Cristina Petre

Vaccination of HIV positive children... a genuine challenge.

Methods During 01 January 2012 – 01 September 2013, in the Pediatric and Adolescents Immunosuppression Department of the National Institute for Infectious Diseases “Prof. Dr. Matei Bals” we performed an analysis of the immunizations in children perinatally exposed to HIV, aged 0-18 months. Data from medical records and vaccination history refer to the vaccination share and track, namely from the maternity to the general practitioner. A major setback is parents’ reluctance in accessing medical services. Most of them expose various reasons for avoiding contact with the medical staff, so that most children do not benefit from prevention through vaccination.

Postpartum evolution of newborns to mothers addicted to “new drugs” and recently diagnosed with HIV infection

Background In 2011 and 2012 Romania registered a significant increase in the number of intravenous drug users (IVDUs) along with a change in the use pattern, namely the replacement of heroin with the so called “new drugs”. These are mostly synthetic cannabinoids and cathiones. Within this context, the share of new IVDU-HIV cases expanded from 3% in 2010 to 29% in 2012. Our objective was to observe the evolution of 30 newborns to mothers recently diagnosed with HIV infection, who were also “new drugs” consumers.

Adherence to antiretroviral treatment in 2013 between myth and reality

Case report We present the case of a 9 year, 6 month old girl, diagnosed with HIV at the age of 2, right after the death of her HIV seropositive father (later the mother was also diagnosed with HIV). For more than 7 years the mother did not administer the child the antiretroviral treatment that she was supplied with. In January 2013, after the mother’s death, the patient’s health worsened. She was admitted for multiple opportunistic associated infections, but, despite the complex therapeutic treatment administered, the evolution was not favorable.

ART management in children perinatally infected with HIV from mothers who experience behavioural changes in Romania

During the recent years the rate of HIV perinatally exposed children in Romania has increased as a consequence of the expanding number of HIV‐infected women. These women belong to Romanias long‐terms survivors, aged between 20 and 24 years and to the group of new HIV infection cases (20–24 years), acquired through unsafe sexual contact and use of new psychoactive substance (IV).

Birth defects in HIV vertically exposed children

Objective: to identify types of birth defects in HIV vertically exposed children and to determine the rate of congenital disorders counted in children born to HIV infected mothers. We analyzed the data recorded for HIV perinatally exposed children followed up in the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, Bucharest, the Pediatric Department from January 1st 2006 to December 31st 2012. Of 203 children with data on clinical, imagistic and virologic aspects, 20% were diagnosed with HIV infection and more than 33% had at least one congenital condition. The birth defects identified in studied children were: congenital heart defects 63%, musculoskeletal defects 23%, renal malformations 10%, neurologic defects 10%, digestive tract malformations 5%, metabolic and storage disorders 2% and genetic disorders 2%. 9% from studied children with birth defects had more than one organ involvement. Among HIV infected children the most frequent congenital disease was heart malformation, followed by renal and neurologic malformations. In total less than 30% from HIV vertical infected children and more than 33% HIV exposed but negative children had congenital diseases. The difference is not statistically significant (p=0.38). Comparing the group of children born by treated mothers to those from untreated mothers we have noticed that the use of antiretrovirals during or before pregnancy is not associated with malformations (p=0.45). In the same time the risk of congenital diseases in our patients is associated with mothers being part of Romanian cohort (p=0.05). The relative risk to have malformations in the second generation of Romanian cohort is 1.49 higher comparing with children born by more recently infected mothers. We also found very rare congenital diseases: chromosomal hermaphroditism, gangliosidosis and Niemann Pick syndrome (less than 1/100,000 live births). The rate of malformations is relatively high among HIV exposed children compared with general population in Romania and it was associated with long history of HIV disease (Romanian cohort).

Immunizations in children exposed perinatally to HIV – from theory to practice

Increased vulnerability of HIV infected children to numerous infections argues vaccination to protect them. Lately we faced diseases preventable by vaccination in children perinatally exposed to HIV infection and, prematurity, abandonment, social condition, lack of understanding, drug mothers are among the causes that prevent children from immunization HIV-positive women. During 01.01.2011-31.12.2013, in the department of immunocompromised children at the National Institute for Infectious Diseases “Prof. Dr. Matei Bals” we conducted an analysis of immunizations to 198 children exposed perinatally to HIV infection aged 0-18 months. Data from medical records and history refers to the share of vaccinations starting maternity and continuing thereafter through family physicians or pediatricians within hospital units caring for these children. A major role is parents’ avoidance to health services. Most of them rely on various reasons to avoid contact with health workers, so that most children do not benefit from prevention through vaccination. A percentage of 79.29% were vaccinated in hospital. Only 63.13% were BCG vaccinated, prematurity and knowing immunological status (CD4) representing key factors for deprivation of BCG vaccination. Optional vaccinations are hard supported by parents, such as 5.94% children were vaccinated for flu, RSV, 3.96%, 1.98% and Prevenar Rotarix. We found an increased incidence of RSV, rotavirus enterocolitis, pneumococcal pneumonia and otitis, and measles, often evolving severely. HIV perinatally exposed infants need protection against vaccine-preventable diseases. Immunization does not influence disease progression, but the lack of vaccination can lead to severe infection, potentially fatal.

OC-8 Use of new psychoactive drugs by hiv-infected women and its’ impact on mother-to-child hiv transmission in romania

Background and aims The national antenatal HIV screening process in Romania revealed an increase in the number of HIV infected women-IDUs since 2011, due to the use of synthetic cannabinoids and cathinones, or “legal highs”. Moreover, the percentage of new IDU/HIV cases increased from 2.8% in 2010 to 20% in 2015, most of them living in or around Bucharest. The aim of the surveillance was to have a more accurate view on the drug-using HIV infected mothers and the effect of this phenomenon on their babies. Methods Between January 2012 and December 2016, the Paediatric Immunosuppression Unit of INBI “Prof. Dr. Matei Bals” surveyed 468 HIV-exposed newborns. 13,46% (63/468) were perinatally exposed to “new drugs”. However, at the end of 2015 the rate of HIV mother-to-child transmission in Romania remained stable- below 2.3%. The following parameters were evaluated for mothers: time of HIV screening, time of HIV diagnosis, age, prenatal care, time when taken into active surveillance, treatment/prophylaxis, type of birth, drugs taken and screening for co-infections (HBV, HCV, STIs). For children we focused on: sex, age, time of diagnosis, ART prophylaxis, type of birth, feeding, neurological assessment, CD4 count, HIV-RNA, ultrasound evaluation. Results During the 4 year monitoring period, the following results of HIV time of detection in IDU/HIV mothers were obtained: 41.26% (26/63 mothers tested) were found with HIV before pregnancy, 11.1% (7/63) during pregnancy, 41.26% (26/63) during delivery and 6.34 % (4/63) in the first 24 hours after birth. Although all newborns perinatally exposed to HIV/IDU benefitted from post partum prophylaxis and received artificial nutrition, 14.2 % (9/63) exposed to drug use were HIV infected. All children had poor neonatal adaption, mainly severe withdrawal syndrome – 63.49% (40/63) of newborns monitored and more than 50% had neurological lesions. Conclusions Most drug-using HIV infected pregnant women have little access to antenatal care, which leads to late detection of HIV. The use of synthetic cannabinoids and cathinones by these women has significant effects on newborns and their subsequent development which is a challenge for the post-?partum surveillance system. These women come from poor families who don’t ensure them a proper support. Furthermore, due to issues associated to risky behaviour it is difficult to include them in HIV screening or prevention programmes, which need to be adapted to their needs.

Antiretroviral treatment and association with prematurity in perinatal HIV-exposed children

Results From 206 children with complete 18 months follow up, 21% (43 cases) were diagnosed with HIV infection and more than 33% had at least one congenital condition. We found birth defects in various organs in studied children: heart (130 cases), musculoskeletal system (47 cases), kidney (20 cases), nervous system (20 cases), digestive tract (10 cases) and metabolic and genetic disorders (2 cases each). 26 from the 163 HIV-exposed children and 6 from the 43 HIV-infected cases were born before 37 weeks of gestation, 4 HIV-exposed and 4 HIV-infected children were small for gestational age. We found low birth weight (<2500 g) in 18 HIV-exposed children and 3 HIV infected children and extremely low birth weight (1000) in one HIV-exposed child. We found congenital malformation in 11 preterm HIV-exposed children and 2 preterm HIV-infected children, but also in 38 HIV-exposed children and 19 HIV-infected babies with normal gestation period. The difference between the rate of congenital malformation and prematurity was not statistically significant (p=0.08) in any of studied groups and HIV diagnosis was not associated with a higher risk of preterm birth (p=0.93). Mother being part of the Romanian cohort was not statistically associated with higher risk of prematurity. We found a significant association between antiretroviral treatment during pregnancy and prematurity (p=0.003). The most used drugs to treat mothers were boosted protease inhibitors (99% cases).

Tuberculosis in children perinatally exposed to HIV in the current epidemiological TB context

Method During 01.01.2011 -01.07.2014 in the Immunocompromised Children Department from the National Institute for Infectious Diseases “Prof. Dr. Matei Bals” we analyzed the dynamical evolution of 214 perinatally HIV exposed children, aged 0-4 years. Lack of vaccination due to prematurity and the degree of immunosuppression in maternity contributed considerably to the increased incidence of TB in the family’s epidemiological context (at least one family member is diagnosed with tuberculosis). A troubling aspect is that these children come from families with resistant forms of tuberculosis (TB MDR) due to their parents’ poor adherence to treatment, mainly those pertaining to the 1989-1993 HIV cohort in Romania.

The National Registry of pregnant women infected with HIV and of perinatally exposed children – a need for Romania?

Background The recent years’ experience made us face a new typology of HIV cases (the outbreak within the people who inject drugs) as well as the necessity to adapt specific cares to the needs of the patients coming from the 1987-1990 cohort. The latter presents a complex pathology: they are therapeutically multi experienced, have adherence and ART resistance problems and experience advanced stages of disease. Furthermore, most of them have reached a fertile age, giving birth to a new generation of HIV children, which makes us update our approach to HIV infection. The National Registry of pregnant womeninfected with HIV and of perinatally exposed children represents an operational tool that collects data on the item “mother-child”, whose main role is to clearly display a national overview on the phenomenon of mother to child transmission. The registry sides with a prospective observational study launched at 1 January 2014 that focuses on pregnant women and HIV exposed children from all the regions in Romania.