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.

Effectiveness of antiretroviral therapy in treating paediatric HIV/AIDS in Jamaica / Efectividad de la terapia antiretroviral en el tratamiento del VIH/SIDA pediátrico en Jamaica

BACKGROUND AND PURPOSE: 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. METHODS: 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. RESULTS: 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 enrolment; 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. CONCLUSIONS: A successfully implemented ambulatory model for paediatric HIV care in Jamaica has improved the quality of life and survival of HIV-infected children.

ANTECEDENTES Y PROPÓSITO: El VIH/SIDA pediátrico sigue representando un desafío mayor en los países en vías de desarrollo. Describimos la efectividad de las intervenciones en niños infectados con el VIH, que asisten a las clínicas de enfermedades infecciosas en Jamaica. MÉTODOS: Ciento noventa y siete niños infectados con el VIH fueron objeto de un seguimiento prospectivo en las clínicas ambulatorias multicentros, entre septiembre 1 de 2002 y agosto 31 de 2005, como parte del Programa VIH/SIDA Prenatal y Pediátrico de Kingston, Jamaica, y se describen los resultados. RESULTADOS: El seguimiento medio fue de 23 meses-niño (rango intercuartil [IQR] 12-31) con 12 niños (6.0%) perdidos al seguimiento y las muertes (n = 13) ocurridas en 4.64 por 100 años-niño de seguimiento. La media de la edad fue 5.0 años (IQR 2.2-8.1) y 32.1% tuvieron enfermedades de categoría C en Centros de Control y Prevención de las Enfermedades a la hora de su enrolamiento, 62% estuvieron siempre bajo terapia antiretroviral (TAR) con una duración promedio de 15.4 meses (IQR 5.5-25.5); 85% iniciaron TAR con zidovudina/lamivudina/nevirapina. El peso medio por altura fue 0.13 ± 1.02 (diferencia media -1.71 [95% intervalo de confianza (CI) -2.73, -0.69]; p = 0.001) y el índice de masa corporal por edad 0.05 ± 1.11 (diferencia media -1.11, [CI -1.79, -0.43]; p = 0.002) las puntuaciones z aumentaron luego de 24 meses bajo TAR.; sin embargo, los niños permanecieron raquíticos. Reducciones en la incidencia de hospitalizaciones (diferencia media 30.95, [CI 3.12, 58.78]; p = 0.03) y en los episodios de neumonía, sepsis probada por cultivo positivo, y tuberculosis, ocurrieron entre aquellos que se hallaban bajo TAR. CONCLUSIONES: Un modelo ambulatorio exitosamente implemente para la atención pediátrica del VIH en Jamaica, ha mejorado la calidad de vida y la supervivencia de los niños infectados con el VIH.

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.

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.

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

Tuberculosis, chickenpox and scabies outbreaks in an orphanage for children with HIV/AIDS in Jamaica

OBJECTIVES: The aim of this study is to describe the investigation and management of outbreaks of acute tuberculosis, varicella zoster virus and scabies in a residential facility for children with HIV/AIDS. METHOD: A review of the results and management for diagnosed cases of acute TB (four between 2001 and 2002) as well as varicella zoster virus (15) and scabies (14) (concurrent in March--June 2003), in a residential facility housing 24 abandoned children with HIV/AIDS was conducted. Outbreak control methods and challenges are described The modified WHO criteria were used for TB diagnosis. The diagnoses of varicella and scabies were entirely clinical. RESULTS: Of the surviving 22 children, 12 (mean age 8 years 2 months) were female, and 10 (mean age 5 years 6 months) were male. Full immunization (primary series) was documented for 16 children, partial in one child, unknown status was documented in five children. One child had received varicella vaccine previously. Eleven (50) children had been receiving antiretroviral triple therapy since 2002 (all in Centers for Diseases Control immunological categories 2-3). Two of the four children with tuberculosis died between 2001 and 2002; these were not on antiretroviral therapy--the 2 survivors are still on antiretroviral therapy. All staff mantoux test results were negative. Fifteen (68) children developed chickenpox as well as three caregivers. The index case was a 13-year-old resident attending a nearby school with HIV negative children. This varicella outbreak went on to affect household members for the caregivers as well as other residential facilities nearby. Scabies affected 14 children (no caregivers); the index cases were most likely three new child residents who entered the institution in 2002 (from other homes) with histories of scabies infestation. Chickenpox and scabies dual infection occurred in seven (31) of residents. No cases of herpes zoster, disseminated varicella infection or death because of varicella occurred Diagnosed cases of chickenpox were treated with oral acyclovir Knowledge about these disease outbreaks and their control was generally lacking. CONCLUSIONS: Improvement in immunization coverage for children and staff as well as educating staff about infectious disease outbreaks, is necessary for effective control. Appropriate screening for infection/disease for all susceptible persons is essential along with timely reporting of outbreaks/reportable diseases. There is need for in

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

Paediatric HIV/AIDS in Jamaica. A hospital-based description

The continuing worldwide epidemic of adult HIV/AIDS has led to an increase in the number of HIV-positive children mainly through perinatal transmission. Although national data are available, there is no published report of the epidemiology of HIV/AIDS in children in Jamaica. A multicentre retrospective analysis of 183 HIV seropositive children admitted to hospitals in Jamaica between 1990 and 1996 was conducted. Ages at diagnosis were available for 172 patients with 61 diagnosed in the first year of life. Clinical histories were available for 129 patients with the primary presenting symptoms of infected children being failure to thrive, pneumonia, diarrhoea, dermatitis and lymphadenopathy. Classification was possible in 128 patients: 49 were exposed, 76 were infected and three were seroreverters. Infected children had a longer hospital stay than those classified as exposed or seroreverters. As of December 31, 1997, 125 patients had defaulted, nine patients were alive and 51 were reported dead with a median age of death of 12 months. From these data, it is estimated that the hospital-based HIV incidence among children in Jamaica increased from 0.149 per 10,000 person years in 1990 to 1.331 per 10,000 person years in 1996. This study demonstrates a rise in the estimated incidence of HIV/AIDS but we were unable to estimate survival reliably since the data required were not available for 75 of children identified. These data highlight the urgent need for targeted interventions to reduce vertical transmission of HIV as well as a need for prospective studies to establish reliable data on incidence and long-term outcome for HIV-infected children.