Children
infected with HIV in resource-poor settings are at a significant risk for
developmental impairment
– affecting neurocognitive functions as well as growth
– in spite of increased access to antiretroviral treatment, researchers reported
at the Eighteenth International Conference on AIDS in Vienna on July 19.
Earlier
initiation of treatment for optimum growth is strongly indicated in the light
of these findings, said researchers from the Perinatal HIV Research
Unit, Soweto, and colleagues in Vancouver. They found that children who had
started treatment with a CD4 count over 200 had better improvements in
weight-for-age and height-for-age scores after starting treatment.
Another
study in Jamaica
showed that healthcare workers having appropriate screening tools to detect the
signs and symptoms of
neurological damage (and referring to appropriate treatment and services) as children move into adolescence will be key to mitigating
the impact of HIV in children.
In additional,
Luminita Ene and colleagues in Romania
reported that the presence of viral subtype F may worsen neurological problems.
They found
a high prevalence of neurocognitive impairment and of AIDS-defining
opportunistic infections among a cohort of HIV-infected Romanian children,
a homogenous group that included those exposed to HIV clade F and who had been on combination antiretroviral
treatment for at least ten years.
Among 528
children treated between 1996 and 2008, 43.7% (231) had central nervous system
complications. While the number of cases of HIV encephalopathy and
opportunistic central nervous system infections decreased with the introduction
of combination antiretroviral treatment, the proportion within all
AIDS-defining illnesses remained unchanged.
In Jamaica,
researchers conducted a two-part analysis (consisting of a database review and
a prospective nested case-control study ) of the neurological outcomes of
infected children at four paediatric clinics in the Greater Kingston
Metropolitan Area of Jamaica from September 2002 to August 2008. Samantha Walker
and colleagues found that 23.3% (67) of the children had been diagnosed with HIV encephalopathy, at a
median age of 1.57 years (IQR: 1.08 to 3.43).
The primary
neuro-developmental abnormalities at diagnosis included: delayed growth (88%);
hyperreflexia (being overactive, causing twitching, muscle tension) (88%);
spasticity (muscle tension and stiffness) (65%); microcephaly (small skull
circumference for age) (63%); and quadriparesis (muscle weakness in all four
limbs) (31%).
No significant changes in neurodevelopmental abnormalities
were seen after one
year on antiretroviral therapy.
Children
who had previously been diagnosed with
HIV encephalopathy had difficulty with concept-forming tests, poor
short-term memory and inconsistent attention spans, and small skull circumference
(for age), as well as needing more time to complete tests that required motor-skill
co-ordination, compared to the case controls.
Dr Walker
said it was possible that antiretroviral treatment may have started after
irreversible central nervous system damage had already happened. She stressed
the importance of having feasible, cost-effective screening tools for early
detection of neurocognitive impairment to allow for appropriate intervention
strategies
– for example, rehabilitation services
– particularly as children
grow into adolescence.
Erica
Maxine Lazarus and colleagues reported on a retrospective cross-sectional
analysis at the Perinatal HIV Research Unit in Soweto, South Africa, of adolescents
(aged 11 to 19 years) on antiretroviral therapy, to look at the effects of baseline
CD4 cell count (categorised as above and below 200 cells/mm3), viral response (categorised
as above and below 400 copies/ml), and length of time on treatment, on growth.
Of the 107
adolescents, median age at the start of antiretroviral treatment was 8.4 years
(IQR: 6.07 to 11.4), and 14.75 years (IQR: 13.49 to 16.47) at the time of the review. Median
time on antiretroviral therapy was 6.1 years (IQR: 2.4 to 9.1).
Fifty-nine per cent
of the adolescents had a CD4 cell count greater than 200 cells/mm3 at the start of
treatment. Eighty-four per cent had viral loads under 400 copies/ml at their most recent visit. Of
the four measures (CD4 cell count; baseline age; length of time on
treatment; and most recent viral load), baseline CD4 cell count alone was associated
with significant increases in height.
Children
with CD4 cell counts greater than 200 cells/mm3 at the start of treatment had
almost three times the odds of improved height compared to those with baseline
CD4 cell count under 200 cells/mm3.
For best
growth outcomes into adolescence, Dr Lazarus and her colleagues recommended
starting antiretroviral treatment in children over five years of age with CD4
cell counts over 200 cells/mm3.