Chikungunya in Jamaica: Public health effects and clinical features in children / Chikungunya en Jamaica ­ Efectos en la Salud Pública y Características Clínicas en Niños

Chikungunya virus (CHIKV) entered the Caribbean for the first time in 2013 and Jamaica experienced its maiden epidemic with Chikungunya Fever in 2014. We aimed to describe the public health effects and describe the clinical features in children and adolescents in Jamaica. METHODS: This study reviewed the public health effects of the illness in Jamaica by reviewing available data sources and the clinical features in 210 children and adolescents meeting the case definition at two hospitals, Bustamante Hospital for Children and University Hospital of the West Indies between August 23 and October 31, 2014 by chart review. Descriptive analyses and comparisons between groups using the Mann-Whitney U test were performed with SPSS version 22. RESULTS: The majority of households were affected by the illness which caused widespread absenteeism from school and work, loss of productivity and economic losses estimated at 60 billion dollars. The health sector was impacted by increased numbers seen in clinics and emergency departments, increased need for bed space and pharmaceuticals. Ninety-nine per cent of the children were febrile with a median maximal temperature of 102.4 F. Ninety-three per cent had household contacts of 0­20 persons. In addition to fever, maculopapular rash and joint pains, infants six months and younger presented with irritability and groaning (p = 0.00) and those between six months and six years presented with febrile seizures (p = 0.00). Neurologic involvement was noted in 24%. Apart from anaemia, few had other laboratory derangements. Few had severe organ dysfunction and there were no deaths. CONCLUSION: The Chikungunya Fever epidemic had significant public health and economic impact in Jamaica. In children, there were characteristic presentations in neonates and young infants and in children six months to six years. Neurologic involvement was common but other organ dysfunction was rare. These findings underscore the need to prevent further epidemics and the quest for a vaccine.(AU)

Antecedentes: El virus de Chikungunya (CHIKV) entró en el Caribe por primera vez en 2013, y Jamaica experimentó su primera epidemia de fiebre de Chikungunya en 2014. Nos propusimos como objetivo describir sus efectos en la salud pública y describir sus características clínicas en niños y adolescentes en Jamaica. Métodos: Este estudio examinó los efectos de la enfermedad en la salud pública en Jamaica. El examen se realizó mediante la revisión de fuentes de datos disponibles y las características clínicas en 210 niños y adolescentes que cumplían con la definición del caso en dos hospitales ­ Hospital Pediátrico Bustamante y el Hospital Universitario de West Indies ­ entre el 23 de agosto y 31 de octubre de 201, según las historias clínicas. Se realizaron análisis descriptivos y comparaciones entre los grupos usando la prueba U de Mann-Whitney y la versión 22 de SPSS Resultados: La mayoría de los hogares fueron afectados por la enfermedad, que causó un ausentismo generalizado en escuelas y trabajos, pérdida de productividad, y pérdidas económicas estimadas en 60 billones de dólares. El sector de la salud fue afectado por un aumento del número de personas atendidas en clínicas y departamentos de urgencias, y una mayor necesidad de camas en los hospitales y productos farmacéuticos. Noventa y nueve por ciento de los niños presentaron un estado febril con una temperatura mediana máxima de 102.4 F. Un noventa y tres por ciento tuvo contactos domésticos de personas de 0­20. Además de fiebre, erupciones maculopapulares y dolores en las articulaciones, los niños de seis meses o menos edad, presentaron irritabilidad y quejidos (p = 0.00), y aquellos entre seis meses y seis años de edad presentaron convulsiones febriles (p = 0.00). Se observó compromiso neurológico en el 24%. Aparte de anemia, algunos tenían otros trastornos de laboratorio. Otros presentaban una disfunción orgánica severa y no hubo muertes. Conclusión: La epidemia de fiebre de Chikungunya tuvo un impacto significativo tanto en la salud pública como en la economía de Jamaica. Los niños presentaron manifestaciones características, observadas tanto en recién nacidos y bebés pequeños como en niños de seis meses a seis años. El compromiso neurológico fue común, pero cualquiera otra disfunción orgánica fue rara. Estos hallazgos subrayan la necesidad de hacer más por evitar las epidemias y buscar la solución de una vacuna.(AU)

Emergence of zika virus epidemic and the national response in Jamaica

BACKGROUND: Jamaica, along with the Americas, experienced major epidemics of arboviral diseases transmitted by the Aedes aegypti mosquito in recent years. These include dengue fever in 2012, Chikungunya fever in 2014 and Zika virus infection (ZIKV) in 2016. We present the emergence of the ZIKV epidemic in Jamaica and outline the national response. METHODS: The Ministry of Health's preparedness included: heightened surveillance, clinical management guidance, vector control and management, laboratory capacity strengthening, training and staffing, risk communication and public education, social mobilization, inter-sectoral collaboration, resource mobilization and international cooperation. RESULTS: The first case of ZIKV was confirmed on January 29, 2016 with date of onset of January 17, 2016. From January 3 to July 30, 2016 (Epidemiological Week (EW) 1-30), 4648 cases of ZIKV were recorded (4576 suspected, 72 laboratory-confirmed). Leading symptoms were similar among suspected and confirmed cases: rash (71% and 88%), fever (65% and 53%) and joint pains (47% and 38%). There were 17 suspected cases of Guillain Barre syndrome; 383 were reported in pregnant women, with no reports of microcephaly to date. Zika and dengue viruses were circulating predominantly in 2016. At EW30, 1744 cases of dengue were recorded (1661 suspected and 83 confirmed). Dengue serotypes 3 and 4 were circulating with 121 reports of dengue haemorrhagic fever...(AU) CONCLUSION:The possibility exists for endemicity of ZIKV similar to dengue and chikungunya in Jamaica. A ZIKV vaccine, similar to the dengue and chikungunya vaccines, is needed to be fast-tracked into clinical trials to mitigate the effects of this disease.

Neurocognitive function in HIV-positive children in a developing country.

OBJECTIVES: We aimed to characterize neurological outcomes and determine the prevalence of HIV encephalopathy in a cohort of HIV-infected children in Jamaica. METHODS: Data for 287 HIV-infected children presenting between 2002 and 2008 were reviewed and neurological outcomes characterized. A nested case-control study was conducted between July and September 2009 used 15 randomly selected encephalopathic HIV-infected children aged 7-10 years and 15 matched controls (non-encephalopathic HIV-infected). Their neurocognitive functions were evaluated using clinical assessment and standardized tests for intelligence, short term memory (visuo-spatial and auditory), selective attention, and fine motor and coordination functions. Outcomes were compared using Fisher's exact test and the Mann-Whitney U-test. RESULTS: Sixty-seven (23.3%) children were encephalopathic. The median age at diagnosis of HIV encephalopathy was 1.6 years (interquartile range (IQR) 1.1-3.4 years). Predominant abnormalities were delayed milestones (59, 88.1%), hyperreflexia (59, 86.5%), spasticity (50, 74.6%), microcephaly (42, 61.7%), and quadriparesis (21, 31.3%). The median age of tested children was 8.7 years (IQR 7.6-10.8 years) in the encephalopathic group and 9 years (IQR 7.4-10.7 years) in the non-encephalopathic group. Encephalopathic children performed worse in all domains of neurocognitive function (p<0.05). CONCLUSIONS: A high prevalence of HIV encephalopathy was noted, and significant neurocognitive dysfunction identified in encephalopathic children. Optimized management through the early identification of neurological impairment and implementation of appropriate interventions is recommended to improve quality of life.

Eliminating vertically-transmitted HIV/AIDS while improving access to treatment and care for women, children and adolescents in Jamaica.

BACKGROUND AND METHODS: To celebrate Jamaica's 50th birthday after receiving independence from Great Britain, we summarize our collaborative published research in the prevention, treatment and care of paediatric, perinatal and adolescent HIV/AIDS in Jamaica. RESULTS: Public access to antiretroviral therapy (ART) in Jamaica has shown that a "test and treat" strategy associated with "treatment for prevention" works for HIV-infected pregnant women by reducing their HIV-attributable morbidity and mortality and reducing mother-to-child transmission (MTCT) rates to < 2%, islandwide. These women experience significant psychosocial stress and targeted interventions are assisting them to improve their quality of life. HIV-exposed and infected children come from large families with high rates of teen pregnancies and significant financial challenges needing sustained interventions. HIV-exposed but uninfected Jamaican infants have higher rates of community-acquired infections, including lower respiratory tract infections, sepsis and gastroenteritis compared to community controls, although their growth rates are normal. In evaluation of replication capacity, viral control and clinical outcomes after vertical transmission in Jamaican mother-infant pairs, HLA-B57 was found to confer the advantage of restricted HIV replication primarily by driving and maintaining a fitness-attenuating mutation in p-24 Gag. Viral sequences from 52 MTCT Jamaican pairs were compared and 1475 sites of mother-infant amino acid divergence within Nef, Gag and Pol were identified, suggesting modest fitness cost with many CD8 mutations. HIV-infected Jamaican children are surviving into adolescence and adulthood, as a result of increased public access to ART and improved collaborative capacity in ART management. Successful transition of HIV-infected children through adolescence into adulthood requires a strong multidisciplinary team approach, including long-term ART management addressing non-adherence, drug resistance and toxicity, treatment failure and limited options for second line and salvage therapy, while attending to their sexual and reproductive health, psychosocial, educational and vocational issues and palliative care. CONCLUSION: Over the past nine years, Jamaica has made excellent strides to eliminate vertically transmitted HIV/AIDS, while reducing the HIV-attributable morbidity and mortality in pregnant women and in HIV-infected children. Continued successful transition of HIV-infected children through adolescence into adulthood will require a strong multidisciplinary team approach.

Rotavirus vaccine trial in Jamaica.

Worldwide, rotaviruses have been a significant cause of dehydrating gastroenteritis. This contributed to increased infant morbidity and mortality in Jamaica. We enrolled 1804 Jamaican infants in the international randomized, placebo-controlled, pentavalent (G1, G2, G3, G4 and P1) rotavirus vaccine trial. This pentavalent vaccine was found to significantly reduce rotavirus gastroenteritis attributable emergency room visits and hospitalizations, without increasing the rates of intussusception, or other serious adverse events in Jamaican infants. It is recommended that the rotavirus vaccine be included in Jamaica's National Immunization Programme in accordance with recommendations from the World Health Organization.

Antibiotic resistance among pathogens causing disease in Jamaican children with HIV/AIDS.

OBJECTIVE: There are limited data regarding the antimicrobial resistance patterns of pathogens in children with HIV/AIDS from developing countries. We aimed to determine the prevalence and antibiotic susceptibility patterns of bacterial pathogens causing urinary tract infections (UTIs) and sepsis in a cohort of 219 HIV-infected Jamaican children. METHODS: This cross-sectional study examined clinical and microbiological data for children enrolled in the Kingston Paediatric/Perinatal HIV/AIDS programme from September 1, 2002 to May 31, 2007. Cases were defined as physician-diagnosed, laboratory confirmed UTIs and sepsis based on Centers for Disease Control and Prevention (CDC) criteria. Only isolates from urine, blood and sterile sites were considered. RESULTS: Forty-four patients (20.1%) accounted for 74 episodes of UTIs and sepsis. Mean number of infections was 1.7 +/- 1.3 per patient. There were 31 males (70.5%) and mean age at time of infection was 5.6 +/- 4.7 years. Bacterial infections comprised cystitis (n = 52, 70.3%), bacterial pneumonia (n = 15, 20.3%), meningitis (n = 4, 5.4%), septicaemia (n = .2, 2.7%) and bone infection (n = 1, 1.4%). Among 52 UTIs, 39 were caused by a single organism. The most common UTI isolates included Escherichia coli (n = 21, 53.8%) and Enterobacter spp (n = 5, 12.8%). Among 22 cases of sepsis, isolates included Streptococcus pneumoniae (n = 8, 36.4%) and coagulase negative Staphylococcus (n = 6, 27.3%). All E coli isolates at two of three clinical sites were resistant to cotrimoxazole. There were 79.7% (n = 51) of infectious episodes with a cotrimoxazole-resistant organism occurring among those on cotrimoxazole prophylaxis. CONCLUSIONS: Escherichia coli was the most frequent bacterial isolate. Cotrimoxazole is a poor choice for empiric treatment of sepsis and UTIs in this clinical setting.

High genetic diversity in human immunodeficiency virus-type 1 in Jamaica.

The subtypes of the human immunodeficiency virus - type 1 (HIV-1) strains from 54 HIV-1 - infected persons including 44 strains which were typed previously by heteroduplex mobility assay (HMA) were determined by DNA sequencing and phylogenetic analysis. Of 54 HIV- infected persons, 92.5% were infected with HIV-1 subtype B and 7.5% with other HIV-1 subtypes including subtypes D (3.7%), A (1.9%) and J (1.9%). In the phylogenetic analysis, the subtype A virus found in the sample clustered with subtype A reference strains and a circulating recombinant form (CRF) reference strain which originates in Central Africa and is circulating in Cuba indicating a close relationship between these viruses. There was 86% concordance between HMA and DNA sequencing in assigning subtype B viruses. For the non-B subtype viruses, there was less concordance between the two methods (67%). The results confirm the predominance of HIV-1 subtype B strains and the high genetic diversity of HIV-1 strains in circulation in Jamaica. The efficacies and some limitations of the HMA as a method of HIV-1 subtyping also were noted. It is important that the HIV/AIDS epidemic in Jamaica be monitored meticulously for possible expansions in non-B subtypes and the emergence of inter-subtype recombinant forms. We recommend that the more expensive DNA sequencing and phylogenetic analysis, including HIV-1 genotyping for antiretroviral drug resistance testing, be used as an adjunct to the more cost-effective HMA to track the HIV/AIDS epidemic in Jamaica.

Evolving care of HIV-infected pregnant women in Jamaica--from nevirapine to HAART.

BACKGROUND: The Ministry of Health, Jamaica, is scaling-up programmes to improve the health of HIV-positive pregnant women according to the modified WHO recommended preventative mother to child transmission (pMTCT) regimens of therapy based upon the mother's clinical and immunological status. Highly-active antiretroviral drugs (HAART) can result in successful pMTCT to < 1%. We report the clinical and immunological characteristics of HIV/AIDS in an era of evolving treatment and care of HIV-infected pregnant Jamaican women. SUBJECTS AND METHOD: Clinical records were reviewed of patients registered in antenatal clinics in Greater Kingston and St. Catherine, Jamaica (annual birth cohort--20,000) between September 2002 and August 2006. Disease status was determined using the Centers for Disease Control and Prevention (CDC) classification system for adult HIV/AIDS. Demographic, clinical and laboratory data were documented and analyzed. RESULTS: During the four-year period, 571 HIV-infected women were enrolled; 62% from Victoria Jubilee Hospital, 25% from Spanish Town Hospital and 13% from the University Hospital of the West Indies. Mean age was 27-29 (range 15-41) years, median parity was 2 (range 0-9) and 68-70% were unemployed. Ninety-five per cent had live births. CDC categories of illnesses were A--mild disease in 82% (n=473), B--moderate disease in 4.4% (n=24) and C--severe disease in 1.4% (n=8) while 12% (n=66) had insufficient data. During the first three years, CD4+ cell counts were evaluated in only 2.5% (10 of 406) of patients with median of 344 cells/microL, compared to CD4 evaluation in 50% (83 of 165 women) in the last year with median of573 cells/uL. Antiretroviral (ARV) medications primarily for pMTCT were given to 89% (n=506) ofwomen. Of these, uptake of HAART increased during years 1-3 from 2-3% to 62% in year four Within two years post-partum, 24 women died, 92% (n=22)from the direct complications of HIV/AIDS. CONCLUSION: A comprehensive system of care of HIV in the peripartum period has been developed in Jamaica. Detailed medical evaluation during pregnancy is performed with modern guidelines and increasing laboratory availability of CD4+ cell counts and viral loads. We believe declining HIV infection rates in Jamaican infants and healthier mothers are a direct consequence of increased testing in pregnancy with early diagnosis and initiation of HAART-based pMTCT regimens in pregnant women.

Paediatric and perinatal HIV/AIDS in Jamaica an international leadership initiative, 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 ofHIVin pregnant women, infants and children in Jamaica. A team of academic and government healthcare personnel collaborated to address the paediatric and perinatal HIV epidemic in Greater Kingston as a model for Jamaica (population 2.6 million, HIV seroprevalence 1.5%). A five-point plan was utilized and included leadership and training, preventing mother-to-child transmission (pMTCT), treatment and care of women, infants and children, outcomes-based research and local, regional and international outreach. 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%0 CI--0.10, 0.68). During 2005 to 2007 using maternal highly active antiretroviral therapy (HAART) with zidovudine and lamivudine with either nevirapine, nelfinavir or lopinavir/ritonavir and infant zidovudine and nevirapine, MTCT was further reduced to an estimated 1.6% in Greater Kingston and 4.75% islandwide. In five years, we evaluated 1570 children in four-weekly paediatric infectious diseases clinics in Kingston, St Andrew and St Catherine and in six rural outreach sites throughout Jamaica; 24% (377) had HIV/AIDS and 76% (1193) were HIV-exposed. Among the infected children, 79% (299 of 377) initiated HAART resulting in reduced HIV-attributable childhood morbidity and mortality islandwide. An outcomes-based research programme was successfully implemented. 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.

Effectiveness of antiretroviral therapy in treating paediatric HIV/AIDS in 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 enrollment; 62% were ever on antiretroviral therapy (ART) with median duration of 15.4 months (IQR 5.5-25.5); 85% initiated ART with zidovudine/lamivudine/nevirapine. Mean weight-for-height 0.13 +/- 1.02 (mean difference -1.71 [95% Confidence interval (CI) -2.73, -0.69]; p = 0.001) and body mass index-for-age 0.05 +/- 1.11 (mean difference -1.11, [CI -1.79, -0.43]; p = 0.002); z scores increased after 24 months on ART; however, children remained stunted. Reductions in the incidence of hospitalizations (mean diff 30.95, [CI 3.12, 58.78]; p = 0.03) and in episodes of pneumonia, culture-positive sepsis and tuberculosis occurred in those on ART. CONCLUSIONS: A successfully implemented ambulatory model for paediatric HIV care in Jamaica has improved the quality of life and survival of HIV-infected children.

Adherence to antiretroviral drug therapy in children with HIV/AIDS in 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 microL (IQR 268-897 cells/pL) and 24.9% (IQR 15.6 - 42.7%), respectively. Median viral load was 9.60 x 103 copies/ml (IQR 0.05 x 10(3) - 52.50 x 10(3)) with 16% (10/63) having viral loads < or = 50 copies/ml. Children in residential care (n=26), receiving directly observed therapy had higher CD4 counts (p = 0.006) and CD4 per cent (p < or = 0.001). Factors associated with non-adherence were primarily caregiver related, especially long work hours (p = 0.002) and nausea as a side effect of ART (p = 0.007). Non-adherence was positively correlated with missing clinic appointments (r = 0.342, p = 0.009) and increasing age of child (r = 0.310, p = 0.013). CONCLUSION: In resource-limited settings, psychosocial factors contribute significantly to nonadherence and should complement biomedical markers in predicting adherence to antiretroviral therapy in children.

Safety of antiretroviral drug therapy in Jamaican children with HIV/AIDS.

BACKGROUND: HIV has been a leading cause of death in Jamaican children aged < or = five years. Antiretroviral drugs (ARVs) are increasingly available in Jamaica through the Global Fund. Adverse effects of ARVs are a major cause for non-adherence to medications. Knowledge of the use and side effects of these drugs are crucial in the management of HIV-infected children as we scale-up the use of antiretroviral therapy, islandwide. We evaluated the adverse events and safety of antiretroviral therapy in children attending four Infectious Disease Clinics in Kingston, Jamaica, a resource limited setting. 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 regimen was utilized in 93%, trimethoprim/sulphamethoxazole prophylaxis was used in 100% and five were completing antituberculous drugs. Anaemia occurred in all patients, with increased severity in those on ARVs. Macrocytosis occurred in 83% and thrombocytopenia in 8% of those on ARVs. Elevation of bilirubin, aspartate transaminase (AST) and alanine transaminase (ALT) levels and reversed albumin to globulin ratio prior to commencing AR Vs, with significantly lower prevalence following use of ARVs emphasized the severity of HIV disease at time of ARV initiation. Clinical adverse reactions were uncommon and included nail discoloration (8%), vomiting (7%), nausea (3%), peripheral lipodystrophy (4%) and abnormal dreams (1%). Ten children required change of ARV medication because of severe adverse effects: three for severe anaemia with repeat blood transfusions, three for severe nevirapine-associated rash and four for indinavir-associated haematuria. 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.

Absence of opportunistic parasitic infestations in children living with HIV/AIDS in children's homes in Jamaica: pilot investigations.

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.

Renal manifestations in HIV-infected Jamaican children.

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.

Clinical manifestations of adolescents with HIV/AIDS in Jamaica.

OBJECTIVE: To characterize the clinicopathological manifestations and outcomes of a cohort of HIV-infected Jamaican adolescents. METHODS: This is a retrospective cohort study to determine demographic, clinical, immunological characteristics, antiretroviral uptake and mortality in 94 adolescents aged 10-19 years followed in the Kingston Paediatric and Perinatal HIV/AIDS Programme (KPAIDS) between September 2002 and May 2007. Parametric and non-parametric tests are used to compare variables. RESULTS: The median age at initial presentation was 10.0 years (interquartile range (IQR) 7.0-12.0 years), 54.3% (51) were female (p = 0.024), transmission was primarily mother-to-child (70, 73.4%), with 87% (61) of the latter presenting as slow progressors. Sexual transmission accounted for 19.1% and there was significant female predominance (n=15; p = 0.024). At most recent visit, perinatally infected adolescents were more likely (p < 0.0001) to reside with a non-parent (n=42) than a biological parent (n=19) and most had Centers for Disease Control and Prevention (CDC) category C (35/50%) disease, whereas the majority of non-perinatally infected children were classified CDC category A. Mean z scores for height-for-age was -1.47 +/- 1.21 (n=77), weight-for-age -1.06 +/- 1.44 (n=80) and BMI-for-age -0.34 +/- 1.21 (n=76) respectively; females (n=41) were taller than males (n=36) at their current height (p = 0.031). Lymphadenopathy (82%), dermatitis (72.0%), hepatomegaly (48%) and parotitis (48%) were the most common clinical manifestations, with significant predilection for lymphadenopathy (p < or = 0.0001), dermatitis (p = 0.010), splenomegaly (p = 0.008), hepatomegaly (p = 0.001) and parotitis (p = 0.007) among perinatally infected children. Median baseline CD4+ cell count was 256.0/microL (IQR 71.0 - 478.0 cells/microL); median most recent CD4+ cell count was 521/microL (IQR 271.0 - 911.0 cells/microL). Seventy-six per cent (n=71) were initiated with highly active antiretroviral therapy (HAART) and 62 (87.3%) were currently receiving first-line therapy. Six behaviourally infected females became pregnant, resulting in five live births. There were seven deaths (7.4%). CONCLUSION: This study comprehensively characterizes HIV infection among perinatally infected teens with predominantly slow-progressor disease and an increasing population of sexually-infected adolescents. As the cohort transitions to adulthood, adolescent developmental, mental health and life planning issues must be urgently addressed.

HIV-related mortality in Jamaican children.

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 (180%) HIV/AIDS-related deaths among 50 HIV-infected children of whom 23 (46%) were males and 21 (43%) were AIDS orphans. Five children (10%0) received ARV prophylaxis, 31 (62%) were breastfed and 39 (78%) received HAART Surviving children displayed primarily non-AIDS defining illnesses (pneumonia and sepsis) but there was no difference in AIDS-defining illnesses among living and deceased children. The median age at diagnosis was 26 months (range 3-121; IQR 10, 54). The median age at death was 30 months (range 7-122 months; IQR 17, 118). Both surviving and deceased children presented with primarily moderate symptoms at diagnosis (21, 42%) and death (7, 78%). In rapid progressors, 19 of 20 (95%) on HAART remained alive and all 4 (100%) who did not receive HAART died. The mortality rate in children on HAART was 30.78 per 100 person years and 48 per 100 person years in children not receiving HAART. 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.

Voices of the women: feedback from women of child-bearing age who are living with HIV can help improve efficacy of psychosocial interventions.

BACKGROUND: We hypothesized that voluntary counselling and testing during pregnancy are necessary but not sufficient to provide the holistic psychosocial support needed by Jamaican women living with HIV and/or AIDS. Based on this hypothesis, we investigated a range of coping methods and support systems used by HIV-infected women and a group of their HIV-negative counterparts before, during and immediately after their pregnancies. METHODS: Women attending obstetric clinics in urban Jamaica completed a quantitative survey aimed at discovering coping behaviours, social and spiritual support systems. Pre-survey focus group studies and key informant interviews contributed to the design of the questionnaire while post-survey focus groups were used to probe the validity of the data gleaned from the questionnaire survey Survey data were analyzed using non-parametric tests for trend with independent univariate tests. RESULTS: Fifty-five HIV-infected women and 51 HIV-negative women completed the survey Compared with HIV-negative women, more HIV-infected women reported both feeling depressed (p = 0.07) and having difficulty concentrating (p = 0.05) during the month immediately prior to the study. Other statistically significant differences included: HIV-infected women were more likely to pray, to sleep and to change eating habits in response to worry and stress (p = 0.001 in each instance). Although several women declared religious faith, significantly fewer HIV-infected women were willing to talk to a religious leader about their problems compared to their HIV-negative counterparts (p < 0.001). CONCLUSIONS: Participation of HIV-infected women in post-survey focus groups augmented the survey findings. Many of the women reported negative emotions and some indicated serious challenges in accessing social support. The results point to the need for systematic documentation of psychosocial profiles as part of the approach to caring for these women. In addition, in the Jamaican sociocultural context, we recommend improved training of religious leaders and healthcare providers in psychosocial issues.

Predictors of HIV/AIDS confirmation and differences by guardian status in HIV+ adolescents in Jamaica.

BACKGROUND: Approximately 25% of the cumulative AIDS cases in Jamaica involve adolescents and young adults. However the lives of adolescents living with HIV within Jamaica and the Caribbean have been understudied. OBJECTIVES: (1) To describe the sociodemographic characteristics of HIV+ Jamaican adolescents who have ever been a part of the Kingston Paediatric/Perinatal HIV Programme (KPAIDS) from September 1, 2002 to August 31, 2006 (2). To identify predictors of HIV/AIDS confirmation as well as factors associated or uniquely present in these adolescents by their guardian status. METHODS: Seventy-two HIV+ adolescents, ages 10-19 years, were included. Factors studied included demographics as well as time to and time between HIV and AIDS confirmation. Data were analyzed by bivariate and multivariate statistics. RESULTS: The mean age of the adolescents was 12.6 +/- 2.8 years with slightly more males (52.8%) in the programme. There were equal proportions of adolescents living with HIV as with AIDS (43.1%). There were equal proportions who were lost to follow-up or deceased (8.3%). Twenty-two of them lived with parents, 25 with guardians and 18 in residential institutions. The primary mode of transmission was perinatal infection (68.1%), followed by sexual (20.8%), blood transfusion (2.9%) and unknown (8.3%). The mean time from HIV exposure to HIV confirmation and AIDS confirmation in mother-to-child transmission (MTCT) cases were 8.0 +/- 2.9 years and 9.6 +/- 3.3 years, respectively. In the multivariate analysis model, age and gender were significant in predicting time from HIV exposure to HIV confirmation. CONCLUSION: The majority of HIV-positive adolescents reside with parents and guardians and this might indicate support in spite of stigma and discrimination. However; the mean time to HIV confirmation in MTCT cases is quite long and must be reduced.

Isoniazid-resistant disseminated Mycobacterium tuberculosis in a Jamaican infant with HIV/AIDS.

A case report of isoniazid-resistant disseminated tuberculosis in a young child perinatally co-infected with human immunodeficiency virus (HIV-1) and the challenges managing this child in a resource-constrained setting.

Bacille Calmette-Guérin lymphadenitis and immune reconstitution syndrome in HIV-infected children on antiretroviral therapy in 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