The changing epidemic of pediatric hiv infection in romania

PURPOSE: By the late 1980s, over 100,000 infants and children were living in public institutions in Romania. It was not uncommon for children in these facilities to receive one or more 'micro-transfusions' of blood, unscreened for HIV, as therapy for anemia or malnutrition. To assess the impact of pediatric HIV infection in Romania, the European country with the most pediatric cases, cross-sectional and cohort studies were implemented in Constanta (the epi-center of pediatric HIV in Romania) in April 1999.METHODS: Demographic, clinical and social data are collected once for all cross-sectional subjects. Similar data are collected every 11-13 months for subjects in the cohort. The cross-sectional study population was defined as all living HIV-infected infants and children, 0-18 years, known to the investigators from April to September 1999. The cohort consists of subjects diagnosed with HIV between 1995 and 1999.RESULTS: Enrolled are 791 subjects, of which 357 are in the cohort study. The majority (83%) are Romanian, vs Gypsy or Turkish/Hun and their mean age is 11 years (SD = 1.3). Biologic parents are the primary caretakers of 77% and 86% attend school. Mode of transmission was perinatal for 8%; blood transfusion/parental therapy modes account for 89% of the transmission and the presumed timing was between 1-12 months of age. Mean age at HIV confirmation was 5 years (SD = 3.2). AIDS has been diagnosed in 40% and 52% are receiving antiretroviral therapy.CONCLUSIONS: The Romanian pediatric HIV epidemic differs vastly from that in the US. Fewer children are with their biologic parent(s) and attending school. Early diagnosis of infection is rare, as therapy did not become available until the late 1990's. Perinatal transmission is increasing, however, which supports the need for HIV education and intervention in Eastern Europe.     

Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection

Human immunodeficiency virus (HIV) targets the immune system, making an infected person susceptible to infection and neoplasm because of an impaired ability to mount an adequate immune response. Malnutrition and its complications can further render an HIV-infected person susceptible to opportunistic infection and reduced effectiveness and tolerance to medications and other therapies. Though effective antiretroviral treatments have dramatically reduced death rates in the United States and Canada, HIV-infected people face a lifetime of vigilant polypharmacy to control HIV and associated complications. Malnutrition, various forms of tissue wasting, fat accumulation, increased lipid levels, and risk of additional chronic disease have become central issues in health care plans. It is the position of the American Dietetic Association and Dietitians of Canada that efforts to optimize nutritional status, including medical nutrition therapy and nutrition-related education, should be components of the total health care provided to people infected with human immunodeficiency virus HIV.     

Team care: a necessity for a child with HIV infection]

In four children, a boy aged 2.5 years, a girl of 4, her brother of 7 years and a girl aged 10 months, HIV infection was diagnosed. Since 1996 HIV-infected children in the Netherlands are treated with a combination of two nucleoside analogs and a protease-inhibitor. This therapy improves the quality of life, increases the life expectancy of HIV-infected children and is generally well tolerated. However, the current combination therapy is complex and puts a burden on the child and the family. Therefore, long term compliance will be difficult. Moreover, the majority of the families have extremely difficult social circumstances which interfere with an optimal medical treatment for the child. The parents of three of the children were refugees from African countries. Intensive support of the family by a team of health care and social workers is usually necessary to make antiretroviral combination therapy possible. Care directed at the individual needs of the child and family is crucial to help this vulnerable group of children and families in our society.     

Emerging pediatric HIV epidemic related to migration

In 2002, Canada introduced routine, mandatory HIV antibody screening for all residency applicants, including selected children. We report screening results from January 2002 to February 2005. Thirty-six pediatric HIV cases were detected (14/100,000 applicants); 94% of infected children were eligible to arrive in Canada. Thirty-two of the affected children were from Africa, and maternal infection was the main risk factor. Only 4 (11%) of the children had received antiretroviral therapy. In countries of low HIV incidence, migration-related imported infection in children may be an emerging epidemic. The early identification of HIV-infected immigrant women permits intervention to prevent mother-to-child HIV transmission. Routine HIV testing as a component of the medical examination of immigrants has national and international health policy and programmatic implications.     

HIV/AIDS in African children: the Bristol-Myers Squibb Foundation and Baylor response

In 2000, 1.4 million children were living with HIV/AIDS in sub-Saharan Africa, according to the Joint United Nations Programme on HIV/AIDS. Few of them were receiving lifesaving antiretroviral therapy because public health systems lacked the clinical infrastructure and trained health care workers to implement and disseminate high-quality care. Research has shown that without treatment, half of HIV-infected infants die by age two. From 2000 to 2011 the Bristol-Myers Squibb Foundation worked with the Baylor International Pediatric AIDS Initiative, governments in sub-Saharan Africa, and other funders to help ensure that children received needed treatment and care. The partnership led to the creation of seven Children's Clinical Centers for Excellence and the Pediatric AIDS Corps of physicians. The mortality rate for the 13,154 children receiving antiretroviral therapy at the centers was 3.35 deaths per 100 patient-years, which compares favorably with results of similar programs in Africa. The experience showed that strategic investments by foundations and others can have a positive impact on health service delivery and the training of health professionals to meet the specific needs of HIV-infected children for the short and long terms.     

Physicians' Attitudes Toward Children with AIDS: Issues of Group Care

Quality of life for AIDS-infected children can be greatly enhanced when they have opportunities to attend programs appropriate for their ages and developmental levels. Long- and short-term educational planning for HIV-infected children and their families require a team approach with a physician as a willing and active participant. This paper presents research findings regarding opinions about group care for asymptomatic HIV-infected children and issues of confidentiality regarding children's HIV status of senior residents in Pediatric and Family Medicine training programs across the United States. Results indicated that residents were willing to certify children to attend group care activities but differences were observed by physician specialty and age of the child. Most physicians felt that program administrators should be aware of the child's HIV status and that parents should be the informing agent.     

Managing illness

Although most infants infected with HIV manifest no symptoms of their infected status at birth, HIV-infected children usually develop clinical signs of HIV/AIDS much sooner after infection than do adults. A small percentage of children manifest no signs of HIV infection until reaching age 10 years or older. More than half of all HIV-infected children live for more than 5 years. It is extremely important that HIV-infected children lead normal lives, being allowed to play with friends, go to school, and play sports. Such children cannot transmit HIV to others through everyday activities. HIV status need not be known for the majority of infections an HIV-infected child is likely to have. Rather, such children need the same preventative care as all children, including routine immunization, good nutrition, basic hygiene, the prompt treatment of illnesses, and regular growth monitoring. Common illnesses in children with HIV infection include candidiasis, recurrent fever, recurrent bacterial infections, persistent diarrhea, chronic cough, and skin diseases. HIV-specific illnesses include pneumocystis carinii pneumonia, cerebral toxoplasmosis, and cryptococcal meningitis. Supportive care should be provided to sick children to relieve symptoms and reduce pain.     

Shedding of live vaccine virus, comparative safety, and influenza-specific antibody responses after administration of live attenuated and inactivated trivalent influenza vaccines to HIV-infected children

HIV-infected children (N=243), >or=5 to <18 years old, receiving stable antiretroviral therapy, were stratified by immunologic status and randomly assigned to receive intranasal live attenuated influenza vaccine (LAIV) or intramuscular trivalent inactivated influenza vaccine (TIV). The safety profile after LAIV or TIV closely resembled the previously reported tolerability to these vaccines in children without HIV infection. Post-vaccination hemagglutination inhibition (HAI) antibody responses and shedding of LAIV virus were also similar, regardless of immunological stratum, to antibody responses and shedding previously reported for children without HIV infection. LAIV should be further evaluated for a role in immunizing HIV-infected children.     

Antiretroviral therapy in critically ill patients: a French national study

SETTINGS: The HIV-positive population is still increasing because the incidence of the disease remains high while the effectiveness of highly active antiretroviral therapy (HAART) has dramatically reduced mortality. HIV infected patients have an increased life expectancy and are more readily admitted to intensive care units. METHOD: We conducted a nation-wide comparative study in France of how these patients are managed by ICU specialists, on one hand, and HIV specialists, on the other, to better understand the use of antiretroviral therapy in critically ill patients. RESULTS: The results show heterogeneous responses of ICU specialists with an important proportion of non decisive answers. The answers of HIV specialists are more homogeneous. There appears to be little or no cooperation between the two specialties. The CISIH (French centers for the information and care of human immunodeficiency) are rarely consulted. CONCLUSIONS: ICU specialists must be better informed on this rapidly evolving disease. Access to updated information or to an HIV specialists must be made easier. Studies should also be made on how HAART is employed in ICUs (pharmacology, pharmacodynamics...).     

Prenatal HIV testing and antiretroviral prophylaxis at an urban hospital--Atlanta, Georgia, 1997-2000

In 1994, the U.S. Public Health Service (USPHS) recommended the use of zidovudine (ZDV) to reduce perinatal human immunodeficiency virus (HIV) transmission; in 1995, USPHS recommended universal prenatal HIV counseling and voluntary testing. Widespread implementation of these recommendations, together with increased use of antiretroviral therapy (ART) and scheduled cesarean delivery, has resulted in substantial declines in perinatal HIV transmission. However, perinatal HIV transmission continues to occur. To identify missed prevention opportunities, CDC analyzed the incidence of perinatal HIV infection among a cohort of HIV-exposed infants born during 1997-2000 at Grady Memorial Hospital (GMH) in Atlanta, Georgia. This report describes the results of that analysis and underscores the challenges to universal prevention of infant HIV infections. Efforts to reduce perinatal HIV transmission should focus on increasing prenatal care rates, promoting adherence to recommended treatment regimens during pregnancy, and increasing prenatal HIV testing, particularly in areas where missed opportunities for prevention of perinatal HIV transmission persist.     

U.S. Public Health Service Task Force recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States.

These recommendations update the February 4,2002, guidelines developed by the Public Health Service for the use of zidovudine (ZDV) to reduce the risk for perinatal human immunodeficiency virus type 1 (HIV-1) transmission. This report provides healthcare providers with information for discussion with HIV-1-infected pregnant women to enable such women to make an informed decision regarding the use of antiretroviral drugs during pregnancy and use of elective cesarean delivery to reduce perinatal HIV-1 transmission. Various circumstances that commonly occur in clinical practice are presented, and the factors influencing treatment considerations are highlighted in this report. The Perinatal HIV Guidelines Working Group recognizes that strategies to prevent perinatal transmission and concepts related to management of HIV disease in pregnant women are rapidly evolving and will continually review new data and provide regular updates to the guidelines. The most recent information is available from the HIV/AIDS Treatment Information Service (available at http.//www.hivatis.org). In February 1994, the results of Pediatric AIDS Clinical Trials Group (PACTG) Protocol 076 documented that ZDV chemoprophylaxis could reduce perinatal HIV-1 transmission by nearly 70%. Epidemiologic data have since confirmed the efficacy of ZDV for reduction of perinatal transmission and have extended this efficacy to children of women with advanced disease, low CD4+ T-lymphocyte counts, and prior ZDV therapy. Additionally, substantial advances have been made in the understanding of the pathogenesis of HIV-1 infection and in the treatment and monitoring of persons with HIV-1 disease. These advances have resulted in changes in standard antiretroviral therapy for HIV-1-infected adults. More aggressive combination drug regimens that maximally suppress viral replication are now recommended. Although considerations associated with pregnancy may affect decisions regarding timing and choice of therapy pregnancy is not a reason to defer standard therapy. Use of antiretroviral drugs in pregnancy requires unique considerations, including the possible need to alter dosage as a result of physiologic changes associated with pregnancy the potential for adverse short- or long-term effects on the fetus and newborn, and the effectiveness of the drugs in reducing the risk for perinatal transmission. Data to address many of these considerations are not yet available. Therefore, offering antiretroviral therapy to HIV-1-infected women during pregnancy, whether primarily for HIV-1 infection, for reduction of perinatal transmission, or for both purposes, should be accompanied by a discussion of the known and unknown short- and long-term benefits and risks of such therapy to infected women and their infants. Standard antiretroviral therapy should be discussed with and offered to HIV-1-infected pregnant women. Additionally, to prevent perinatal transmission, ZDV chemoprophylaxis should be incorporated into the antiretroviral regimen.     

Factors affecting reproductive decisions of African American women living with HIV

PURPOSE: This exploratory study used focus groups to examine attitudes and beliefs of HIV-infected African American women of child-bearing age about pregnancy and antiretroviral therapy. METHODS: A convenience sample of thirty-three African American women of child-bearing age participated in five focus groups. Attitudes and beliefs about pregnancy decisions and the use of antiretroviral therapy during pregnancy were examined. RESULTS: Many of the women in this study living with HIV remained committed to having children and expressed confusion about their chances of transmitting the virus to their children. CONCLUSIONS: Health care providers must be aware of these concerns and convey clear and accurate information through the most readily accepted channels. Participants suggested that messages about these issues be conveyed by other women living with HIV who have faced these same decisions.     

Rapid point-of-care testing for HIV-1 during labor and delivery--Chicago,Illinois, 2002

On November 7, 2002, the Food and Drug Administration (FDA) approved the OraQuick Rapid HIV-1 Antibody Test (OraSure Technologies, Inc., Bethlehem, Pennsylvania). Rapid human immunodeficiency virus (HIV) testing during labor and delivery allows pregnant women who were not tested previously during pregnancy to be tested and, if HIV-infected, to begin antiretroviral therapy immediately to prevent perinatal transmission. To evaluate whether point-of-care rapid HIV testing during labor and delivery expedites the diagnosis of HIV infection in pregnant women, CDC assessed turnaround testing times at three hospitals in Chicago, Illinois, in which obstetric staff performed rapid tests on whole blood specimens at point of care, and at a fourth hospital in which testing was performed in the hospital laboratory. This report summarizes the results of that analysis, which indicate that point-of-care rapid testing provided HIV test results faster than laboratory testing, resulting in prompt administration of intrapartum and neonatal antiretroviral prophylaxis. Hospitals should assess the costs and benefits of implementing point-of-care HIV testing within their institutions.     

Preventing perinatal transmission of HIV--costs and effectiveness of a recommended intervention.

OBJECTIVE. To calculate the national costs of reducing perinatal transmission of human immunodeficiency virus through counseling and voluntary testing of pregnant women and zidovudine treatment of infected women and their infants, as recommended by the Public Health Service, and to compare these costs with the savings from reducing the number of pediatric infections. METHOD. The authors analyzed the estimated costs of the intervention and the estimated cost savings from reducing the number of pediatric infections. The outcome measures are the number of infections prevented by the intervention and the net cost (cost of intervention minus the savings from a reduced number of pediatric HIV infections). The base model assumed that intervention participation and outcomes would resemble those found in the AIDS Clinical Trials Group Protocol 076. Assumptions were varied regarding maternal seroprevalence, participation by HIV-infected women, the proportion of infected women who accepted and completed the treatment, and the efficacy of zidovudine to illustrate the effect of these assumptions on infections prevented and net cost. RESULTS. Without the intervention, a perinatal HIV transmission rate of 25% would result in 1750 HIV-infected infants born annually in the United States, with lifetime medical-care costs estimated at $282 million. The cost of the intervention (counseling, testing, and zidovudine treatment) was estimated to be $ 67.6 million. In the base model, the intervention would prevent 656 pediatric HIV infections with a medical care cost saving of $105.6 million. The net cost saving of the intervention was $38.1 million. CONCLUSION. Voluntary HIV screening of pregnant women and ziovudine treatment for infected women and their infants resulted in cost savings under most of the assumptions used in this analysis. These results strongly support implementation of the Public Health Service recommendations for this intervention.     

Nutrition and HIV in the international setting.

HIV infection has become increasingly prevalent globally, with more than 40 million infected individuals worldwide, the majority of whom live in the resource-limited world, especially sub-Saharan Africa and Asia. There are nutritional and metabolic issues that significantly impact morbidity and mortality in HIV-infected populations. In addition, malnutrition has been associated with an increased risk of transmission of HIV from infected mothers to infants, and malnutrition may further compromise HIV-infected individuals who have tuberculosis or persistent diarrheal disease. The introduction of highly active antiretroviral therapy will have a significant impact on the mortality of HIV, but will not completely alleviate the malnutrition associated with HIV infection in the global setting.     

Aging and HIV Infection

With the advent of highly active antiretroviral therapy (HAART) in mid-1995, the prognosis for HIV-infected individuals has brightened dramatically. However, the conjunction of potent antiviral therapy and longer life expectancy may engender a variety of health risks that, heretofore, HIV specialists have not had to confront. The long-term effects of HIV infection itself and exposure to antiretroviral agents is unknown. Several aspects of aging, including psychiatric disease, neurocognitive impairment, and metabolic and hormonal disorders, may be influenced by chronic exposure to HIV and/or HIV therapeutics. In this paper, we discuss the health issues confronting HIV-infected older adults and areas for future research. Dr. Klein and Dr. Schoenbaun are with the Division of Infectious Diseases, Department of Medicine and The AIDS Research Program, Department of Epidemiology and Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Dr. Anastos is with the Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Dr. Minkoff is with the Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY; Dr. Sacks is with the Department of Community and Preventive Medicine, Mount Sinai School of Medicine, New York, NY.     

“The pediatric social worker really shepherds them through the process”: Care team members' roles in transitioning adolescents and young adults with HIV to adult care

Increasing numbers of adolescents and young adults (AYA) with HIV need to transition from pediatric to adult infectious disease care. Little research has examined the roles of the care team members in the transition process. Nineteen pediatric and adult providers with experience caring for HIV-infected AYA were interviewed to explore their perspectives on the roles of care team members on multidisciplinary pediatric and adult infectious disease teams. Interviews were transcribed and coded for emergent themes by independent reviewers. All care team members played important roles in the transition process. Qualitative analyses indicated that pediatric social workers played an especially pivotal role in facilitating the transition of AYA with HIV from pediatric to adult care. Pediatric social workers communicated with other providers and prepared the adolescent and family for the upcoming transition. Both pediatric and adult social workers engaged in assessment of psychosocial functioning and facilitated referrals to community resources. Social workers in the adult infectious disease clinic helped the adolescent and family adjust to the new setting. Pediatric medical providers supported the patient and family during transition and communicated pertinent medical information to the family and medical provider in the adult clinic. Participants stated that the role of the adult medical provider was to welcome the newly transition adolescent into the clinic and to obtain a new comprehensive medical history including sexual behavior. Findings offer insight into the roles held by various members of teams associated with the transition of AYA living with HIV from pediatric to adult care. The effectiveness of medical care teams can influence the quality of care provided to patients and can be improved by understanding team roles.     

Perinatal HIV Prevention Outcomes in U.S.-Born Versus Foreign-Born Blacks,PSD Cohort, 1995–2004

We examined differences in HIV-infected U.S.-born and foreign-born black mothers who delivered perinatally HIV-exposed and -infected children during 1995–2004 in the Pediatric Spectrum of HIV Disease Project, a longitudinal cohort study. Prevalence ratios were calculated to explain differences in perinatal HIV prevention opportunities comparing U.S.-born to foreign-born and African-born to Caribbean-born black mothers. U.S.-born compared with foreign-born HIV-infected black mothers were significantly more likely to have used cocaine or other non-intravenous illicit drugs, exchanged money or drugs for sex, known their HIV status before giving birth, received intrapartum antiretroviral (ARV) prophylaxis, and delivered a premature infant; and were significantly less likely to have received prenatal care or delivered an HIV-infected infant. African-born compared with Caribbean-born black mothers were more likely to receive intrapartum ARV prophylaxis. These differences by maternal geographical origin have important implications for perinatal HIV transmission prevention, and highlight the validity of disaggregating data by racial/ethnic subgroups.     

Clinical research, prophylaxis, therapy, and care for HIV disease in Africa.

By the end of the century, citizens of resource-poor countries will constitute 90% of the world's human immunodeficiency virus (HIV)-infected people. Clinical management of such persons in developing countries has been neglected; most AIDS research has concentrated on epidemiology, and donor agencies have generally invested in the prevention of HIV infection. The heavy burden of HIV disease in Africa requires that care for AIDS be addressed, and prevention and care should be seen as interrelated. Prevention and treatment of tuberculosis, the commonest severe infection in persons with AIDS in Africa, illustrate this interrelationship. We outline priorities for applied research on the management of HIV disease in a resource-poor environment, and discuss prophylaxis, therapy for opportunistic diseases, terminal care, and use of antiretroviral therapy. Research should define the standard of care that can realistically be demanded for HIV disease in a resource-poor environment. Research and public health programs for AIDS in developing countries must address AIDS care and attempt to reduce the widening gap between interventions available for HIV-infected persons in different parts of the world.