HIV positive by ELISA and four were confirmed by Western Blot, yielding a 1.9 per cent incidence. The four confirmed patients received 2-9 total body blood volume turnovers during their postburn period in hospital. At 4 years post-exposure, two patients show active disease, one is currently asymptomatic and one has died from AIDS-related sepsis.     

Evaluation of a new paediatric scavenging valve

BACKGROUND: Prolonged exposure to anaesthetic gases may be associated with adverse effects. Scavenging is in widespread use in adult anaesthesia but it has been more difficult to find a satisfactory solution for use in paediatric anaesthesia. The Exeter Paediatric T-piece Scavenging (Exeter PTS) valve has been designed for use with a modified Jackson-Rees system to allow connection to an active or passive Approved Gas Scavenging System. METHODS: Use of the Exeter PTS valve was evaluated in 35 spontaneously breathing paediatric patients (mean age 4.7 years, mean weight 16.7 kg) using each patient as their own control. Atmospheric pollution was measured using a Miran 1B infrared spectrophotometer. RESULTS: When using a modified Jackson-Rees breathing system with an open-ended bag, pollution levels of isoflurane exceeded the Occupational Exposure Standard of 50 p.p.m. When the Exeter PTS valve and an active scavenging system were used, pollution was significantly reduced to below 5% of the recommended limit. CONCLUSIONS: We conclude that there is a need to reduce atmospheric pollution when using a modified Jackson-Rees system in spontaneously breathing patients and that this can be achieved by use of the Exeter PTS valve.     

Ultrasonography-guided rectus sheath block in paediatric anaesthesia--a new approach to an old technique

Background. The purpose of this study was an anatomical andclinical evaluation of ultrasonography-guided rectus sheathblocks in children. Method. A total of 30 children were included in the sono-anatomicalpart of the study. The depth of the anterior and posterior rectussheath was evaluated with a portable SonSite 180 plus ultrasoundmachine and a 5–10 MHz linear probe. In total, 20 consecutivechildren undergoing umbilical hernia repair were included inthe clinical part of this study. After induction of generalanaesthesia children received a rectus sheath block under real-timeultrasonographic guidance by placing 0.1 ml kg^–1 bilaterallyin the space between the posterior aspect of the sheath andthe rectus abdominis muscle. Results. Ultrasonographic visualization of the posterior rectussheath was possible in all children. The correlation betweenthe depth of the posterior rectus sheath and weight (adjustedr²=0.175), height (adjusted r²=0.314) and body surface area(adjusted r²=0.241) was poor. The ultrasound-guided rectus sheathblockade provided sufficient analgesia in all children withno need for additional analgesia in the perioperative period. Conclusion. The bilateral placement of levobupivacaine 0.25%0.1 ml kg^–1 in the space between the posterior aspectof the rectus sheath and the rectus abdominis muscle under real-timeultrasonographic guidance provides sufficient analgesia forumbilical hernia repair. The unpredictable depth of the posteriorrectus sheath in children is a good argument for the use ofultrasonography in this regional anaesthetic technique in children.      

New drugs and new understandings of paediatric pharmacology

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Management of the paediatric airway: new developments

During the last 2 years, some interesting new devices have been made available to improve airway management in children and infants, and several studies have advanced our understanding concerning risks and benefits of the current practice in the field. Certain risk factors for airway related problems during anaesthesia in children having a cold have been identified, and new aspects of the controversy concerning the use of cuffed endotracheal tubes in children presented. Novel video-assisted systems have been introduced for the management of the difficult airway in paediatric patients, and new applications for well known devices have been suggested, such as the laryngeal mask airway serving as guidance for fibreoptic intubation. Recent studies also demonstrated specific problems with the laryngeal mask airway in infants, as well as the advantages of a new prototypic laryngeal mask airway for children, similar to the ProSeal (LMA International S.A. Group, USA). Furthermore, the following review presents new data about the use of the cuffed oropharyngeal airway, the laryngeal tube, and the Arndt bronchus blocker in paediatric patients.     

High prevalence of febrile urinary tract infections after paediatric renal transplantation.

BACKGROUND: Adult data suggest that urinary tract infections occur frequently after renal transplantation (RTx) and contribute to mortality and graft loss; data in children are limited. Therefore, we evaluated prevalence, short and long-term morbidity and confounding factors of febrile UTI (fUTI) after paediatric RTx. METHODS: In a retrospective cross-sectional study of three centres, we analysed data on 110 children followed for 4.9+/-3.4 years after successful transplantation. RESULTS: 40/110 (36%) patients had at least one fUTI at a median time of 0.98 years (range 0.02-8.96) after RTx; 11 patients (28%) had recurrent fUTI. Serum creatinine (SCr) rose significantly from 1.15+/-1.13 to 1.83+/-1.69 mg/dl, (P<0.001) during the fUTI, declining to baseline values after treatment. At the last followed-up calculated mean, GFR was comparable between fUTI and non-fUTI groups (75+/-26 vs 71+/-22 ml/min/1.73 m2). During fUTI mean, C-reactive protein (CRP) increased to 123+/-75 mg/l. Febrile UTI were significantly more frequent in girls compared to boys (22/44 vs 18/66, P<0.05) but occurred significantly earlier in boys than in girls [median 0.63 (range 0.02-4.15) vs 1.07 (0.04-8.96) years after RTx; P<0.02]. Also, patients with urinary tract malformations (UTMs) and neurogenic bladder as underlying diagnosis and those with urological surgery prior to transplantation had an increased risk for fUTI. CONCLUSION: fUTI is a frequent complication with significant short-term morbidity especially in girls and children with UTMs, neurogenic bladder and those with urological surgery. Long-term follow-up and prospective studies confirming specific risk factors, preventive measures and impact on graft survival are necessary.