Andres F. Camacho-Gonzalez

Neonatal Infectious Diseases: Evaluation of Neonatal Sepsis

Neonatal sepsis remains a feared cause of morbidity and mortality in the neonatal period. Maternal, neonatal, and environmental factors are associated with risk of infection, and a combination of prevention strategies, judicious neonatal evaluation, and early initiation of therapy are required to prevent adverse outcomes. This article reviews recent trends in epidemiology and provides an update on risk factors, diagnostic methods, and management of neonatal sepsis.

Risk Factors for Vitamin D Deficiency and Relationship with Cardiac Biomarkers, Inflammation, and Immune Restoration in HIV-Infected Youth

BACKGROUND Vitamin D deficiency is common in HIV-infected individuals. In adults, traditional and HIV-related factors play a role in vitamin D status, and deficiency appears to impair immune restoration and exacerbate HIV complications, like cardiovascular disease (CVD). This study sought to determine factors contributing to vitamin D status in HIV-infected youth and investigate the relationship with CVD risk, inflammation and immune restoration. METHODS HIV-infected subjects (1-25 years old) were enrolled prospectively along with healthy controls that were group-matched by age, sex and race. HIV data were collected for the HIV-infected group, while traditional risk factors, including vitamin D intake, sun exposure, skin pigmentation, physical activity level and body mass index (BMI) were collected for both groups. Fasting lipids, plasma 25-hydroxyvitamin D (25[OH]D), and inflammation markers were measured. RESULTS In total, 200 HIV-infected subjects and 50 controls were enrolled. HIV group had 53% male, 95% Black and a mean age of 17.2 ±4.6 years. There was no difference in 25(OH)D between groups; 77% of HIV+ and 74% of controls had 25(OH)D<20 ng/ml. Only Fitzpatrick skin type was independently associated with 25(OH)D. No HIV variables were associated with 25(OH)D, even when HIV sub-populations were examined. Inflammation, CVD risk factors and immune restoration were not independently associated with 25(OH)D. CONCLUSIONS Vitamin D deficiency is common among HIV-infected youth. However, HIV factors, CVD risk, inflammation and immune restoration do not appear to have the same relationship with vitamin D as has been shown in adults. Supplementation trials are needed to determine if increasing 25(OH)D concentrations could better elucidate these relationships.

24 weeks of valganciclovir prophylaxis in children after renal transplantation: a 4-year experience.

Background. Cytomegalovirus (CMV) is the most common opportunistic infection after solid-organ transplant. Valganciclovir prophylaxis significantly reduces disease, but limited data are available on its use in children. Recently, an increase in delayed-onset CMV disease has been noted with some arguing that longer prophylaxis may decrease late-onset disease. Methods. Single-center, retrospective analysis of pediatric renal transplant patients receiving 24 weeks valganciclovir prophylaxis (15 mg/kg/day, maximum 900 mg/day) from January 2004 to December 2008, aiming to measure the incidence of CMV disease and toxicity of valganciclovir. Results. We enrolled 111 patients, 60% males, 46% African Americans, and median age at transplant 14.5 years (range 1.4–20.4 years). Sixty-nine percent of donors and 44% of recipients were seropositive pretransplant. Median duration of valganciclovir use was 5.9 months (range 0.5–24 months). CMV viremia and disease occurred in 27% and 4.5%, respectively. All patients with disease presented after prophylaxis ended and all were D+/R−. Thymoglobulin use (P=0.04) and positive donor CMV status (P=0.02) were associated with a higher risk of CMV viremia. Twenty-four percent had hematologic toxicity directly associated with valganciclovir. Conclusions. Valganciclovir use in children was effective as prophylaxis against CMV disease; no children at our institution developed disease while on therapy. Our regimen of 24 weeks of prophylaxis was associated with a lower rate of late-onset disease than previous reports with 12-week regimens. Further controlled studies should be considered to compare longer versus shorter periods of prophylaxis and dose reductions and their impact on prevention of late-onset disease, resistance, cost, and toxicity.

Missed opportunities for prevention of mother-to-child transmission in the United States.

Objective:To describe system failures potentially contributing to perinatal HIV transmission in the state of Georgia, United States, between 2005 and 2012. Design:A retrospective chart review of antenatal and postnatal records of HIV-infected infants between 1 January 2005 and 31 December 2012. Methods:Study participants included all HIV-infected infants referred for specialized management to the Ponce Family and Youth Clinic within Grady Health Systems in Atlanta. Main outcomes included identification of maternal, perinatal, and neonatal risk factors associated with vertical transmission. Results:Twenty-seven cases were identified; 89% of mothers were African–American between 16 and 30 years of age. Seventy-four percent of women knew their HIV status prior to pregnancy, 44% had no prenatal care, and 52% did not receive combination antiretroviral therapy during pregnancy or intrapartum zidovudine. HIV-1 RNA near the time of delivery was available in only 10 of 27 mothers, and of those, only three had an undetectable HIV-1 RNA level. Caesarean section was performed in 70% of women. Of the 27 children, the mean gestational age was 37 (SD: 2.9) weeks, with 33% requiring neonatal ICU admission. Fifty-nine percent were men, and only 67% received postnatal zidovudine prophylaxis. Conclusion:Mother-to-child transmission of HIV continues to occur in Georgia at unacceptable levels. Increased education with adherence to existing national guidelines, as well as coordinated efforts between healthcare and public health providers to improve linkage and retention in medical care are urgently needed to prevent further vertical transmission events in Georgia.

Risk Factors for HIV Transmission and Barriers to HIV Disclosure: Metropolitan Atlanta Youth Perspectives

Youth carry the highest incidence of HIV infection in the United States. Understanding adolescent and young adult (AYA) perspectives on HIV transmission risk is important for targeted HIV prevention. We conducted a mixed methods study with HIV-infected and uninfected youth, ages 18-24 years, from Atlanta, GA. We provided self-administered surveys to HIV-infected and HIV-uninfected AYAs to identify risk factors for HIV acquisition. By means of computer-assisted thematic analyses, we examined transcribed focus group responses on HIV education, contributors to HIV transmission, and pre-sex HIV status disclosure. The 68 participants had the following characteristics: mean age 21.5 years (standard deviation: 1.8 years), 85% male, 90% black, 68% HIV-infected. HIV risk behaviors included the perception of condomless sex (Likert scale mean: 8.0) and transactional sex (88% of participants); no differences were noted by HIV status. Qualitative analyses revealed two main themes: (1) HIV risk factors among AYAs, and (2) barriers to discussing HIV status before sex. Participants felt the use of social media, need for immediate gratification, and lack of concern about HIV disease were risk factors for AYAs. Discussing HIV status with sex partners was uncommon. Key reasons included: fear of rejection, lack of confidentiality, discussion was unnecessary in temporary relationships, and disclosure negatively affecting the mood. HIV prevention strategies for AYAs should include improving condom use frequency and HIV disclosure skills, responsible utilization of social media, and education addressing HIV prevention including the risks of transactional sex.

The HIV-Infected Adolescent

HIV-infected adolescents represent a unique, yet diverse, population requiring specialized medical and psychosocial HIV care. Perinatally infected and behaviorally infected adolescents often have differing therapeutic needs, but may share common difficulties, including medication nonadherence, high-risk sexual behavior, psychosocial stressors, and concomitant psychiatric disorders. Addressing these needs within a culturally sensitive framework and in the context of a population-specific approach to treatment is paramount to optimizing care. Harm reduction for this group to maximize their health and limit HIV transmission to others is also critical with respect to the rising incidence of newly diagnosed HIV-positive adolescents. Implementing a formal, multidisciplinary program that involves individual youths and their families for improved transition to adult HIV care will afford such adolescents a better chance for a healthy adulthood.

The association of uncontrolled HIV infection and other sexually transmitted infections in metropolitan Atlanta youth.

Background: Half of the 19 million sexually transmitted infections (STIs) and 26% of HIV infections annually in the United States occur in youth aged 13–24 years. STIs are a risk factor for HIV acquisition and transmission, but data are lacking on HIV treatment as an intervention to reduce STIs. Methods: A single-centered, retrospective analysis of HIV-infected sexually active adolescents and young adults from January 2009 to December 2011 was performed to compare STI incidence among patients with controlled and uncontrolled HIV and to identify associated risk factors. Results: Of 205 enrolled subjects, 59% were male and 92% African American with mean age of 21 years (2.1 SD). Sixty-six percent were horizontally infected, and 19% met the definition of controlled HIV. Forty-seven percent were men who have sex with men, 76% reported condom use, 27% prior sexual abuse, 58% drug use and 50% claimed >5 lifetime sexual partners. Sixty-seven percent contracted a co-STI for a cumulative incidence rate of 35 STIs per 100 person-years. Subjects with uncontrolled HIV had a significantly higher STI incidence than did subjects with controlled infection (42.7 vs. 19.7 per 100 person-years, P < 0.001). Uncontrolled individuals had more STIs (P = 0.01), sexual partners (P = 0.008) and horizontal acquisition (P = 0.001). In an adjusted logistic model, having ≥1 STI was associated with older age (P = 0.033), >5 sexual partners (6–10 partners, P = 0.001; >10, P < 0.001) and no condom use (P = 0.025). Subjects with uncontrolled infection had 2.8 times [95% confidence interval (CI): 1.16–6.94] the odds of ≥1 STI relative to controlled HIV. Conclusions: Uncontrolled HIV increases the incidence of co-STIs among adolescents and young adults. Interventions to improve antiretroviral compliance and reduce risk behaviors are urgently needed.

Increased prevalence of elevated blood pressures in HIV-infected children, adolescents and young adults.

Background: HIV-infected children and young adults have cardiovascular disease risk factors reflecting chronic infection and the effects of combination antiretroviral (ARV) therapy. We thus sought to characterize the prevalence of and risk factors for high blood pressure (HBP) in this population. Methods: Retrospective chart review classified subjects aged 2–25 years based on a single clinic blood pressure (BP) reading as normal BP, pre-HBP or HBP. Variables suspected to contribute to elevated BP were compared including body mass index, tobacco use, medical comorbidities, ARV or other medication use, dyslipidemia, ethnicity and family history. Results: In all, 47 of 266 subjects (18%) were found to have HBP. Among children and adolescents aged 2–17 years, 21 of 107 (20%) had HBP. Comorbidities believed to elevate BP, such as polycystic ovarian syndrome, obstructive sleep apnea or cocaine exposure, were significant risk factors for elevated BP, with 35% of subjects with these comorbidities having HBP, compared with 16% of subjects without (P = 0.01). Male gender and tobacco use were also risk factors associated with elevated BPs. HBP was more common in overweight subjects (26%) than not overweight (15%) but did not reach statistical significance (P = 0.15). ARV medication use and higher HIV-1 RNA were not associated with HBP. Conclusions: Our finding of 20% prevalence of HBP in a cohort of HIV-infected children represents a potentially alarming figure. The explanation for this finding is unclear, but even if it is because of comorbid conditions, the life-long cardiovascular risks associated with HIV infection and its management mandate the need for closer monitoring and possibly treatment of elevated BP in this population.

Transitioning young adults from paediatric to adult care and the HIV care continuum in Atlanta, Georgia, USA: a retrospective cohort study

Introduction: The transition from paediatric to adult HIV care is a particularly high‐risk time for disengagement among young adults; however, empirical data are lacking.

The Clinical Care of the HIV-1–Infected Infant

Despite well-established strategies to decrease the mother-to-child transmission of HIV-1, new perinatal infections continue to occur globally, reflecting marked disparities in access to health care. Once HIV-1 infection has been established in an infant, the combination of early initiation of antiretroviral therapy and prophylaxis against Pneumocystis jiroveci pneumonia is paramount to reducing disease progression. This article reviews the recommendations and evidence for the treatment of HIV-1-infected infants.