Clinical Update in Aspects of the Management of Autoimmune Thyroid Diseases

Aspects of autoimmune thyroid disease updated in this review include: immunoglobulin G4 (IgG4)-related thyroid disease (Riedel's thyroiditis, fibrosing variant of Hashimoto's thyroiditis, IgG4-related Hashimoto's thyroiditis, and Graves' disease with elevated IgG4 levels); recent epidemiological studies from China and Denmark indicating that excess iodine increases the incidence of Hashimoto's thyroiditis and hypothyroidism; immunomodulatory agents (ipilimumab, pembrolizumab, nivolumab) activate immune response by inhibiting T-cell surface receptors which down-regulate immune response, i.e., cytotoxic T-lymphocyte antigen 4 and programmed cell death protein 1 pathways; alemtuzumab is a humanised monoclonal antibody to CD52 which causes immune depletion and thyroid autoimmune disease especially Graves' hyperthyroidism; small molecule ligand (SML) agonists which activate receptors, SML neutral antagonists, which inhibit receptor activation by agonists, and SML inverse agonists which inhibit receptor activation by agonists and inhibit constitutive agonist independent signaling have been identified. SML antagonism of thyroid-stimulating hormone-receptor stimulatory antibody could treat Graves' hyperthyroidism and Graves' ophthalmopathy; and thyroxine treatment of subclinical hypothyroidism can produce iatrogenic subclinical hyperthyroidism with the risk of atrial fibrillation and osteoporosis. The increased risk of harm from subclinical hyperthyroidism may be stronger than the potential benefit from treatment of subclinical hypothyroidism.

Differential Effects of Anaesthesia on the phMRI Response to Acute Ketamine Challenge.

Aims: Pharmacological-challenge magnetic resonance imaging (phMRI) is powerful new tool enabling researchers to map the central effects of neuroactive drugs in vivo. To employ this technique pre-clinically, head movements and the stress of restraint are usually reduced by maintaining animals under general anaesthesia. However, interactions between the drug of interest and the anaesthetic employed may potentially confound data interpretation. NMDA receptor (NMDAR) antagonists used widely to mimic schizophrenia have recently been shown to interact with the anaesthetic halothane. It may be the case that neural and cerebrovascular responses to NMDAR antagonists are dependent on the types of anaesthetic used. Methodology: We compared the phMRI response to NMDAR antagonist ketamine in rats maintained under -chloralose to those under isoflurane anaesthesia. A randomized placebo/vehicle controlled design was used in each of the anaesthetic groups. Results: Changes in the anaesthetic agent resulted in two very different profiles of activity. In the case of -chloralose, positive activations in cortical and sub-cortical structures reflected a response which was similar to patterns seen in healthy human volunteers and metabolic maps of conscious rats. However, the use of isoflurane completely reversed such effects, causing widespread deactivations in the cortex and hippocampus. Conclusion: This study provides initial evidence for a drug-anesthetic interaction between ketamine and isoflurane that is very different from responses to -chloraloseketamine.

Sociodemographics and clinical presentation of HIV in Jamaica over 20 years: a comparative analysis of surveillance data / Sociodemografía y presentación clínica del VIH en Jamaica por más de 20 años: análisis comparativo de datos de vigilancia

OBJECTIVE: To delineate changes in the epidemiology of HIV including morbidity and mortality patterns based on three key time points in Jamaica s HIV response. METHOD: Surveillance data from Jamaica s HIV/AIDS Tracking system (HATS) were analysed and distribution of cases by age, gender, sexual practice, risk factors and clinical features were determined for three time periods (1988 - 1994: formal establishment of HIV surveillance at the national level; 1995-2003: introduction ofHAART globally; 2004 -June2008: introduction of HAART and HIV rapid testing in Jamaica). Factors that predicted late stage diagnosis (AIDS or AIDS death) were also determined. RESULTS: 22 603 persons with HIV were reported to the Ministry of Health, Jamaica, between 1988 and June 2008. Between the first and last time blocks, the modal age category remained constant (25-49 years) and the proportion of women reported with HIV non-AIDS increased from 32.5% to 61.4% (p < 0.001). However, the male: female ratio for persons reported with AIDS remained at 1.3:1 between 1995 and 2008. Although heterosexual transmission was the most frequent mode of transmission in each time period, sexual behaviour was consistently under-reported (4769 persons or 21% of all cases ever reported). Late stage diagnosis (AIDS or AIDS death) decreased significantly between the first and last time blocks (16% decline, p < 0.0001) with men, older persons and persons with unknown risk history being more likely to be diagnosed at AIDS or AIDS death. CONCLUSION: HIV testing and treatment programmes have improved timely diagnosis and reduced morbidity associated with HIV infection in Jamaica. However, new strategies must be developed to target men and older persons who are often diagnosed at a late stage ofdisease. Surveillance systems must be strengthened to improve understanding ofpersons reported with unknown risk behaviours and unknown sexual practices.

OBJETIVO: Delinear los cambios en la epidemiologia del VIH incluyendo patrones de morbilidad y mortalidad sobre la base de tres momentos claves de la respuesta de Jamaica frente al VIH. MÉTODO: Se analizaron datos de vigilancia del sistema de rastreo epidemiológico del VIH/SIDA (HATS) en Jamaica, y se determinó la distribución de casos por edad, género, práctica sexual, factores de riesgo, y características clinicas en los tres periodos de tiempo siguientes. (1988-1994): Establecimiento formal de vigilancia del VIH a nivel nacional. (1995 - 2003): Introducción de la terapia TARGA a nivel global. (2004 - junio 2008): Introducción de la terapia TARGA y pruebas rápidas de VIH en Jamaica. Asimismo se determinaron los factores que predijeron el diagnóstico en fase tardia (SIDA o muerte por SIDA). RESULTADOS: Entre 1988 y junio de 2008, se reportaron 22 603 personas con VIH al Ministerio de Salud de Jamaica. Entre el primer y el último bloque de tiempo, la categoria modal edad permaneció constante (25-49 anos) y el número de mujeres reportadas con VIH sin SIDA aumentó de 32.5% a 61.4% (p < 0.001). Sin embargo, la proporción varón:hembra entre las personas reportadas con SIDA permaneció en 1.3:1 entre 1995 y 2008. Aunque la transmisión heterosexual fue el modo de transmisión más frecuente en cada periodo del tiempo, los reportes sobre comportamiento sexual fueron persistentemente insuficientes (sólo 4769 personas o 21% de todos los casos reportaron alguna vez). El diagnóstico de fase tardia (SIDA o muerte por SIDA) disminuyó significativamente entre el primer y el último bloque de tiempo (una disminución del 16%, p < 0.0001), con una mayor probabilidad de diagnóstico de SIDA o muerte por SIDA entre los hombres, las personas de más edad y las personas con una historia de riesgo desconocida. CONCLUSIÓN: La prueba de VIHy los programas de tratamiento han mejorado el diagnóstico oportuno y reducido la morbilidad asociada con la infección por VIH en Jamaica. Sin embargo, se hace imprescindible desarrollar nuevas estrategias destinadas a hombres y personas de edad que a menudo reciben el diagnóstico en una etapa avanzada de la enfermedad. Deben fortalecerse los sistemas de vigilancia para mejorar la comprensión de las personas reportadas con conductas de riesgo desconocidas y prácticas sexuales desconocidas.

A comprehensive response to the HIV/AIDS epidemic in Jamaica: a review of the past 20 years / Una respuesta integral a la epidemia de VIH/SIDA en Jamaica: a review of the past 20 years

Jamaica has a well-established, comprehensive National Human Immunodeficiency Virus (HIV) programme that has slowed the HIV epidemic and mitigated its impact. Adult HIV prevalence has been stable at approximately 1.5% since 1996. HIV rates are high among those most at risk such as sex-workers (9%) and men who have sex with men [MSM] (31.8%). Risk behaviour among adults with AIDS includes multiple sexual partners (80%), a history of a sexually transmitted infection [STI] (51.1%), commercial sex (23.9%) and crack/cocaine (8.0%). Approximately 20% of all reported AIDS cases, mainly women, give no history of any of the usual risk factors for HIV infection. The national programme is based in the Ministry of Health. Since 1988, Jamaica has had a national plan to guide its HIV response. A National AIDS Committee was established in 1988 to lead the multi-sectoral response. Prevention approaches have included information, education and communication campaigns, condom promotion, sexually transmitted infections (STI) control, targeted interventions, cultural approaches, outreach and peer education, workplace programmes and HIV counselling and testing. Concerted efforts have been made to reduce HIV stigma and discrimination. Antiretroviral therapy (ARV) was introduced for prevention of mother-to-child transmission in 2001 and a public access treatment programme introduced in 2004. A national HIV/AIDS Policy was adopted unanimously in parliament in 2005. The National Strategic plan 2007-2012 commits Jamaica to achieving universal access to HIV prevention, treatment and care. Awareness of HIV and how to prevent it is near universal though belief in myths remains strong. The condom market has increased from approximately 2.5 million in 1985 to 12 million in 2006 while condom use has grown significantly with nearly 75% of men and 65% of women reporting condom use at last sex with a non-regular partner. The proportion of women 15-24 years reporting ever having a HIV test increased from 29.8% in 2004 to 48.9% in 2008. HIV transmission from mother-to-child has declined from 25% prior to 2000 to less than 8% in 2007. As of September 2008, 4450 persons or an estimated 68.5% of persons with advanced HIV and AIDS have been placed on ARV treatment resulting in a significant decline in mortality and morbidity due to HIV.

Jamaica tiene un Programa Integral Nacional del Virus de la Inmunodeficiencia Humana bien establecido, gracias al cual se ha disminuido la epidemia de VIH y mitigado su impacto. La prevalencia del VIH en los adultos se ha mantenido estable en aproximadamente 1.5% desde 1996. Las tasas de VIH son altas entre aquellos que presentan un mayor riesgo, tales como las trabajadoras sexuales (9%) y los hombres que tienen sexo con otros hombres (31.8%). El comportamiento de riesgo entre los adultos con SIDA incluye parejas sexuales múltiples (80%), historia de infección por transmisión sexual (ITS) (51.1%), sexo comercial (23.9%) y crack/cocaína (8.0%). Aproximadamente el 20% de todos los casos de SIDA reportados, principalmente las mujeres, no reportaron historia ninguna de los factores de riesgo usualmente asociados con la infección de VIH. El Programa Nacional tiene su base en el Ministerio de Salud. Desde 1988, Jamaica ha tenido un plan nacional para guiar su respuesta al VIH. En 1988, se creó un Comité Nacional de SIDA con el propósito de dirigir la respuesta multi-sectorial. Los enfoques en relación con la prevención han incluido campañas de información, educación y comunicación, promoción del uso del condón, control de las infecciones por transmisión sexual (ITS), intervenciones dirigidas, enfoques culturales, actividades de vinculo con las comunidades (outreach) y educación entre iguales, programas en el centro de trabajo, así como aconsejamiento y pruebas de VIH. Se han concertado esfuerzos a fin de reducir el estigma y la discriminación por VIH. En 2001, se introdujo la terapia antiretroviral (ARV) para la prevención de la transmisión de madre a hijo en 2001, y un programa de tratamiento de acceso al público fue introducido en 2004. Una Política Nacional en relación con el VIH/SIDA fue adoptada unánimemente por el Parlamento en 2005. Con el Plan Estratégico Nacional 2007-2012, Jamaica se compromete a lograr el acceso universal a la prevención, tratamiento y cuidado del VIH. La conciencia con respecto al VIH y cómo prevenirlo es casi universal, si bien la creencia en mitos relacionados con la enfermedad sigue siendo fuerte. El mercado del condón ha aumentado, de aproximadamente 2.5 millones en 1985 a 12 millones en 2006, mientras que el uso del condón ha crecido significativamente. Así, casi el 75% de los hombres y el 65% de las mujeres reportan haber hecho uso del condón la última vez que tuvieron sexo co su pareja habitual. La proporción de mujeres de 15-24 años que reportan haber tenido prueba de VIH alguna vez, aumentó de 29.8% en 2004 a 48.9% en 2008. La transmisión de VIH de madre a hijo ha disminuido de un 25% antes del año 2000 a menos de un 8% en el 2007. A partir de septiembre de 2008, una cifra de 4450 personas o un estimado de 68.5% de personas con VIH y SIDA avanzados, se han puesto bajo tratamiento ARV, con el resultado de un descenso significativo en la mortalidad y morbilidad por VIH.

Paediatric and perinatal HIV/AIDS in Jamaica: an international leadership initiative, 2002-2007 / VIH/SIDA pediátrico y perinatal en Jamaica: iniciativa de liderazgo internacional, 2002-2007

BACKGROUND: Paediatric and Perinatal HIV/AIDS remain significant health challenges in the Caribbean where the HIV seroprevalence is second only to Sub-Saharan Africa. METHOD: We describe a collaborative approach to the prevention, treatment and care of HIV in 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. RESULTS: 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% 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. CONCLUSION: 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.

ANTECEDENTES: El VIH/SIDA pediátrico y el perinatal continúan siendo retos significativos para la salud en el Caribe, donde la seroprevalencia de VIH ocupa el segundo lugar tras el África Subsahariana. MÉTODO: Se describe un enfoque colaborativo para tratamiento, prevención y cuidado de embarazadas, bebés y niños en Jamaica. Un equipo de personal académico y gubernamental vinculados a la salud, colaboraron para abordar la epidemia de VIH pediátrico y perinatal en Greater Kingston, como modelo para Jamaica (población de 2.6 millones, 1.5% seroprevalencia VIH). Se utilizó un plan de cinco puntos que incluyó liderazgo y entrenamiento, prevención de la transmisión madre a hijo (PTMAH), tratamiento y cuidado de mujeres, bebés y niños, investigaciones basadas en resultados, y outreach local, regional e internacional. RESULTADOS: Un grupo básico de profesionales del VIH pediátrico/perinatal, que incluía pediatras, obstetras, trabajadores de la salud, enfermeras, microbiólogos, administradores de datos, así como personal y estudiantes de la tecnología de la información, fue entrenado para servir en Greater Kingston (cohorte de nacimiento 20 000). De septiembre de 2002 hasta Agosto de 2007, más de 69 793 embarazadas se presentaron para recibir atención prenatal. Durante estos cinco años, tuvieron lugar mejoras significativos en cuanto a la recepción de asesoramiento (40% to 91%) y pruebas (53% to 102%) de VIH voluntarios. Ochocientos ochenta y tres mujeres resultaron VIH positivas en las pruebas, con tasas de seroprevalencia de 1-2% cada año. El uso de un ciclo corto modificado de zidovudina o nevirapina en los primeros tres años, redujo la transmisión madre a hijo (TMAH) de VIH significativamente de 29% a 6% (RR 0.27; 95% CI - 0.10, 0.68). Durante el 2005 hasta 2007, usando terapia antiretroviral altamente activa (TARAA) materna, con zidovudina y lamivudina con nevirapina, nelfinavir o lopinavir/ritonavir y nevirapina y zidovudina para niños, la TMAH se redujo a un estimado de 1.6 % en Greater Kingston y a .75% a lo largo de la isla. En cinco años, evaluamos 1570 niños en cuatro clínicas infecciosas pediátricas semanales en Kingston, Saint Andrew y Saint Catherine, así como en seis otros lugares destinados al servicio comunitario (outreach) por toda Jamaica; 24% (377) tenían VIH/SIDA y 76% (1193) estaba expuestos al VIH. Entre los niños infectados, 79% (299 de 377) iniciaron el TARAA, lo que trajo como resultado una reducción de la mortalidad y la morbilidad infantil atribuible al VIH, en todo el país. Se implementó exitosamente un programa de investigación basado en resultados. CONCLUSIÓN: Trabajando en colaboración, estamos logrando nuestra misión de prevenir la TMAH del VIH, y mejorar la calidad de vida de las familias que viven afectadas por el VIH/SIDA en Jamaica.

Adherence to antiretroviral drug therapy in children with HIV/AIDS in Jamaica / Adhesión a la terapia con medicamento antiretroviral en niños con VIH/SIDA en Jamaica

OBJECTIVE: We aimed to describe the adherence patterns to antiretroviral therapy (ART) in a cohort of HIV-infected children. METHODS: 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. RESULTS: 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 µL (IQR 268-897 cells/µL) and 24.9% (IQR 15.6-42.7 %), respectively. Median viral load was 9.60 x 103 copies/ml (IQR 0.05 x 103 - 52.50 x 103) with 16% (10/63) having viral loads # 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 # 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). CONCLUSION: In resource-limited settings, psychosocial factors contribute significantly to non-adherence and should complement biomedical markers in predicting adherence to antiretroviral therapy in children.

OBJETIVO: Este trabajo tiene por objeto describir los patrones de adhesión a la terapia antiretroviral (TAR) en una cohorte de niños infectados por el VIH. MÉTODOS: Entre los períodos de mayo a octubre de 2005, se entrevistaron 63 niños infectados con el VIH y las personas a cargo de su cuidado, reclutados consecutivamente en cuatro clínicas pediátricas de enfermedades infecciosas en Greater Kingston y Saint Catherine, Jamaica. La adhesión fue definida en términos de las dosis no perdidas en los últimos cuatro días. Se exploraron los marcadores y factores biomédicos asociados con la adhesión. RESULTADOS: El nivel de adhesión global fue de 85.7% (54/63) y fue significativamente más alto para niños en cuidados residenciales (cerca de 100%) en comparación con el 76.3% de los niños en cuidado familiar (p = 0.008). La edad promedio de los niños fue de 7.9 años (rango 0.8 - 19.4 años) y el 57% eran varones. La duración promedio del TAR fue de 18.3 meses (rango 0.1 - 123.8 meses). El conteo medio de CD4 y el porciento disponible para el 95.2% (60/63) y el 92.1% (58/63) de los niños fueron 440 células por µL (IQR 268-897 células/µL) y 24.9% (IQR 15.6 - 42.7 %), respectivamente. La carga viral media fue 9.60 x 103 copias/ml (IQR 0.05 x 103 - 52.50 x 103) con 16% (10/63) con cargas virales # 50 copias/ml. Los niños en cuidado residencial (n = 26), que recibían terapia directamente observada, tuvieron conteos más altos CD4 (p = 0.006) y porciento de CD4 (p # 0.001). Los factores asociados con la no adhesión estuvieron fundamentalmente relacionados con el encargado del cuidado, especialmente largas horas de trabajo (p = 0.002) y náuses como un efecto colateral de TAR (p = 0.007). La no adhesión fue correlacionada positivamente con los turnos médicos perdidos (r = 0.342, p = 0.009) y el aumento de la edad del niño (r = 0.310, p = 0.013). CONCLUSIÓN: En escenarios donde los recursos son limitados, los factores psicosociales contribuyen significativamente a la no adhesión y deben complementar los marcadores biológicos a la hora de predecir la adhesión a la terapia antiretroviral en niños.

Safety of antiretroviral drug therapy in Jamaican children with HIV/AIDS / Seguridad de la terapia con medicamento antiretroviral en niños jamaicanos con VIH/SIDA

BACKGROUND: HIV has been a leading cause of death in Jamaican children aged # 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. METHODS: Data for children prospectively enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme during September 2002 to April 2005 were analyzed. RESULTS: 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 regime was utilized in 93%, trimethoprim/sulphamethoxazole prophylaxis was used in 100% and five were completing anti-tuberculous 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 ARVs, 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. CONCLUSIONS: 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.

ANTECEDENTES: EL VIH ha sido la principal causa de muerte en los niños jamaicanos de # cinco años de edad. Las drogas antiretrovirales (ARVs) se hallan cada vez más a disposición en Jamaica a través del Fondo Global. Los efectos adversos de los ARVs constituyen una causa fundamental para la no adherencia a los medicamentos. El conocimiento del uso y los efectos colaterales de estos medicamentos son cruciales para el tratamiento de los niños infectados por VIH en la medida en que escalamos el uso de la terapia antiretroviral a lo largo de toda la isla. Evaluamos los eventos adversos y la seguridad de la terapia antiretroviral en niños que asisten a cuatro clínicas de enfermedades infecciosas en Kingston, Jamaica, las cuales constituyen un escenario limitado en recursos. MÉTODOS: Se analizaron los datos de niños prospectivamente alistados en el Programa VIH/SIDA Prenatal y Pediátrico de Kingston, Jamaica, durante septiembre de 2002 hasta abril de 2005. RESULTADOS: Entre los 121 niños infectados con VIH, 77 (64%) estaban bajo medicación con ARVs, 90% tenían enfermedades del subgrupo C según la clasificación de CDC, 60% eran varones y predominó la transmisión perinatal. El régimen basado en AZT/3TC fue utilizado en 93%, trimeto-prima/sulfametoxazol se usó en el 100%, y cinco estaban completando medicamentos antituberculosos. La anemia estaba presente en todos los pacientes, con mayor severidad en aquellos bajo ARVs. Se observó macrocitosis en el 83% y trombocitopenia en un 8% de los que se hallaban bajo ARVs. La elevación de los niveles de bilirrubina, aspartato transaminasa (AST) y alanina transaminasa (ALT) y la relación albúmina/globulina invertida antes de comenzar con los ARVs, con una prevalencia significativamente menor tras el uso de los ARVs, enfatizaron la severidad de la enfermedad del VIH al momento de la iniciación del ARV. Las reacciones clínicas adversas fueron poco común e incluyeron decoloración de las uñas (8%), vómitos (7%), náuseas (3%), lipodistrofia periférica (4%) y sueños anormales (1%). Diez de los niños necesitaron cambio de medicación ARV debido a los severos efectos adversos: tres a causa de una anemia severa con repetidas transfusiones de sangre, tres debido a una severa erupción asociada con la nevirapina, y cuatro a causa de hematuria asociada con indinavir. CONCLUSIONES: Los medicamentos ARVs han comenzado a ser administrados exitosamente en niños jamaicanos infectados por el VIH, usando el modelo de salud pública. El excelente perfil de seguridad, la buena tolerancia y el pequeño número de efectos adversos significativos reportados, auguran un buen futuro a la escalada de la terapia antiretroviral en toda la isla.

Renal manifestations in HIV-infected Jamaican children / Manifestaciones renales en niños jamaicanos infectados por el VIH

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

ANTECEDENTES: La documentación en relación con las complicaciones renales de la infección pediátrica por VIH en países en vías de desarrollo, es escasa. En la era de la terapia antiretroviral pre-altamente activa (TARAA), los niños infectados por VIH en Jamaica que desarrollaron nefropatía asociada con VIH evolucionaron hacia la enfermedad renal en fase terminal (ERFT) y la muerte dentro de pocos meses de hecho el diagnóstico. Con el aumento del acceso público a la terapia antiretroviral a partir de 2002 y la subsiguiente supervivencia, cada vez más las complicaciones renales se observan entre la cohorte sobreviviente de niños infectados. MÉTODOS: A una cohorte de 196 niños infectados con VIH, se le practicó un seguimiento en cuatro clínicas ambulatorios multicentros, desde septiembre 1 de 2002 hasta agosto 31 de 2005, como parte del Programa VIH/SIDA Prenatal y Pediátrico de Kingston, Jamaica. El trabajo describe las presentaciones clínicas y la historia natural de los pacientes que desarrollaron complicaciones renales. RESULTADOS: Las infecciones de las vías urinarias fueron el diagnóstico más común en 16.8% de los pacientes, acompañadas de una alta tasa de recurrencia, y el organismo más común fue el Escherichia coli. Cuatro de siete pacientes que comenzaron tratamiento con indinair, desarrollaron complicaciones de nefrolitiasis y nefropatía tubulointersticial. Seis pacientes (3%), cinco de ellos varones, satisfacían los criterios de NAVIH. La edad promedio al momento del diagnóstico fue de cinco años. Todos representaron con la enfermedad de VIH avanzada, síndrome nefrótico o proteniuria de rango nefrótico, y tres con fallo renal crónico. Los pacientes recibieron tratamiento médico estándar y se iniciaron en el uso de inhibidores de enzimas convertidoras de angiotensina (IECAs) y el TARAA. Si bien la proporción de la mortalidad fue 50%, sólo una muerte estuvo asociada con NAVIH y el tiempo medio de supervivencia fue 3.1 años. CONCLUSIONES: Los niños infectados con VIH se presentaron con una variedad de complicaciones renales. Con el mejoramiento de la supervivencia a partir de la introducción del TARAA, se espera que la incidencia de NAVIH aumente entre la cohorte pediátrica en maduración. La detección precoz y el tratamiento temprano optimizarán los resultados obtenidos con estos niños.

Absence of opportunistic parasitic infestations in children living with HIV/AIDS in children's homes in Jamaica: pilot investigations / Ausencia de infecciones parasitarias oportunistas en niños que viven con VIH/SIDA en los hogares para niños en Jamaica: investigaciones pilotos

BACKGROUND: 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. OBJECTIVE: To determine the prevalence and potential risk factors for intestinal parasitic infections in HIV-infected children living in two institutions in Jamaica. METHODS: 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). RESULTS: 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. CONCLUSION: 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.

ANTECEDENTES: Muchos niños que viven VIH/SIDA en los países en vías de desarrollo, están infectados con parásitos intestinales. Estas infecciones añaden una innecesaria morbilidad a los niños que ya sufren el insulto clínico de vivir con el VIH/SIDA. OBJETIVO: Determinar la prevalencia y los factores de riesgo potencial por infecciones parasitarias intestinales en niños infectados por VIH que viven en dos instituciones en Jamaica. MÉTODOS: Un total de 82 especimenes fecales fueron tomados de 41 niños infectados con VIH (rango de la edad 2-14 años) que residían en dos Hogares para Niños. Un cuestionario estructurado de 42 item fue administrado entre los encargados del cuidado de los niños, a fin de obtener datos clínicos y demográficos en cada niño. Los especimenes fecales de cada paciente fueron examinados usando técnicas microbiológicas estándar y se llevo a cabo la detección del antígeno de Cryptosporidium, usando inmunoensayos por enzimas (EIA) comercialmente disponibles. RESULTADOS: No se identificaron parásitos intestinales oportunistas en este estudio. Los parásitos no oportunistas diagnosticados incluyeron Giardia lamblia (12.2%) y Ascaris lumbricoides (2.4%) mientras que los comensales Endolimax nana y Entamoeba hartmanni, fueron hallados en 4.9% y 2.4% de los niños, respectivamente. CONCLUSIÓN: Los niños que viven con VIH/SIDA en instituciones de Jamaica estrechamente supervisadas, no parecen correr serio riesgo alguno de parásitos intestinales. Esto puede deberse al monitoreo clínico estricto de los niños y a las prácticas de higiene personal y ambiental.

HIV-related mortality in Jamaican children / Mortalidad relacionada con el VIH en niños jamaicanos

OBJECTIVE: 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. METHODS: 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. RESULTS: There were 9 (18%) HIV/AIDS-related deaths among 50 HIV-infected children of whom 23 (46%) were males and 21(43%) were AIDS orphans. Five children (10%) 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. CONCLUSIONS: HAART is the only factor identified which prolonged survival for HIV-infected children who are rapid progressors, have AIDS-defining illnesses and are orphans.

OBJETIVO: El VIH pediátrico es la principal causa de morbilidad y mortalidad a nivel mundial. El presente trabajo describe la mortalidad relacionada con el VIH en una cohorte de niños jamaicanos infectados por el VIH y factores identificados que influyeron en la supervivencia. MÉTODOS: Se llevó a cabo un estudio retrospectivo para el período de marzo de 2003 a diciembre 2005 en el Hospital Regional Cornwall, de Montego Bay, Jamaica. Resumimos los datos clínicos y demográficos de los niños infectados por el VIH, tanto de los fallecidos como de los vivos, e identificamos los factores que influyeron en la supervivencia de progresores rápidos y lentos. Los progresores rápidos son niños infectados por el VIH identificados clínicamente antes de los dos años de edad y los preopresores lentos son aquellos identificados después de los dos años de edad. RESULTADOS: Hubo 9 (18%) muertes relacionadas con el VIH/SIDA entre 50 niños infectados por el VIH, de los cuales 23 (46%) eran varones y 21(43%) eran huérfanos del SIDA. Cinco niños (10%) recibieron profilaxis ARV, 31(62%) fueron amamantados y 39 (78%) recibieron TARAA. Los niños sobrevivientes mostraron enfermedades primariamente no definitorias de SIDA (neumonía y sepsis), pero no hubo diferencia en las enfermedades definitorias del SIDA entre los niños vivos y los fallecidos. La edad mediana al momento del diagnóstico fue de 26 meses ( rango 3-121; IQR 10, 54). La edad mediana al momento de la muerte fue de 30 meses (rango 7-122 meses; IQR 17 118). Tanto los niños sobrevivientes como los fallecidos presentaron síntomas primariamente moderados en el momento del diagnóstico (21 para un 42%) y la muerte (7 para un 78%). En los progresores rápidos, 19 de 20 (95%) bajo TARAA continuaron vivos y el total de los 4 (100%) que no recibieron TARAA murieron. La tasa de mortalidad en los niños bajo TARAA fue de 30.78 por cada 100 años-persona y 48 por 100 años-persona en niños que recibieron TARAA. CONCLUSIONES: TARAA es el único factor identificado que prolongó la supervivencia de los niños infectados con el VIH que eran rápidos progresores, tenían enfermedades definitorias del SIDA y eran huérfanos.

Evaluation of adherence to highly active antiretroviral therapy in adults in Jamaica / Evaluación de la adhesión a la terapia antiretroviral altamente activa en adultos en Jamaica

BACKGROUND AND PURPOSE: Highly active antiretroviral therapy (HAART) has improved morbidity and mortality and quality of life, revitalized communities and transformed the perception of HIV/AIDS from being a "death sentence" to a chronic illness. Strict and sustained adherence to medication is essential long-term viral suppression. In April 2005, an Adherence Support Programme was introduced to Jamaica's HIV Programme, whereby Persons Living with HIV/ AIDS (PLWHA) who had achieved high levels of adherence were trained to provide support to other PLWHA in order to increase their adherence to HAART regimens. METHODS: A cross-sectional survey of 116 individuals with advanced HIV and on HAART was performed in June and July 2006. RESULTS: Many participants were unemployed, poor persons with limited education. Based on self-report of seven-day adherence, 54.8% of persons were 95-100% adherent, 37.5% were 80-94% adherent and 7.7% were < 80% adherent. Having interacted with an adherence counsellor was not associated with adherence levels. Factors associated with nonadherence were: being away from home (38%), sleeping through dose-time (37%), forgetfulness (37%) and running out of pills (31%). Having no food (26.9%), not wanting to be seen taking medication (20%) and intolerable side effects (18.8%) were also reasons given. Only 44% of persons used aids to remind them of dose times. CONCLUSION: Adherence in this study group is low and may have worsened since 2005. More emphasis must be placed on preparing adults to start HAART. The use of pillboxes and other reminders such as alarm clocks and cell phones must be reinforced.

ANTECEDENTES Y PROPÓSITO: La terapia antiretroviral altamente activa (TARAA) ha producido un marcado mejoramiento en relación con la morbilidad y la mortalidad así como la calidad de la vida. Asimismo, ha revitalizado las comunidades y transformado la percepción del VIH/SIDA, de una "sentencia de muerte" a una enfermedad crónica. La adhesión estricta y sostenida a la medicación es esencial para una supresión viral a largo plazo. En abril de 2005, se introdujo un Programa de Apoyo a la Adhesión como parte del Programa de VIH de Jamaica, mediante el cual personas que viven con VIH/SIDA (PVCVS) y que han alcanzado altos niveles de adhesión, fueron entrenadas con el fin de ayudar a otras PVCVS a aumentar su adhesión a los regimenes de TARAA. MÉTODOS: En junio y julio de 2006 se llevó a cabo un estudio transversal de 116 individuos con VIH avanzado y bajo TARAA. RESULTADOS: Muchos participantes eran personas desempleadas y pobres, con un nivel de educación limitado. Según un auto-reporte de adhesión por 7 días, 54.8% de las personas mostraron una adhesión de 95-100%, 37.5% presentaban una adhesión de 80-94% y 7.7% tenían una adhesión de < 80%. El haber interactuado con un consejero de adhesión no guardaba relación con los niveles de adhesión. Los factores asociados con la adhesión fueron el estar fuera de casa (38%), pasar durmiendo la hora de la dosis (37%), olvido (37%), y el quedarse sin tabletas (31%). No tener alimentos (26.9%), no querer ser visto tomando medicamentos (20%) y efectos colaterales intolerables (18.8%) fueron también razones dadas. Sólo el 44% de las personas usaban ayudas para recordarles las horas de las dosis. CONCLUSIÓN: La adhesión en este grupo de estudio es baja y puede haber empeorado desde el 2005. Hay que hacer más énfasis en preparar a los adultos para que comiencen con TARAA. El uso de cajas de tabletas y otros medios recordatorios tales como despertadores y celulares tiene que ser reforzado.

Bacille Calmette-Guérin lymphadenitis and immune reconstitution syndrome in HIV-infected children on antiretroviral therapy in Jamaica / Linfadenitis por Calmette-Guérin y síndrome de reconstitución inmune en niños infectados con el VIH bajo terapia antiretroviral en Jamaica

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.

El síndrome inflamatorio de la reconstitución inmune (SIRI) es una complicación reconocida asociada con infecciones oportunistas que ocurren en individuos infectados por el VIH, luego de su iniciación en la terapia antiretroviral altamente activa (TARAA). Se reporta el caso de tres infantes infectados por VIH con enfermedad VIH de progresión rápida, que se presentan con SIRI debido a la vacuna BCG, 3-6 semanas después de la iniciación de TARAA.

Nevirapine-associated rash in a Jamaican child with HIV/AIDS

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

HIV/AIDS following sexual assault in Jamaican children and adolescents: a case for HIV post-exposure prophylaxis

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

Nursing interventions in the Kingston Paediatric and Perinatal HIV/AIDS Programme in Jamaica

BACKGROUND: Nursing care has been the [quot]grass roots[quot] 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. PURPOSE: 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. METHOD: 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. RESULTS: 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. CONCLUSION: 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

Antiretroviral drug therapy in HIV-infected Jamaican children

BACKGROUND: The study describes a cohort of HIV-infected Jamaican children receiving antiretroviral therapy (ART) and reports the outcome. METHOD: 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. RESULTS: 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. CONCLUSION: 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

CDC-defined diseases and opportunistic infections in Jamaican children with HIV/AIDS

OBJECTIVE: To document the frequency of Centers for Disease Control and Prevention (CDC)-defined clinical conditions, opportunistic and co-infections among children with HIV/AIDS. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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

Uptake of interventions, outcomes and challenges in caring for HIV-exposed infants in Kingston, Jamaica

BACKGROUND: 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 . OBJECTIVES: 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. METHOD: 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. RESULTS: 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. CONCLUSION: 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)

Socio-demographic characteristics of HIV-exposed and HIV-infected Jamaican children

BACKGROUND: 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. OBJECTIVE: To document the socio-demographic characteristics of paediatric and perinatal HIV/AIDS in Kingston, Jamaica. METHODS: 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. RESULTS: 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. CONCLUSION: 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

p53-independent checkpoint controls in a plant cell model

Allium cepa L. meristems were used as a plant model to study the p53-independent control of S and G2 phases by checkpoint pathways, in eukaryotic cells. Checkpoint blocks were induced at early and mid S by hydroxyurea. After their spontaneous override, cells became accumulated in G2-prophase, giving rise later on to a delayed mitotic wave. Cell growth was maintained during the checkpoint blocks, as the delayed mitoses were larger in size than the control ones. Under continuous hydroxyurea treatment, the delayed mitotic was formed by two subpopulations: normal mitoses corresponding to cells having properly recovered from the checkpoint block, and abnormal ones resulting from checkpoint adaptation. These latter cells displayed broken chromatids as they had unduly overriden the G2 checkpoint block, without completing DNA repair. The frequency of the checkpoint-adapted mitoses increased with the hydroxyurea concentration from 0.25 to 1.0 mM. However, from 1 mM hydroxyurea upwards, some of the cells lost their competence for checkpoint adaptation. Therefore, the dose of a genotoxic agent that still allows G2 checkpoint adaptation should always be applied in order to get rid of uncontrolled proliferating cells. This is specially suitable for cells lacking a functional p53 protein.