Peninnah Oberdorfer

Immune Reconstitution Syndrome After Highly Active Antiretroviral Therapy in Human Immunodeficiency Virus-Infected Thai Children

Background: There is little information about the immune reconstitution syndrome (IRS) in children, especially from resource-poor countries. Objective: To determine the incidence and spectrum of IRS in advanced stage human immunodeficiency virus (HIV)-infected children after initiation of highly active antiretroviral therapy (HAART). Methods: Between May 2002 and April 2004, 153 symptomatic HIV-infected children who had CD4 lymphocyte percentage ≤15% initiated HAART in a national antiretroviral drug access program. All patients were followed for 48 weeks. In this study, IRS was defined as a disease event caused by microorganisms or conditions previously reported to be associated with IRS in patients having immunologic and/or virologic response to HAART. Results: The incidence of IRS was 19% (95% confidence interval, 13.1–26.1). The median time of onset was 4 weeks after start of HAART (range, 2–31). There were 32 episodes of IRS, including 14 caused by mycobacterial organisms, 7 by varicella-zoster virus, 7 by herpes simplex virus, 3 by Cryptococcus neoformans and 1 episode of Guillain-Barré syndrome. Patients who had IRS develop had lower baseline CD4 lymphocyte percentages compared with those who did not (P = 0.02). Conclusions: IRS is common among HIV-infected children who received HAART in their advanced stage of disease. Educational programs for patients and health care workers on recognizing and treating these conditions should be integrated into antiretroviral treatment access programs.

Disclosure of HIV/AIDS diagnosis to HIV-infected children in Thailand

Background:  With the availability of highly active antiretroviral therapy, more HIV‐infected children have lived longer. Many children are at the age that they should know the diagnosis.

Hospitalization and Mortality among HIV-Infected Children after Receiving Highly Active Antiretroviral Therapy

BACKGROUND Pediatric antiretroviral therapy programs have recently been implemented in resource-limited settings. Their impact in a prospective cohort is not well documented. The aim of this study was to evaluate the rates and causes of hospitalization and mortality among human immunodeficiency virus (HIV)-infected Thai children after receiving highly active antiretroviral therapy (HAART). METHODS Children who started receiving HAART from August 2002 to March 2005 were prospectively observed. The patients included in the study were antiretroviral-naive HIV-infected children who had CD4 cell percentages < or =15% before treatment. All patients were observed for at least 48 weeks. RESULTS One hundred ninety-two children were included. The mean age at HAART initiation was 7.6 years (range, 0.4-14.8 years). At baseline, the mean CD4 cell percentage (+/-SD) was 5.2%+/-4.9%, and the mean plasma HIV RNA level (+/-SD) was 5.4+/-0.5 log(10) copies/mL. Sixty-seven children (35%) were hospitalized a total of 108 times. The hospitalization rate decreased from 30.7% during the first 24-week period to 2.0% during weeks 120-144 after initiation of HAART. Fifty-nine hospital admissions (54.6%) occurred during the first 24 weeks of HAART. Causes of hospitalization were pneumonia and other bacterial infections (61.7%), immune reconstitution syndrome (23.4%), noninfectious illness (6.5%), opportunistic infection (5.6%), and drug-related events (2.8%). The mortality rate decreased from 5.7% in the first 24 weeks to 0%-0.6% in the subsequent 24-week intervals. CONCLUSION Hospitalization and mortality rates significantly decreased among HIV-infected children receiving HAART. Most hospitalizations and deaths occurred during the first 24 weeks of HAART.

Sustained immunologic and virologic efficacy after four years of highly active antiretroviral therapy in human immunodeficiency virus infected children in Thailand.

We report the long-term efficacy of highly active antiretroviral therapy (HAART) in 107 antiretroviral-naive human immunodeficiency virus (HIV)-infected Thai children. In an intention-to-treat analysis, 70% of the children had undetectable HIV RNA titers after 192 weeks of HAART. The mean CD4 cell percentage increased from 5.3% to 26.6%. HAART is effective for HIV-infected children in this resource-poor setting despite initiation of treatment in the advanced stage of disease.

Acute fulminant myocarditis in scrub typhus

Abstract Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi in which humans are accidental hosts. It is a febrile illness which is confined to rural Asia and the Western Pacific islands. Severe complications are very rare. We report four cases of acute fulminant myocarditis in children with scrub typhus. This complication led to severe cardiogenic shock and death in two of them. We believe this is the first report of fulminant myocarditis complicating scrub typhus in children.

Quality of Life Among HIV-Infected Children in Thailand

The aim of the study was to measure quality of life in human immunodeficiency virus-infected children. This is a cross-sectional study among main caregivers of human immunodeficiency virus-infected children. The questionnaire consisted of 5 main domains: general health, physical functioning, symptoms, psychological well being, and social and role functioning. A total of 131 main caregivers (21% males, average age 42.5 years) of human immunodeficiency virus-infected children (28% male, average age 10.1 years) answered the questionnaires. Four out of 5 domains showed that children without immune suppression had a significantly higher quality of life than children with immune suppression. There was a significant correlation between health care utility and physical functioning, symptoms, and social and role functioning. The instrument had acceptable internal consistency and was a feasible measure of quality of life among human immunodeficiency virus-infected children. The information obtained will enable health care providers to establish comprehensive health care services to serve the needs of these children and their families.

Risk-taking behaviors among vertically HIV-infected adolescents in Northern Thailand.

Purpose. To examine risk-taking behaviors and HIV self-disclosure among vertically HIV-infected adolescents in northern Thailand. Methods. A quantitative survey was conducted from 2007 to 2008 at 2 pediatric HIV clinics in northern Thailand among vertically HIV-infected adolescents aged ≥13 years, with disclosed HIV status. The survey assessed sociodemographics, substance use, sexual behavior, peer behaviors, knowledge, and attitudes regarding HIV disclosure. Results. Fifty-four adolescents (median age 14.6 years) participated; 18.5% reported previous alcohol use but none reported drug use; 35.2% reported presexual activity, and 3.7% reported sexual activity. Nearly all (96.3%) knew that HIV could be transmitted sexually, but knowledge regarding other sexually transmitted infections (STIs) was poor. Nearly half (48.1%) had never disclosed their status to anyone. Conclusions. Rates of substance use and sexual activity were low in this population. STI knowledge was poor and diagnosis self-disclosure was infrequent. Improved sexual education and self-disclosure skills are needed among vertically HIV-infected adolescents in Thailand.

Psychosocial Functioning in Adolescents with Perinatal HIV Infection Receiving Highly Active Antiretroviral Therapy

Background: With effective highly active antiretroviral therapy (HAART), perinatally HIV-infected children are living longer through adolescence. Methods: We conducted a cross-sectional study of perinatally HIV-infected adolescents, aged 11 to 18 years. Demographically matched controls were also enrolled. The adolescents completed the Youth Self-Report (YSR), while the caregivers filled out the Child Behavior Checklist (CBCL), to determine emotional and behavioral problems. Results: The sample included 50 HIV-infected adolescents and 56 controls. The internalizing problem scores from the YSR were significantly higher in the HIV-infected group than those in the control group (13.76 versus 9.95, P = .02). The total competence scores, from both the self-report and the caregiver report in the HIV-infected group, were significantly lower than those of the control group (P = .005 and .001). Conclusion: Although HAART has prolonged the survival of HIV-infected children, they remain at increased risk of psychosocial problems as well as impaired social functioning.

Factors associated with high rates of antiretroviral medication adherence among youth living with perinatal HIV in Thailand

Antiretroviral medication adherence behaviour among Thai youth with perinatal HIV in Thailand has received growing attention. However, few studies have examined individual predictors of antiretroviral adherence using multiple self-reports. A convenience sample of 89 Thai youth (interquartile range 14–16 years) with perinatal HIV at three paediatric programmes in Chiang Mai completed a structured questionnaire and reported their antiretroviral adherence in the past one, seven and 30 days using count-based recall and a visual analog scale. Mean self-reported adherence rates ranged from 83.5% (past 30 days) to 99.8% (yesterday) of the time. One-inflated beta regression models were used to examine the associations between antiretroviral adherence outcomes, treatment self-efficacy, depression, anxiety, social support and beliefs/attitudes about medications. Higher percentage of medications taken in the past 30 days was independently associated with higher treatment self-efficacy and fewer symptoms of depression. Adherence monitoring would benefit from focal assessment of youth depression and perceived capacity to follow their antiretroviral regimen.

Characterizing HIV manifestations and treatment outcomes of perinatally infected adolescents in Asia.

Background: More perinatally HIV-infected children in Asia are reaching adolescence. Methods: We analyzed data from July 1991 to March 2011 reported by 18 clinics in 6 countries of children age >12 years. Results: Of 1254 adolescents, 33 (2.6%) died, and 52 (4.1%) were lost to follow-up within 2.4-year (3566 person-years) median follow-up period. Of 1061 adolescents under active follow-up, 485 (46%) were male, median (interquartile range) age was 14.7 (13.3–16.4) years, 73% had lost a parent(s), 93% attended school and 62% were aware of their HIV status. At the most recent evaluation, 93% were receiving highly active antiretroviral therapy, 71% (N = 737/1035) had CD4 ≥500 cells/mm3 and 87% (N = 718/830) had viral load (VL) <400 copies/mL. Current CD4 ≥200 cells/mm3, no previous World Health Organization stage 3 or 4 and being on a first-line regimen were independently associated with recent VL <400 copies/mL. Current age <15 years, VL <400 copies/mL, CD4 15–24% (vs. <10%) at antiretroviral therapy initiation, no previous World Health Organization stage 3 or 4 and antiretroviral therapy duration of ≥1 year were associated with recent CD4 ≥500 cells/mm3. Primary causes of death after age 12 were opportunistic infections (N = 15/33) and other AIDS- or treatment-related conditions (N = 9/33). Those at age 12 with CD4 <200 versus ≥500 cells/mm3 and those with VL ≥10,000 versus <10,000 copies/mL were 17.4 and 4.76 times more likely to die in adolescence, respectively. Conclusion: Adolescents in this cohort have been successfully maintained in HIV care. Initiating treatment at earlier stages of disease was associated with immune recovery and virologic suppression during adolescence.