[Show abstract][Hide abstract] ABSTRACT: We sought to identify immunologic and virologic correlates of spontaneous viral control among long-term survivors of perinatal HIV infection expressing the protective human leukocyte antigen (HLA)-B57 allele.
The frequency, epitope specificity, and functional attributes of HIV-specific T cells and sequence variation within B57-restricted epitopes were compared between 'spontaneous controllers' who maintained normal CD4 percentages and viral loads less than 3000 copies/ml without antiretroviral therapy, and 'treated progressors' who had initiated HAART.
Recognition of HIV optimal epitopes was assessed by interferon gamma (IFNgamma) enzyme-linked immunosorbent spot. Functional characterization of CD8 cells targeting B57 epitopes was performed by staining for cytokine production (intracellular IFNgamma, interleukin-2, tumor necrosis factor alpha) and degranulation. Sequencing of autologous RNA was performed to determine the prevalence of viral escape mutations within B57-restricted epitopes and associated compensatory mutations.
HLA-B57 remained immunodominant during chronic infection in both controllers and progressors, but controllers recognized fewer epitopes and targeted epitopes within Gag and reverse transcriptase only, whereas progressors demonstrated a broader response targeting additional proteins. No individual epitope was targeted more frequently by spontaneous controllers. CD8 cytokine production patterns were heterogeneous among individuals and even among different epitopes in the same individual and did not correlate with spontaneous viral control. Extensive sequence variation within B57 epitopes was observed in both groups, but only progressors displayed additional capsid mutations that are known to offset the viral fitness cost of B57-driven immune escape.
Among HLA-B57-positive long-term survivors, spontaneous control of viremia is not associated with a qualitatively or quantitatively superior T-cell response, but with uncompensated fitness-attenuating mutations in the viral capsid.
AIDS (London, England) 06/2010; 24(10):1425-35. DOI:10.1097/QAD.0b013e32833a2b5b · 6.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Expression of HLA-B57 is associated with restricted replication of human immunodeficiency virus (HIV), but the mechanism for its protective effect remains unknown. If this advantage depends upon CD8 T-cell recognition of B57-restricted epitopes, mother-to-child transmission of escape mutations within these epitopes could nullify its protective effect. However, if the B57 advantage is largely mediated by selection for fitness-attenuating viral mutations within B57-restricted epitopes, such as T242N in TW10-Gag, then the transmission of such mutations could facilitate viral control in the haploidentical infant. We assessed the consequences of B57-associated mutations on replication capacity, viral control, and clinical outcome after vertical transmission in 13 mother-child pairs. We found that expression of HLA-B57 was associated with exceptional control of HIV during infancy, even when mutations within TW10 and most other B57-restricted epitopes were transmitted, subverting the natural immunodominance of HLA-B57. In contrast, most B57-negative infants born to B57-positive mothers progressed rapidly to AIDS. The presence of T242N led to a reproducible reduction in viral fitness, as demonstrated by in vitro assays using NL4-3 constructs encoding p24 sequences from individual mothers and infants. Associated compensatory mutations within p24-Gag were observed to reverse this impairment and to influence the propensity of T242N to revert after transmission to B57-negative hosts. Moreover, primary failure to control viremia was observed in one infant to whom multiple compensatory mutations were transmitted along with T242N. These parallel in vivo and in vitro data suggest that HLA-B57 confers its advantage primarily by driving and maintaining a fitness-attenuating mutation in p24-Gag.
Journal of Virology 07/2009; 83(17):8616-27. DOI:10.1128/JVI.00730-09 · 4.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Perinatal HIV infection is characterized by a sustained high-level viremia and a high risk of rapid progression to AIDS, indicating a failure of immunologic containment of the virus. We hypothesized that age-related differences in the specificity or function of HIV-specific T cells may influence HIV RNA levels and clinical outcome following perinatal infection. In this study, we defined the HIV epitopes targeted by 76 pediatric subjects (47 HIV infected and 29 HIV exposed, but uninfected), and assessed the ability of HIV-specific CD8 and CD4 T cells to degranulate and produce IFN-gamma, TNF-alpha, and IL-2. No responses were detected among HIV-uninfected infants, whereas responses among infected subjects increased in magnitude and breadth with age. Gag-specific responses were uncommon during early infancy, and their frequency was significantly lower among children younger than 24 mo old (p = 0.014). Importantly, Gag responders exhibited significantly lower HIV RNA levels than nonresponders (log viral load 5.8 vs 5.0; p = 0.005). Both the total and Gag-specific T cell frequency correlated inversely with viral load after correction for age, whereas no relationship with targeting of other viral proteins was observed. Functional assessment of HIV-specific T cells by multiparameter flow cytometry revealed that polyfunctional CD8 cells were less prevalent in children before 24 mo of age, and that HIV-specific CD4 cell responses were of universally low frequency among antiretroviral-naive children and absent in young infants. These cross-sectional data suggest that qualitative differences in the CD8 response, combined with a deficiency of HIV-specific CD4 cells, may contribute to the inability of young infants to limit replication of HIV.
The Journal of Immunology 01/2009; 181(11):8103-11. DOI:10.4049/jimmunol.181.11.8103 · 5.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Perinatal HIV infection is characterized by a sustained high-level viremia and a high risk of rapid progression to AIDS, indicating a failure of immunologic containment of the virus. We hypothesized that age-related differences in the specificity or function of HIV-specific T cells may influence HIV RNA levels and clinical outcome following perinatal infection. In this study, we defined the HIV epitopes targeted by 76 pediatric subjects (47 HIV infected and 29 HIV exposed, but uninfected), and assessed the ability of HIV-specific CD8 and CD4 T cells to degranulate and produce IFN-, TNF-, and IL-2. No responses were detected among HIV-uninfected infants, whereas responses among infected subjects increased in magnitude and breadth with age. Gag-specific responses were uncommon during early infancy, and their frequency was significantly lower among children younger than 24 mo old (p 0.014). Importantly, Gag responders exhibited significantly lower HIV RNA levels than nonresponders (log viral load 5.8 vs 5.0; p 0.005). Both the total and Gag-specific T cell frequency correlated inversely with viral load after correction for age, whereas no relationship with targeting of other viral proteins was observed. Functional assessment of HIV-specific T cells by multiparameter flow cytometry revealed that polyfunctional CD8 cells were less prevalent in children before 24 mo of age, and that HIV-specific CD4 cell responses were of universally low frequency among antiretroviral-naive children and absent in young infants. These cross-sectional data suggest that qualitative differences in the CD8 response, combined with a deficiency of HIV- specific CD4 cells, may contribute to the inability of young infants to limit replication of HIV. The Journal of Immunology, 2008, 181: 8103-8111.
The Journal of Immunology 12/2008; 181(11). · 5.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Paediatric and Perinatal HIV/AIDS remain significant health challenges in the Caribbean where the HIV seroprevalence is second only to Sub-Saharan Africa.
We describe a collaborative approach to the prevention, treatment and care ofHIVin pregnant women, infants and children in Jamaica. A team of academic and government healthcare personnel collaborated to address the paediatric and perinatal HIV epidemic in Greater Kingston as a model for Jamaica (population 2.6 million, HIV seroprevalence 1.5%). A five-point plan was utilized and included leadership and training, preventing mother-to-child transmission (pMTCT), treatment and care of women, infants and children, outcomes-based research and local, regional and international outreach.
A core group of paediatric/perinatal HIV professionals were trained, including paediatricians, obstetricians, public health practitioners, nurses, microbiologists, data managers, information technology personnel and students to serve Greater Kingston (birth cohort 20,000). During September 2002 to August 2007, over 69 793 pregnant women presented for antenatal care. During these five years, significant improvements occurred in uptake of voluntary counselling (40% to 91%) and HIV-testing (53% to 102%). Eight hundred and eighty-three women tested HIV-positive with seroprevalence rates of 1-2% each year The use of modified short course zidovudine or nevirapine in the first three years significantly reduced mother-to-child transmission (MTCT) of HIV from 29% to 6% (RR 0.27; 95%0 CI--0.10, 0.68). During 2005 to 2007 using maternal highly active antiretroviral therapy (HAART) with zidovudine and lamivudine with either nevirapine, nelfinavir or lopinavir/ritonavir and infant zidovudine and nevirapine, MTCT was further reduced to an estimated 1.6% in Greater Kingston and 4.75% islandwide. In five years, we evaluated 1570 children in four-weekly paediatric infectious diseases clinics in Kingston, St Andrew and St Catherine and in six rural outreach sites throughout Jamaica; 24% (377) had HIV/AIDS and 76% (1193) were HIV-exposed. Among the infected children, 79% (299 of 377) initiated HAART resulting in reduced HIV-attributable childhood morbidity and mortality islandwide. An outcomes-based research programme was successfully implemented.
Working collaboratively, our mission of pMTCT of HIV and improving the quality of life for families living and affected by HIV/AIDS in Jamaica is being achieved.
The West Indian medical journal 07/2008; 57(3):204-15. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We aimed to describe the adherence patterns to antiretroviral therapy (ART) in a cohort of HIV-infected children.
Between the periods May to October 2005, 63 HIV-infected children and their caregivers recruited consecutively at four Paediatric Infectious Disease Clinics in Greater Kingston and St. Catherine, Jamaica, were interviewed. Adherence was defined as no missed doses in the last four days. Biomedical markers and factors associated with adherence were explored.
Global adherence level was 85.7% (54/63) and was significantly higher for children in residential care (approaching 100%) compared to 76.3% for children in family care (p = 0.008). Children had median age 7.9 years (range 0.8 - 19.4 years) and 57% were male. Median duration on ART was 18.3 months (range 0.1 - 123.8 months). Median CD4 count and per cent available for 95.2% (60/63) and 92.1% (58/63) children were 440 cells per microL (IQR 268-897 cells/pL) and 24.9% (IQR 15.6 - 42.7%), respectively. Median viral load was 9.60 x 103 copies/ml (IQR 0.05 x 10(3) - 52.50 x 10(3)) with 16% (10/63) having viral loads < or = 50 copies/ml. Children in residential care (n=26), receiving directly observed therapy had higher CD4 counts (p = 0.006) and CD4 per cent (p < or = 0.001). Factors associated with non-adherence were primarily caregiver related, especially long work hours (p = 0.002) and nausea as a side effect of ART (p = 0.007). Non-adherence was positively correlated with missing clinic appointments (r = 0.342, p = 0.009) and increasing age of child (r = 0.310, p = 0.013).
In resource-limited settings, psychosocial factors contribute significantly to nonadherence and should complement biomedical markers in predicting adherence to antiretroviral therapy in children.
The West Indian medical journal 07/2008; 57(3):231-7. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Many children living with HIV/AIDS in developing countries are infected with intestinal parasites. These infections add unnecessary morbidity to children already suffering the clinical insult of living with HIV/AIDS.
To determine the prevalence and potential risk factors for intestinal parasitic infections in HIV-infected children living in two institutions in Jamaica.
A total of 82 faecal specimens were collected from 41 HIV-infected children (age range 2-14 years) who resided in two Children's Homes. A structured 42-item questionnaire was administered to caregivers to obtain clinical and demographic data on each child. Faecal specimens from each patient were examined using standard microbiological techniques and Cryptosporidium antigen detection was conducted using a commercially available enzyme immunoassay (EIA).
No opportunistic intestinal parasites were identified in this study. Non-opportunistic parasites diagnosed included Giardia lamblia (12.2%) and Ascaris lumbricoides (2.4%) while the commensals Endolimax nana and Entamoeba hartmanni were found in 4.9% and 2.4% of children, respectively.
Children living with HIV/AIDS in institutions in Jamaica that are closely supervised do not appear to be at substantial risk for intestinal parasites. This may be due to the strict clinical monitoring of the children and personal and environmental hygiene practices.
The West Indian medical journal 07/2008; 57(3):253-6. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Paediatric HIV/AIDS remains a significant challenge in developing countries. We describe the effectiveness of interventions in HIV-infected children attending Paediatric Infectious Diseases Clinics in Jamaica.
One hundred and ninety-seven HIV-infected children were followed prospectively in multicentre ambulatory clinics between September 1, 2002 and August 31, 2005, in the Kingston Paediatric and Perinatal HIV/AIDS Programme, Jamaica, and their outcomes described.
Median follow-up was 23 child-months (interquartile range [IQR] 12-31) with 12 children (6.0%) lost to follow-up and deaths (n=13) occurred at 4.64 per 100 child-years of follow-up. Median age was 5.0 years (IQR 2.2-8.1) and 32.1% had Centers for Disease Control and Prevention (CDC) category C disease at enrollment; 62% were ever on antiretroviral therapy (ART) with median duration of 15.4 months (IQR 5.5-25.5); 85% initiated ART with zidovudine/lamivudine/nevirapine. Mean weight-for-height 0.13 +/- 1.02 (mean difference -1.71 [95% Confidence interval (CI) -2.73, -0.69]; p = 0.001) and body mass index-for-age 0.05 +/- 1.11 (mean difference -1.11, [CI -1.79, -0.43]; p = 0.002); z scores increased after 24 months on ART; however, children remained stunted. Reductions in the incidence of hospitalizations (mean diff 30.95, [CI 3.12, 58.78]; p = 0.03) and in episodes of pneumonia, culture-positive sepsis and tuberculosis occurred in those on ART.
A successfully implemented ambulatory model for paediatric HIV care in Jamaica has improved the quality of life and survival of HIV-infected children.
The West Indian medical journal 07/2008; 57(3):223-30. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: HIV has been a leading cause of death in Jamaican children aged < or = five years. Antiretroviral drugs (ARVs) are increasingly available in Jamaica through the Global Fund. Adverse effects of ARVs are a major cause for non-adherence to medications. Knowledge of the use and side effects of these drugs are crucial in the management of HIV-infected children as we scale-up the use of antiretroviral therapy, islandwide. We evaluated the adverse events and safety of antiretroviral therapy in children attending four Infectious Disease Clinics in Kingston, Jamaica, a resource limited setting.
Data for children prospectively enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme during September 2002 to April 2005 were analyzed.
Among 121 HIV-infected children, 77 (64%) were on ARVs, 90% had CDC class C disease, 60% were males and perinatal transmission predominated. AZT/3TC based regimen was utilized in 93%, trimethoprim/sulphamethoxazole prophylaxis was used in 100% and five were completing antituberculous drugs. Anaemia occurred in all patients, with increased severity in those on ARVs. Macrocytosis occurred in 83% and thrombocytopenia in 8% of those on ARVs. Elevation of bilirubin, aspartate transaminase (AST) and alanine transaminase (ALT) levels and reversed albumin to globulin ratio prior to commencing AR Vs, with significantly lower prevalence following use of ARVs emphasized the severity of HIV disease at time of ARV initiation. Clinical adverse reactions were uncommon and included nail discoloration (8%), vomiting (7%), nausea (3%), peripheral lipodystrophy (4%) and abnormal dreams (1%). Ten children required change of ARV medication because of severe adverse effects: three for severe anaemia with repeat blood transfusions, three for severe nevirapine-associated rash and four for indinavir-associated haematuria.
ARVs are being successfully initiated in HIV-infected Jamaican children using the public health model. The excellent safety profile, good tolerance and few reported significant adverse effects augur well as antiretroviral therapy is scaled-up islandwide.
The West Indian medical journal 07/2008; 57(3):238-45. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The immune reconstitution inflammatory syndrome (IRIS) is a recognized complication associated with opportunistic infections occurring in HIV-infected individuals after the initiation of highly active antiretroviral therapy (HAART). We report on three HIV-infected infants with rapid progressor HIV disease who present with IRIS due to the BCG vaccine and occurring 3-6 weeks after initiation of HAART
The West Indian medical journal 07/2008; 57(3):302-6. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Documentation regarding the renal complications of paediatric HIV infection from developing countries is scarce. In the era prior to highly active antiretroviral therapy (HAART), HIV-infected children in Jamaica who developed HIV-associated nephropathy (HIVAN) progressed to end stage renal disease (ESRD) and death within a few months of diagnosis. With increased public access to antiretroviral therapy since 2002 and subsequent survival, renal complications are increasingly recognized among the surviving cohort of infected children.
A cohort of 196 HIV-infected children was followed in four multicentre ambulatory clinics from September 1, 2002 to August 31, 2005 as part of the Kingston Paediatric and Perinatal HIV/AIDS Programme, Jamaica. We describe the clinical presentations and natural history of those patients who developed renal complications.
Urinary tract infections were the most common diagnosis, occurring in 16.8% of patients, with a high recurrence rate and the most common organism was Escherichia coli. Four of seven patients who started indinavir developed complications of nephrolithiasis and tubulointerstitial nephropathy. Six patients (3%) fulfilled the criteria for HIVAN, five of whom were male. Median age at diagnosis was five years; all presented with advanced HIV disease, nephrotic syndrome or nephrotic range proteinuria and three with chronic renal failure. Patients received standard medical management and were initiated on angiotensin-converting enzyme (ACE) inhibitors and HAART While the mortality ratio was 50%, only one death was associated with HIVAN and the median survival time was 3.1 years.
HIV-infected children present with a variety of renal complications. With improved survival since the introduction of HAART, the incidence of HIVAN is expected to increase among this maturing paediatric cohort. Early detection and treatment will optimize the outcomes for these children.
The West Indian medical journal 07/2008; 57(3):246-52. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Paediatric HIV is a leading cause of morbidity and mortality worldwide. We describe HIV-related mortality in a cohort of HIV-infected Jamaican children and identified factors which influenced survival.
A retrospective descriptive study was conducted for the period March 2003 - December 2005 at Cornwall Regional Hospital, Montego Bay, Jamaica. We summarized demographic and clinical data of deceased and living perinatally HIV-infected children and identified factors that influenced survival of rapid and slow progressors. Rapid progressors are HIV-infected children identified clinically before age 2 years and slow progressors after age 2 years.
There were 9 (180%) HIV/AIDS-related deaths among 50 HIV-infected children of whom 23 (46%) were males and 21 (43%) were AIDS orphans. Five children (10%0) received ARV prophylaxis, 31 (62%) were breastfed and 39 (78%) received HAART Surviving children displayed primarily non-AIDS defining illnesses (pneumonia and sepsis) but there was no difference in AIDS-defining illnesses among living and deceased children. The median age at diagnosis was 26 months (range 3-121; IQR 10, 54). The median age at death was 30 months (range 7-122 months; IQR 17, 118). Both surviving and deceased children presented with primarily moderate symptoms at diagnosis (21, 42%) and death (7, 78%). In rapid progressors, 19 of 20 (95%) on HAART remained alive and all 4 (100%) who did not receive HAART died. The mortality rate in children on HAART was 30.78 per 100 person years and 48 per 100 person years in children not receiving HAART.
HAART is the only factor identified which prolonged survival for HIV-infected children who are rapid progressors, have AIDS-defining illnesses and are orphans.
The West Indian medical journal 07/2008; 57(3):265-8. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Pediatric HIV/AIDS remains a significant challenge in developing countries. We describe the effectiveness of interventions in HIV-infected children and adolescents attending Paediatric Infectious Diseases Clinics in Jamaica (Gross National Income per capita USD 2,900; annual birth cohort 52,000; HIV sero-prevalence 1.6%).
One hundred and ninety six HIV-infected children were followed prospectively in multicentre ambulatory clinics between 01 September 2002 and August 31, 2005, in the Kingston Pediatric and Perinatal HIV/AIDS Program, Jamaica and their outcomes described.
Results: Median follow-up was 23 patient-months (range <1-81, IQR 12-31), with 12 (6%) lost to follow-up and 13 deaths (6.6%). Median age was 6 years (range < 1-20; IQR 4-10), 50% had CDC category C disease; 62% were ever on ARVs and 85% initiated ARVs with Zidovudine/Lamivudine/Nevirapine; 80% remained on their initial regime; median duration on ARVs was 15.4 months (IQR 5.5-25.5). Median CD4+ percent was 30.8% (IQR 17.6-44.2), and plasma HIV RNA was < 400 copies/ml in 49 children (28%) on ARVs. Mean baseline Z score weight/age was -1.58±2.21, BMI/age -1.06±1.80, weight/height -0.86± 2.94, and height/age -0.48± 2.56; with increase in mean Z score for weight/height (p<0.05), BMI/age (p<0.05) at 3, 6, 24 months on ARVs; however children remained stunted (p<0.05). Significant reduction in incidence of hospitalisations (p=0.03) and overall reduction in episodes of pneumonia, culture-positive sepsis and tuberculosis occurred among those on ARVs.
Conclusion: An ambulatory model for pediatric HIV/AIDS care has been successfully implemented in Jamaica, resulting in improved quality of life and survival of HIV-infected children and adolescents.
Infectious Diseases Society of America 2006 Annual Meeting; 10/2006
[Show abstract][Hide abstract] ABSTRACT: In a few Caribbean islands, prevention of mother-to-child transmission (pMTCT) of HIV with zidovudine prophylaxis has reduced transmission rates from 27 - 44% to 5.5 - 9 %.
To highlight the uptake of interventions, preliminary outcomes and challenges in caring for HIV-exposed infants in a pMTCT HIVprogramme in a resource-limited setting.
A cohort of HIV-infected pregnant women were identified at the leading maternity centres in Greater Kingston through HIV counselling and testing and enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme. Antiretroviralprophylaxis with zidovudine or nevirapine was given to the HIV-positive women and their newborns along with formula feeding. Some infants were enrolled retrospectively and followed irrespective of whether they had or had not received antiretroviral prophylaxis. A multidisciplinary team at the paediatric centres supervised protocol-driven management of the infants. Infants were followed for clinical progress and definitive HIV-infection status was to be confirmed at 18 months of age by ELISA or the Determine Rapid Test.
During September 1, 2002 through August 31, 2003, 132 HIV-exposed infants were identified. For those infants prospectively enrolled (78), 97% received antiretroviral prophylaxis and 90% were not breastfed For all HIV-exposed children, 90% received cotrimoxazole prophylaxis and 88% continued follow-up care. Ninety-two per cent of all the infants remained asymptomatic and five died; of these deaths one is possibly HIV-related (severe sepsis at 11 weeks). This infant was retrospectively identified, had received no antiretroviral prophylaxis and was breastfed The main programme challenges, which were overcome, included the impact of stigma, compliance with antiretroviral chemoprophylaxis, breast-milk substitution and follow-up care. Financial constraints and laboratory quality assurance issues limited early diagnosis of HIV infection.
Despite the challenges, the expected outcome is to prevent 50 new cases of HIV/AIDS in children living in Greater Kingston per year (300 over six years).
The West Indian medical journal 11/2004; 53(5):308-14. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Nevirapine is one of the first line antiretroviral agents used in the treatment of HIV/AIDS as well as for prophylaxis against mother-to-child transmission of HIV As antiretroviral medication becomes more available it is important for physicians to recognize the major clinical toxicities of these medications. We report a HIV-infected infant who developed a rash with systemic symptoms in association with nevirapine administration.
The West Indian medical journal 11/2004; 53(5):356-8. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The study describes a cohort of HIV-infected Jamaican children receiving antiretroviral therapy (ART) and reports the outcome.
An observational prospective study was conducted on HIV-infected Jamaican children receiving anti retroviral drug therapy (ART). The outcome measures, weight, height, hospital admissions and length of stay were compared at initiation and within six months of commencing ART.
There were 37 (33.6%) of 110 HIV-infected children receiving ART during 2001 to 2003. The median age at commencement was six years (age range 1-16 years) with 54.1% (20) males and 48% AIDS orphans. Care was home-based for 68 % of all cases with the University Hospital of the West Indies managing 27 (73%) and the Bustamante Hospital for Children 10 (27%). The distribution by Centers for Disease Control and Prevention (CDC) clinical class was C (severely symptomatic), 22 (59.5%); B (moderately symptomatic), 8 (21.6%); A (mildly symptomatic), 6 (16.2%) and N (asymptomatic), one (2.7%). Among 14 (36%) children with CD4 counts, 8 (57%) were CDC immune class 2 (moderate immunodeficiency) and 6 (43%) were class 3 (severe immunodeficiency). After commencing ART the mean difference in admissions was--1.5+/-2.55 admissions (95% CI -2.3, -0.6; p < 0.001) and in length of stay was -12.9+/-21 day (95% CI -19.9, -0.5.9; p < 0.001). Antiretroviral therapy resulted in a mean weight gain of 2.8 kg+/-4.9 kg (95% CI 1.0, 4.5; p < 0.003) and a mean gain in height of 1.7 cm+/-2.6 cm (95% CI 0.6, 2.8; p < 0.003). Five children required second line therapy.
The introduction of antiretroviral therapy has resulted in improved outcomes and is being initiated in older children cared for mainly at home. Limitations in accessing affordable second line agents underscore the need for compliance with first line therapy.
The West Indian medical journal 11/2004; 53(5):322-6. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Nursing care has been the "grass roots" of healthcare management even before nursing became a profession. Literature on the nursing experience with HIV is minimal and so it is challenging to comment on, or to compare experiences.
This paper highlights the nursing interventions as a key feature in the ongoing development and success of a prevention of mother-to-child HIV transmission (pMTCT) programme in a resource-limited setting.
In the Kingston Paediatric and Perinatal HIV/AIDS Programme, the nurses and midwives were carefully selected and then trained in the management of preventing mother-to-child transmission (pMTCT) of HIV/AIDS, voluntary counselling and testing and the identification and nursing management of paediatric and perinatal HIV/AIDS. The sites of the programme included three large maternity centres and four paediatric centres, with several feeder clinics for pregnant women. A nurse coordinator supervised the interventions at each site. A multidisciplinary team followed protocol-driven management for the care of pregnant HIV-positive women and children. There was strong collaboration with the Jamaican government and other agencies.
The nursing interventions served to: sensitize and encourage other healthcare workers in the care of persons living with HIV/AIDS; sensitize persons in the community about the disease; improve the comfort level of women and families with accessing healthcare; enable prospective data collection for programme assessment and research purposes and to enhance multidisciplinary collaboration to widen the scope of patient care and prevent duplication of healthcare services.
Nursing intervention is a vital part of a pMTCT HIV programme; however, ongoing education and training of the entire healthcare team needs to be continued in order to strengthen the programme. It is hoped that much of what is done in the Kingston Paediatric and Perinatal HIV/AIDS Programme will become integrated in the nursing management of maternal and child health nationally.
The West Indian medical journal 11/2004; 53(5):327-31. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the face of the continuing pandemic of HIV/AIDS, the burden of the disease is now largest in the resource-poor developing world. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has listed the adult prevalence rate for the Caribbean as second only to Sub-Saharan Africa.
To document the socio-demographic characteristics of paediatric and perinatal HIV/AIDS in Kingston, Jamaica.
A cohort of HIV-infected pregnant women were identified at the leading maternity centres in Kingston and St Catherine and were enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme. Infants born to mothers within the programme were prospectively enrolled. Infants and children identified after delivery, whether HIV-exposed or infected, were also enrolled (retrospective group). All were followed according to standardized protocols.
We report on a total of 239 children, 78 (prospective group) and 161 (retrospective group). Among the retrospective group, 68% were classified as infected. For the prospective group, the patients were recruited within twenty-four hours of birth in 98.7% of cases, whereas in the retrospective group, the median age of recruitment was 2.6 years. The median age of the mother was 27 years and that of the father was 33 years. There were seven teenage mothers. Twenty-six per cent of the children were in institutional care. Family size ranged from one to nine children--the median was two children. For those parents where occupation was reported, the majority held semi-skilled or unskilled jobs. Patients attended their regional clinics.
HIV/AIDS represents a significant human and financial burden on a developing country such as Jamaica and this underscores the need for urgent and sustained interventions to stem the epidemic.
The West Indian medical journal 11/2004; 53(5):303-7. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Reported sexual assault in Jamaica is highest among children and adolescents. The risk of HIV transmission after sexual assault, although small, may be significant in certain circumstances, and it is therefore reasonable that post-exposure prophylaxis should be offered. These HIV transmission rates are similar to those of healthcare workers after occupational exposure to known HIV-infected blood for which routine post-exposure prophylaxis is recommended. We present a case series of children/adolescents with HIV/AIDS post-sexual assault and make the case for post-exposure prophylaxis for HIV infection following sexual assault.
The West Indian medical journal 11/2004; 53(5):352-5. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To document the frequency of Centers for Disease Control and Prevention (CDC)-defined clinical conditions, opportunistic and co-infections among children with HIV/AIDS.
This prospective, observational study reports the findings of 110 HIV-infected children followed in multicentre ambulatory clinics during September 1, 2002, to August 31, 2003, from the 239 children enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme, Jamaica. We describe the clinico-pathologic characteristics of these children with HIV/AIDS, using the CDC criteria.
The client distribution by clinic site was as follows: the University Hospital of the West Indies, 71 (64.6%), Bustamante Hospital for Children, 23 (20.9%), Comprehensive Health Centre 13 (11.8/%) and Spanish Town Hospital, 3 (2.7%). The median age of the 110 children with HIV/AIDS was 6.0 years (range 0.9-17.5). Mode of transmission was primarily mother-to-child (88.0%) and only 4% maternal/infant pairs received antiretroviralprophylaxis. Grouped by CDC category: 17 (15.4%) were asymptomatic (N), 22 (20.0%) mildly symptomatic (A), 30 (27.3%) moderately symptomatic (B) and 41 (37.3%) severely symptomatic (C). The most common CDC-defining symptoms were lymphadenopathy (12, 42.8%) and asymptomatic (6, 21.4%) in category N; lymphadenopathy (30, 29.7%), dermatitis (20, 19.8%) and persistent or recurrent upper respiratory tract infections (20, 19.8%) in category A; bacterial sepsis (18, 34.6%) and recurrent diarrhoea (11, 21.2%) in category B; and wasting (28, 30.0%), encephalopathy (26, 27.9%), and serious bacterial infections (15, 16.1%) in category C; Pulmonary tuberculosis (7, 7.5%) and Pneumocystis (jiroveci) carinii pneumonia; (5, 5.4%) were the most frequent opportunistic infections. Streptococcus pneumoniae (10, 30.3%) was the most common invasive bacterial pathogen causing sepsis and Escherichia coli (14, 34.2%) was the most common bacterial pathogen causing urinary tract infections, among the cohort. Thirty-three per cent commenced antiretroviral drugs (ARVs). There were 57 hospitalizations and five deaths.
The study is an important step toward documentation of the natural history of paediatric HIV/AIDS in a primarily ARV-naive population from a developing country. It promotes training in paediatric HIV management as we move toward affordable access to antiretroviral agents in the wider Caribbean and the implementation of clinical trials.
The West Indian medical journal 11/2004; 53(5):315-21. · 0.28 Impact Factor