Dried Blood Spot Test for HIV Exposed Infants and Children and Their Anti-Retro Viral Treatment Status in Selected Hospitals in Ethiopia

BACKGROUND:

Infants and children living with HIV receive antiretroviral treatment often late, are exposed to opportunistic infection and quickly develop AIDS. Few hospitals are providing ART service after Dried Blood Spot (DBS)test.The objective of this study is to assess the status of infants and children linked to ART.

METHODS:

Descriptive cross-sectional study was conducted in hospitals. Data of 138 infants and children exposed to HIV were collected from registration books and data bases from 2009 to 2011. Data were analyzed using SPSS version 16. Chi-squared test and p-value were computed. In-depth interviews were conducted with key informants.

RESULT:

Ninety-eight (71%) infants and children exposed to HIV were diagnosed for HIV infection of which 68(69.4%) initiated ART. Twenty four (35.3%) initiated ART one month after HIV screening results. Thirty-three (50.0%) and 23(35.3%) infants and children dropped from and adhered to ART respectively. Eleven (16.2%) of them who initiated ART died within the study period. HIV infection status (p-value=0.003), dropping from ART (p-value=0.002) and death after ART initiation (p-value=0.010) showed significance with mothers' PMTCT service status.

CONCLUSION:

Seven in ten HIV-exposed infants and children were diagnosed with HIV, and almost all of them initiated ART. The overall turnaround time was 10 days. Based up on mothers' PMTCT service status, there was a significant difference among HIV-exposed infants and children in acquiring HIV infection from mothers during pregnancy (p-value=0.003) and dropping from ART (p-value=0.010). There were challenges in sample collection and transportation. Early HIV screening during pregnancy and PMTCT service should be strengthened.

Treatment and mortality status of HIV diagnosed with infants and children, 2009–2011.

Variable		Number	Percent
Age in months	< 6	72	52.2
	7–12	59	42.8
	13–18	7	5.0
	Total	138	100
Sex	Male	67	48.6
	Female	71	51.4
	Total	138	100
HIV status	HIV+	98	71.0
	HIV−	40	29.0
Was child initiated ART	Yes	68	69.4
	No	30	30.6
	Total	98	100
Was child dropped ART	Yes	34	50.0
	No	34	50.0
	Total	68	100
Mortality status	Yes	11	16.2
	No	23	33.8
	Unknown	34	50.0
	Total	68	100
Was child adhered to ART	Yes	27	79.4
	No	7	20.6
	Total	34	100

Full article at:   http://goo.gl/20yqnC

By:  Wondafrash B1, Hiko D2.

• 1Department of Population and Family Health, Jimma University, Jimma, Ethiopia.
• 2Depatement of Epidemiology, Jimma University, Jimma, Ethiopia. 
• Ethiop J Health Sci. 2016 Jan;26(1):17-24.

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Effectiveness of Community-Based Support for Pregnant Women Living with HIV: A Cohort Study in South Africa

Antiretroviral treatment (ART) initiation in HIV-infected pregnant women in sub-Saharan Africa (SSA) remains inadequate, and there is a severe shortage of professional healthcare workers in the region. The effectiveness of community support programmes for HIV-infected pregnant women and their infants in SSA is unclear. 

This study compared initiation of maternal antiretrovirals and infant outcomes amongst HIV-infected pregnant women and their infants who received and did not receive community-based support (CBS) in a high HIV-prevalence setting in South Africa. A cohort study, including HIV-infected pregnant women and their infants, was conducted at three sentinel surveillance facilities between January 2009 and June 2012, utilising enhanced routine clinical data. 

Through home visits, CBS workers encouraged uptake of interventions in the ART cascade, provided HIV-related education, ART initiation counselling and psychosocial support. Outcomes were compared using Kaplan-Meier analyses and multivariable Cox and log-binomial regression. Amongst 1105 mother-infant pairs included, 264 (23.9%) received CBS. Amongst women eligible to start ART antenatally, women who received CBS had a reduced risk of not initiating antenatal ART, 5.4% vs. 30.3%; adjusted risk ratio (aRR) = 0.18 (95% CI: 0.08-0.44; P < .0001). Women who received CBS initiated antenatal ART with less delay after the first antenatal visit, median 26 days vs. 39 days; adjusted hazard ratio (aHR) = 1.57 (95% CI: 1.15-2.14; P = .004). Amongst women who initiated antenatal zidovudine (ZDV) to prevent vertical transmission, women who received CBS initiated ZDV with less delay, aHR = 1.52 (95% CI: 1.18-2.01; P = .001). Women who received CBS had a lower risk of stillbirth, 1.5% vs. 5.4%; aRR = 0.24 (95% CI: 0.07-1.00; P = .050). 

Pregnant women living with HIV who received CBS had improved antenatal triple ART initiation in eligible women, women initiated ART and ZDV with shorter delays, and had a lower risk of stillbirth. CBS is an intervention that shows promise in improving maternal and infant health in high HIV-prevalence settings.

Purchase full article at:   http://goo.gl/AoZiwS

By:  Fatti G1, Shaikh N1, Eley B2, Grimwood A1.

• 1 Kheth'Impilo , Cape Town , South Africa.
• 2 Department of Paediatrics and Child Health , Red Cross War Memorial Children's Hospital, University of Cape Town , Cape Town , South Africa. 

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Maternal Tenofovir Disoproxil Fumarate Use in Pregnancy and Growth Outcomes among HIV-Exposed Uninfected Infants in Kenya

Background. 

Tenofovir disoproxil fumarate (TDF) is commonly used in antiretroviral treatment (ART) and preexposure prophylaxis regimens. We evaluated the relationship of prenatal TDF use and growth outcomes among Kenyan HIV-exposed uninfected (HEU) infants. Materials and 

Methods. 

We included PCR-confirmed HEU infants enrolled in a cross-sectional survey of mother-infant pairs conducted between July and December 2013 in Kenya. Maternal ART regimen during pregnancy was determined by self-report and clinic records. Six-week and 9-month z-scores for weight-for-age (WAZ), weight-for-length (WLZ), length-for-age (LAZ), and head circumference-for-age (HCAZ) were compared among HEU infants with and without TDF exposure using t-tests and multivariate linear regression models. 

Results. 

Among 277 mothers who received ART during pregnancy, 63% initiated ART before pregnancy, of which 89 (32%) used TDF. No differences in birth weight (3.0 kg versus 3.1 kg, p = 0.21) or gestational age (38 weeks versus 38 weeks, p = 0.16) were detected between TDF-exposed and TDF-unexposed infants. At 6 weeks, unadjusted mean WAZ was lower among TDF-exposed infants (-0.8 versus -0.4, p = 0.03), with a trend towards association in adjusted analyses (p = 0.06). There were no associations between prenatal TDF use and WLZ, LAZ, and HCAZ in 6-week or 9-month infant cohorts. 

Conclusion. 

Maternal TDF use did not adversely affect infant growth compared to other regimens.

Full article at:   http://goo.gl/WcUCw4

By:  Pintye J¹, Langat A², Singa B³, Kinuthia J⁴, Odeny B⁵, Katana A², Nganga L², John-Stewart G⁶, McGrath CJ⁷.

¹Department of Global Health, University of Washington, Seattle, WA 98104, USA; Department of Nursing, University of Washington, Seattle, WA 98195, USA.

²United States Centers for Disease Control and Prevention (CDC), Nairobi 00202, Kenya.

³Center for Microbiology Research and Center for Clinical Research, Kenya Medical Research Institute, Nairobi 00202, Kenya.

⁴Department of Global Health, University of Washington, Seattle, WA 98104, USA; Department of Obstetrics & Gynecology, Kenyatta National Hospital, Nairobi 00202, Kenya.

⁵Department of Global Health, University of Washington, Seattle, WA 98104, USA.

⁶Department of Global Health, University of Washington, Seattle, WA 98104, USA; Department of Medicine, University of Washington, Seattle, WA 98195, USA; Department of Epidemiology, University of Washington, Seattle, WA 98195, USA.

⁷Department of Global Health, University of Washington, Seattle, WA 98104, USA; University of Texas Medical Branch, Galveston, TX 77555, USA

Infect Dis Obstet Gynecol. 2015;2015:276851. doi: 10.1155/2015/276851. Epub 2015 Dec 28.

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Cardiac Effects of Antiretroviral-Naïve versus Antiretroviral-Exposed HIV Infection in Children

Background

Cardiac involvement in HIV infected children has been frequently reported, but whether this is due to HIV infection itself or to antiretroviral treatment (ART) is unknown.

Methods

This cross sectional study involved 114 vertically-acquired HIV-infected (56 ART-naive, 58 ART-exposed) and 51 healthy children in Jakarta, Indonesia. Echocardiography was performed to measure dimensions of the left ventricle (LV) and systolic functions. We applied general linear modeling to evaluate the associations between HIV infection/treatment status and cardiac parameters with further adjustment for potential confounders or explanatory variables. Findings are presented as (adjusted) mean differences between each of the two HIV groups and healthy children, with 95% confidence intervals and p values.

Results

Compared to healthy children, ART-naïve HIV-infected children did not show significant differences in age-and-height adjusted cardiac dimensions apart from larger LV internal diameter (difference 2.0 mm, 95%CI 0.2 to 3.7), whereas ART exposed HIV infection showed thicker LV posterior walls (difference = 1.1 mm, 95%CI 0.5 to 1.6), larger LV internal diameter (difference = 1.7 mm, 95%CI 0.2 to 3.2) and higher LV mass (difference = 14.0 g, 7.4 to 20.5). With respect to systolic function, reduced LV ejection fraction was seen in both ART-naïve HIV infected (adjusted difference = -6.7%, -11.4 to -2.0) and, to a lesser extent, in ART-exposed HIV infected children (difference = -4.5%, -8.5 to -0.4). Inflammation level seemed to be involved in most associations in ART-exposed HIV-infected, but few, if any, for decreased function in the ART-naive ones, whereas lower hemoglobin appeared to partially mediate chamber dilation in both groups and reduced function, mainly in ART-exposed children.

Conclusions

ART-naive HIV infected children have a substantial decrease in cardiac systolic function, whereas the ART-exposed have thicker ventricular walls with larger internal diameter and higher mass, but less functional impairment.

Below: Influence of potential explanatory variables on cardiac structural estimates in ART-naive and ART-exposed HIV infected children.  Note: LVPWd = left ventricular posterior wall thickness at end-diastole; LVIDd = left ventricular internal diameter at end-diastole; LV mass = left ventricular mass; RWT = relative wall thickness; Hb = hemoglobin level; BP = systolic and diastolic blood pressure.

Below:  Influence of potential explanatory variables on cardiac functional estimates in ART-naive and ART-exposed HIV infected children.  Note: EF = ejection fraction; FS = fractional shortening; TAPSE = tricuspid annular plane systolic excursion; Hb = hemoglobin level; BP = systolic and diastolic blood pressure.

Full article at:   http://goo.gl/epfyuV

By:  

Nikmah S. Idris, Nia Kurniati

Department of Child Health, Faculty of Medicine University of Indonesia - Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

Nikmah S. Idris, Diederick E. Grobbee, Cuno S. P. M. Uiterwaal

Julius Global Health, Julius Centre for Health Sciences and Primary Care, the University Medical Centre Utrecht, Utrecht, Netherlands

Nikmah S. Idris, Michael M. H. Cheung, David Burgner

Department of Pediatrics, University of Melbourne; Heart Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Melbourne, Australia

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Pneumococcal Acquisition among Infants Exposed to HIV in Rural Malawi

The prevalence of Streptococcus pneumoniae (pneumococcus) carriage is higher in adults who are infected with human immunodeficiency virus (HIV) than in adults who are not. We hypothesized that infants exposed to HIV become carriers of nasopharyngeal pneumococcus earlier and more frequently than infants who are not exposed to HIV. We compared infant pneumococcal acquisition by maternal HIV status and household exposure in Karonga District, Malawi, in 2009-2011, before the introduction of pneumococcal conjugate vaccine. Nasopharyngeal swabs were collected every 4-6 weeks in the first year of life from infants with known HIV-exposure status, their mothers, and other household members. 

We studied infant pneumococcal acquisition by maternal HIV status, serotype-specific household exposure, and other risk factors, including seasonality. We recruited 54 infants who were exposed to HIV and 131 infants who were not. There was no significant difference in pneumococcal acquisition by maternal HIVstatus (adjusted rate ratio (aRR) = 1.00, 95% confidence interval (CI): 0.87, 1.15). 

Carriage by the mother was associated with greater acquisition of the same serotype (aRR = 3.09, 95% CI: 1.47, 6.50), but the adjusted population attributable fraction was negligible (1.9%, 95% CI: 0.0, 4.3). Serotype-specific exposure to children under 5 years of age was associated with higher acquisition (aRR = 4.30, 95% CI: 2.80, 6.60; adjusted population attributable fraction = 8.8%, 95% CI: 4.0, 13.4). 

We found no evidence to suggest that maternal HIV infection would affect the impact of pneumococcal vaccination on colonization in this population.

Below:  Prevalence of pneumococcal carriage by age of the index infant (weeks), Karonga District, Malawi, 2009–2011. Bars, 95% confidence intervals.

Below:  Fitted parametric seasonal trend in the incidence of pneumococcal carriage among infants in Karonga District, Malawi, 2009–2011. Gray areas, 95% confidence intervals.

Below:  Nonparametric spline fitted to the secular trend in pneumococcal carriage incidence in infants, Karonga District, Malawi, 2009–2011. Gray areas, 95% confidence intervals.

Full article at:   http://goo.gl/iStGNB

By:   Heinsbroek E, Tafatatha T, Chisambo C, Phiri A, Mwiba O, Ngwira B, Crampin AC, Read JM, French N.

Correspondence to Prof. Neil French, Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool L69 7BE, United Kingdom (e-mail: ku.ca.looprevil@hcnerf).

Am J Epidemiol. 2016 Jan 1;183(1):70-8. doi: 10.1093/aje/kwv134. Epub 2015 Dec 1.

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Birth Outcome in HIV Vertically-Exposed Children in Two Romanian Centers

BACKGROUND:

The Romanian HIV epidemic is characterized by a high prevalence among children born in the late '80s, perinatally infected. The impact of long-term treatment on their offspring is unknown. We evaluated the influence of prenatal care on the rate of premature birth among the HIV-exposed children of heavily treated HIV-infected mothers in two Romanian centers.

METHODS:

We retrospectively analyzed data on all patients born by HIV-infected mothers between 2006 and 2012 followed up in two main regional centers. We compared the rate of premature birth and the differences between the sites regarding children and maternal demographic characteristics and antiretroviral exposure in pregnant women.

RESULTS:

A total of 358 children born to 315 women were enrolled between 2006-2012, 262 children from the National Institute for Infectious Diseases "Prof. Dr. Matei Balş" Bucharest (NIID) and 96 children from the Clinical Infectious Diseases Hospital Constanţa (IDHC). Gender rate in newborns and mean age in mothers were similar. We recorded statistically significant differences between centers in the rate of HIV vertical transmission (16.8% vs. 6.2%, p=0.002) and prematurity (25.2 vs. 14.6%, p=0.023). The most used antiretroviral combination during pregnancy in IDHC was boosted lopinavir and fixed dose zidovudine-lamivudine (66% of cases), while in NIID a greater diversity of antiretrovirals were used. Women from IDHC were more frequently treated during pregnancy (83.3% vs. 68.6%, p=0.004). HCV coinfection and illegal drug use were associated with prematurity in the NIID cohort (p=0.037, p=0.024).

CONCLUSION:

We found a higher rate of premature birth and HIV infection in NIID. In IDHC we found a higher rate of low birth weight in children and a higher rate of heavily treated women. Prematurity was associated with hepatitis C infection and illegal drug use in the NIID cohort.

Below:  Distribution of cases over the study period in two Romanian centers

Full article at:   http://goo.gl/IHcz7Z

By:   Tudor AM1, Mărdărescu M2, Petre C3, Neagu Drăghicenoiu R3, Ungurianu R3, Tilişcan C4, Oţelea D5, Cambrea SC6, Tănase DE7, Schweitzer AM8, Ruţă S9.

• 1MD, PhD, Pediatric Department, National Institute for Infectious Diseases "Prof Dr Matei Balş", Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
• 2MD, PhD, Pediatric Department, National Institute for Infectious Diseases "Prof Dr Matei Balş", Bucharest, Romania.
• 3MD, Pediatric Department, National Institute for Infectious Diseases "Prof Dr Matei Balş", Bucharest, Romania.
• 4MD, PhD, National Institute for Infectious Diseases "Prof Dr Matei Balş" Carol Davila, University of Medicine and Pharmacy, Bucharest, Romania.
• 5MD, PhD, National Institute for Infectious Diseases "Prof Dr Matei Balş", Bucharest, Romania.
• 6MD, PhD Pediatric Department, Infectious Diseases Hospital Constanţa, Faculty of Medicine, Ovidius University of Constanţa, Romania.
• 7MD, Pediatric Department Infectious Diseases Hospital Constanţa, Romania.
• 8Psychologist, Executive Director Baylor Black Sea Foundation, Constanţa, Romania.
• 9MD, PhD, Ştefan S. Nicolau Institute of Virology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
• Germs. 2015 Dec 2;5(4):116-24. doi: 10.11599/germs.2015.1079. eCollection 2015. 

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Marijuana Use and Psychiatric Disorders in Perinatally HIV-Exposed Youth: Does HIV Matter?

OBJECTIVE:

 To examine longitudinal reciprocal relationships between marijuana use and psychiatric disorders, and identify the role of HIV in a sample (N = 340) of youth perinatally infected with HIV (PHIV+) and youth perinatally exposed but uninfected with HIV (PHIV-) (60.6% PHIV+; 9-16 years at baseline; 51% female).  

METHODS:  

Cross-lagged structural equation modeling was used to examine longitudinal associations between changes in marijuana use and changes in any behavioral, mood, and anxiety disorders at three time points across adolescence.  

RESULTS:  

Marijuana use predicted behavioral and mood disorders in youth, regardless of HIV status. Behavioral and mood disorders predicted marijuana use for PHIV- youth; behavioral disorders predicted marijuana use for PHIV+ youth. Anxiety disorders and marijuana use were not associated for either group.  

CONCLUSIONS:  For PHIV+ and PHIV- youth, interventions that target early marijuana use may reduce later psychiatric disorders. Similarly, treatment for early behavioral disorders may prevent subsequent marijuana use.

Purchase full article at:   http://goo.gl/3LkRCZ

By:   Elkington KS1, Cruz JE2, Warne P3, Santamaria EK4, Dolezal C3, Mellins CA3.

• 1HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute, ke2143@cumc.columbia.edu.
• 2Special Needs Clinic, New York Presbyterian Hospital and Columbia University Medical Center, and.
• 3HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute.
• 4Department of Behavioral and Social Sciences, Brown University. 

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Growth Patterns in the First Year of Life Differ in Infants Born to Perinatally vs Nonperinatally HIV-Infected Women

Objective: To compare the growth patterns in the first year of life between children born to perinatally HIV-infected (PHIV) vs. nonperinatally HIV-infected (NPHIV) women in the United States.

Design: Retrospective cohort study of HIV-infected pregnant women who received care and delivered a live-born at two urban tertiary centers from January 2004 to March 2012.

Methods: We collected data via chart review on demographics, behavioral risk factors, HIV clinical markers, combination antiretroviral therapy (cART), mode of HIV acquisition, pregnancy outcomes, and infant anthropometrics on study participants. Mixed-effects models were used to assess the association between maternal mode of HIV acquisition and weight-for-age z-score (WAZ), length-for-age z-score (LAZ), and weight-for-length z-score (WLZ).

Results: Of the 152 pregnancies evaluated, 32 and 120 infants were born to 25 PHIV and 99 NPHIV women, respectively. Infants of PHIV women exhibited lower mean WAZ and LAZ throughout the first year of life in unadjusted analyses. After adjusting for potential confounders, the relationship between PHIV women and LAZ persisted (β = −0.54, P = 0.026). Small-for-gestational age for each birth anthropometric parameter (birth length, birth weight, and both birth length and weight) was associated with decreased LAZ (β = −0.48, P = 0.007), WAZ (β = −0.99, P < 0.001), and WLZ (β = −0.36, P = 0.027), respectively. A delivery HIV RNA level below 400 copies/ml was associated with increased WAZ and WLZ (β = 0.43, P = 0.015 and β = 0.38, P = 0.021, respectively).

Conclusions: Infants of PHIV women may remain at persistently decreased lengths throughout the first year of life. Further studies aimed at understanding intrauterine and environmental factors in PHIV women are warranted.

Below:  Loess Plots of Mean Weight for Age (WAZ), Length for Age (LAZ), and Weight for Length (WLZ) Z-scores by Maternal Mode of HIV Acquisition

Full article at:  http://goo.gl/ffy9Kb

By:  Jao J1, Agwu A, Mhango G, Kim A, Park K, Posada R, Abrams EJ, Hutton N, Sperling RS.

• 1aDepartment of Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York bDepartment of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine c Department of Medicine dDepartment of Pediatrics, Icahn School of Medicine at Mount Sinai eICAP, Mailman School of Public Health and College of Physicians & Surgeons, Columbia University, New York fDepartment of Pediatrics, Johns Hopkins University School of Medicine gDepartment of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, USA.

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Antiretroviral Exposure During Pregnancy & Adverse Outcomes in HIV-Exposed Uninfected Infants & Children Using a Trigger-Based Design

Objective: To evaluate the safety of in-utero antiretroviral exposure in children born to mothers with HIV, using a trigger-based design.

Design: The Surveillance Monitoring of ART Toxicities Study is a prospective cohort study conducted at 22 US sites to evaluate safety of in-utero antiretroviral drug exposure in HIV-uninfected children born to HIV-infected mothers. Children meeting predefined clinical or laboratory thresholds have more intensive evaluations to determine whether they meet criteria for adverse events.

Methods: Adverse event “cases” were defined for the following domains: growth, hearing, language, neurology, neurodevelopment, metabolic, hematologic/clinical chemistry and blood lactate. We used adjusted log-binomial models to calculate relative risks (RR) of case status overall and within individual domains for various antiretroviral exposures during pregnancy.

Results: Among 2680 youth enrolled between 2007 and 2012 (48% female, 66% black, 33% Hispanic), 48% met a trigger and 25% were defined as a case in at least one domain. Language (13.2%) and metabolic (11.4%) cases were most common. After adjustment for birth cohort and other factors, there was no association of any antiretroviral regimen, drug class, or individual drug with meeting overall case criteria (case in any domain). Within individual domains, zidovudine (74% exposed) was associated with increased risk of metabolic case [RR = 1.69, 95%confidence interval (CI) 1.08–2.64] and didanosine plus stavudine (<1% exposed) with increased risk of both neurodevelopmental (RR = 12.40, 95%CI 5.29–29.08) and language (RR = 4.84, 95%CI 1.14–20.51) cases.

Conclusion: Our findings support current recommendations for combination antiretroviral therapy during pregnancy, although higher risk of metabolic disorder with zidovudine exposure warrants further study.

Purchase full article at:  http://goo.gl/QP43F0

By:  Williams, Paige L.^a,b,f; Hazra, Rohan^c; Van Dyke, Russell B.^d; Yildirim, Cenk^a; Crain, Marilyn J.^e; Seage, George R. III^a,f; Civitello, Lucy^g; Ellis, Angela^h; Butler, Laurie^h; Rich, Kennethⁱ; for the Pediatric HIVAIDS Cohort Study

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