Mariana Mărdărescu

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.

Chatting online – is this good for you?

Methods We analyze different aspects of a project developed by nongovernmental organizations for people affected by HIV, namely the Romanian Anti-AIDS Association (ARAS), the National Union of Organizations of People Affected by HIV/AIDS (UNOPA) along with the Romanian HIV/AIDS Center and the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”. Medical, psychological and social support was given by Matei Bals personnel. The conferences offered direct connection between AIDS care specialists and patients. The IT logistics was provided by Data Center Solutions.

Pregnancy and birth in HIV seropositive women - present stage results

Background Since 1992, the Clinical Hospital of Obstetrics and Gynecology “Prof. Dr. Panait Sârbu”, Bucharest has been the medical unit to consult, record and monitor pregnancies, births and miscarriages associated with transmittable diseases including HIV positive patients from Bucharest and the surrounding counties, as the hospital had the necessary professional expertise and intrahospital networks. In time, within the “Prof. Dr. Panait Sârbu” Clinic, we have systematized and implemented an obstetric protocol for the prevention of HIV vertical transmission.

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.

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.

The dynamics of HIV trends of transmission in the Romanian cohort

Since the early 1990s Romania has made important progresses in the HIV/AIDS area, also recognised by the international community. These steps forward concern treatment and care for people living with HIV/AIDS (PLWHA) and prevention of HIV transmission among young people and vulnerable groups. However, the global economic crisis has generated a behavioural change especially among the young population, with an increase of incidence at 2.54/100,000 (31 December 2013). At the end of 2013 we performed the annual statistical evaluation of the HIV epidemic. The National Database registered 19,261 cases of HIV and AIDS (cumulative total 1985-2013), of which 12,273 were PLWHA. Most cases (65%) were diagnosed when they were children (<14) at the beginning of the 1990s and since then have experienced multiple ART regimens and reached a fertile age. Most of the new registered cases (797) represent young PLWHA (20-24, 25-29) who suffered changes in their behavioural patterns. Hence, the former intravenous drug users (IDUs) shifted to daily use of new drugs (ethnobotanicals) while young women acquired HIV through unprotected sex and i.v. drug use. Another area of concern was mother to child transmission of HIV that we assessed in the context of prenatal and postnatal cares. Since 2011, the national response to HIV has weakened as a consequence of the economy. Hence, the new IDU-HIV cases boosted from 14 cases (3%) in 2010 to 233 (29.23%) in 2013. At the same time we detected a growth in the share of children born from women using drugs, including women living with HIV/AIDS (WLHA). For the same category we identified 76.83% HCV co-infections, 11% HBV-HCV co-infections. The assessment evinced that late presenters account for more than 50% from the new cases, with CD4<350 cells/cmm. In addition, 32% of patients in treatment have low CD4 counts <350 cells/cmm (end 2013). The rising number of pregnant women addicted to drugs is directly proportional to the expanding figures of drugs and new drugs users. Cares provided to newborns from mothers who use i.v drugs and new drugs, perinatally exposed to HIV are usually associated with hepatitis B, C and with syphilis. Romania needs an upgrade of its national HIV/AIDS policies: broaden access to treatment and integrated services, using ART as prevention measure to avoid HIV transmission among the general population and a strengthened partnership between the medical networks, in order to respond to the emergent HIV trends.

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.