RESUMEN

BACKGROUND: We investigated the effects of individual antiretrovirals on lipids in HIV-infected children and the proportion potentially eligible for dietary or pharmacologic intervention. METHODS: St Mary's and Great Ormond Street Hospital's, London, United Kingdom, patients between 1995 and 2007 were included. Associations between lipids (millimoles per liter) and specific antiretroviral therapy were assessed using mixed-effects models adjusted for confounders. Children eligible for lipid-lowering management were assessed according to American Academy of Pediatric criteria [low-density lipoprotein (LDL) > 190 mg/dL or 4.9 mmol/L for children with no known cardiovascular disease risk factors or LDL > 160 mg/dL or 4.1 mmol/L for children with 2 or more cardiovascular disease risk factors]. RESULTS: Four hundred forty-nine children had median 4.5-year follow-up. On average, antiretroviral therapy-naive children had normal lipids except for low high-density lipoprotein cholesterol (HDL) (median 0.8). All cholesterol subsets were elevated for the 4 drugs assessed. Protease inhibitors had greater rises in total cholesterol with the maximal non-HDL rise for lopinavir/ritonavir at 4+ years of exposure, 0.8 (0.57-1.03). The nonnucleoside reverse transcriptase inhibitors also raised non-HDL, but this was associated with additional clinically significant increases in HDL. Nevirapine raised non-HDL by 0.38 (0.09-0.31) at 2-3 years and HDL by 0.34 (0.28-0.41). Efavirenz raised non-HDL by 0.2 (0.09-0.31) and HDL by 0.12 (0.08-0.17) at 1 year. Ten percent had LDL above the 95th percentile, but only 3 met the 4.9 cutoff for pharmacologic intervention. CONCLUSIONS: Intervention strategies (dietary and exercise advice, treatment switching, and pharmacotherapy) are required for persistent hyperlipidemia and should be assessed in randomized control trials.

Asunto(s)

Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/sangre , Infecciones por VIH/tratamiento farmacológico , Hiperlipidemias/prevención & control , Lípidos/sangre , Fármacos Anti-VIH/administración & dosificación , Fármacos Anti-VIH/efectos adversos , Recuento de Linfocito CD4 , Niño , Preescolar , Estudios de Cohortes , Esquema de Medicación , Femenino , Humanos , Hiperlipidemias/inducido químicamente , Masculino , Carga Viral

RESUMEN

PENTA Guidelines aim to provide practical recommendations for treating children with HIV infection in Europe. Changes to guidance since 2004 have been informed by new evidence and by expectations of better outcomes following the ongoing success of antiretroviral therapy (ART). Participation in PENTA trials of simplifying treatment is encouraged. The main changes are in the following sections: 'When to start ART': Treatment is recommended for all infants, and at higher CD4 cell counts and percentages in older children, in line with changes to adult guidelines. The number of age bands has been reduced to simplify and harmonize with other paediatric guidelines. Greater emphasis is placed on CD4 cell count in children over 5 years, and guidance is provided where CD4% and CD4 criteria differ. 'What to start with': A three-drug regimen of two nucleoside reverse transcriptase inhibitors (NRTIs) with either a nonnucleoside reverse transcriptase inhibitor (NNRTI) or a boosted protease inhibitor (PI) remains the first choice combination. Lamivudine and abacavir are the NRTI backbone of choice for most children, based on long-term follow-up in the PENTA 5 trial. Stavudine is no longer recommended. Whether to start with an NNRTI or PI remains unclear, but PENPACT 1 trial results in 2009 may help to inform this. All PIs should be ritonavir boosted. Recommendations on use of resistance testing, therapeutic drug monitoring and HLA testing draw from data in adults and from European paediatric cohort studies. Recently updated US and WHO paediatric guidelines provide more detailed review of the evidence base. Differences between guidelines are highlighted and explained.

Asunto(s)

Antirretrovirales/uso terapéutico , Terapia Antirretroviral Altamente Activa/métodos , Infecciones por VIH/tratamiento farmacológico , VIH-1 , Adolescente , Adulto , Factores de Edad , Antiinfecciosos/uso terapéutico , Niño , Preescolar , Farmacorresistencia Viral , Europa (Continente) , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/transmisión , Sobrevivientes de VIH a Largo Plazo , Hepatitis Viral Humana/complicaciones , Hepatitis Viral Humana/tratamiento farmacológico , Humanos , Lactante , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa , Educación del Paciente como Asunto , Neumonía por Pneumocystis/prevención & control , Embarazo , ARN Viral/sangre , Ensayos Clínicos Controlados Aleatorios como Asunto , Insuficiencia del Tratamiento , Combinación Trimetoprim y Sulfametoxazol/uso terapéutico , Tuberculosis/complicaciones , Tuberculosis/tratamiento farmacológico , Adulto Joven

RESUMEN

BACKGROUND: Recent evidence suggests that decreases in morbidity and mortality in cohorts of adults infected with human immunodeficiency virus (HIV) are showing signs of reversal. We describe changes over time in these characteristics and in the response to treatment among children in the United Kingdom and Ireland with perinatally acquired HIV infection, many of whom are now adolescents. METHODS: We analyzed prospective cohort data reported to the National Study of HIV in Pregnancy and Childhood (NSHPC) and the Collaborative HIV Paediatric Study. RESULTS: By mid 2006, 1441 HIV-infected children were reported to NSHPC; 40% were > or = 10 years old at their most recent follow-up visit, and 34% were receiving care outside London. The proportion of children born abroad increased from 24% during 1994-1996 to 64% during 2003-2006. The percentage of total child time during which children received highly active antiretroviral therapy (HAART) increased from 36% during 1997-1999 to 61% during 2000-2002 and 63% during 2003-2006. Of children who were naive to antiretroviral therapy at the start of HAART, the percentage with an HIV-1 RNA load of < 400 copies/mL after 12 months increased from 52% during 1997-1999 to 79% during 2003-2006. In multivariate analysis, only calendar time predicted virological response, whereas both younger age and lower CD4 cell percentage at HAART initiation predicted increases of > 10% in the CD4 cell percentage. A total of 31% of children aged 5-14 years and 38% aged > or = 15 years at their most recent follow-up visit had been exposed to drugs from each of the 3 main HAART classes. The rate of AIDS and mortality combined decreased from 13.3 cases per 100 person-years before 1997 to 3.1 and 2.5 cases per 100 person-years, respectively, during 2000-2002 and 2003-2006; rates of hospital admission also declined during this interval. Of 18 children known to have died since 2003, 9 died within 1 month after presentation. CONCLUSIONS: Morbidity and mortality rates among HIV-infected children continue to decrease over time. Because these children are increasingly dispersed outside London, specialist care is now provided in national clinical networks. Transition pathways to adolescent and adult services and long-term observation to monitor the effects of prolonged exposure to both HIV and HAART are required.

Asunto(s)

Terapia Antirretroviral Altamente Activa/estadística & datos numéricos , Infecciones por VIH/mortalidad , Transmisión Vertical de Enfermedad Infecciosa/estadística & datos numéricos , Adolescente , Fármacos Anti-VIH/uso terapéutico , Recuento de Linfocito CD4/estadística & datos numéricos , Niño , Preescolar , Estudios de Cohortes , Femenino , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/transmisión , Hospitalización/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Irlanda/epidemiología , Masculino , Evaluación de Necesidades , Embarazo , Estudios Prospectivos , Sistema de Registros , Análisis de Supervivencia , Reino Unido/epidemiología , Carga Viral/estadística & datos numéricos

RESUMEN

Prior to the introduction of interventions reducing mother-to-child transmission of HIV-1 natural history data reports vertical transmission rates in the order of 25%. The risk of transmission from mother-to-child has been associated with advanced maternal HIV disease, maternal plasma HIV viral load and CD4 lymphocyte count, mode of delivery, length of rupture of membranes, prematurity and breast feeding. During the last 10-15 years the introduction of prelabour cesarean section, formula feeding and antiretroviral therapy has reduced transmission to less than 1% for pregnant women in the UK who are aware of their HIV status. Attention is now turning to the minimization of possible drug side effects for both mother and infant as women are increasingly conceiving on combination antiretroviral therapy. The evolution of current UK guidelines on the prevention of mother-to-child transmission of HIV-1 are discussed.

Asunto(s)

Infecciones por VIH/prevención & control , VIH-1 , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Complicaciones Infecciosas del Embarazo/prevención & control , Fármacos Anti-VIH/administración & dosificación , Fármacos Anti-VIH/efectos adversos , Terapia Antirretroviral Altamente Activa , Lactancia Materna , Recuento de Linfocito CD4 , Cesárea , Ensayos Clínicos como Asunto , Parto Obstétrico , Femenino , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/inmunología , Infecciones por VIH/virología , Humanos , Trabajo de Parto Prematuro/etiología , Guías de Práctica Clínica como Asunto/normas , Preeclampsia/etiología , Embarazo , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Complicaciones Infecciosas del Embarazo/inmunología , Complicaciones Infecciosas del Embarazo/virología , Reino Unido , Carga Viral

RESUMEN

Following the introduction of combination antiretroviral therapy, children vertically infected with the human immunodeficiency virus (HIV-1) living in the developed world are surviving into adult life. This paper reviews the neurodevelopmental outcomes of 62 consecutively-presenting children with HIV-1 infection diagnosed before 3 years of age (32 males, 30 females; median age at presentation 6 mo). Neurological and developmental data are presented with immunological and virological responses to antiretroviral therapy. Fourteen children (22%) had abnormal neurological signs and 25 (40%) demonstrated significant developmental delay on standardized developmental assessments. Children presenting with more severe HIV-1 disease and immune compromise had significantly more abnormal neurological signs and developmental delays than children presenting with milder HIV-1 symptomatology. Immune function, control of HIV-1 viral replication, and growth parameters improved with antiretroviral therapy (median age at last follow-up 7 y 3 mo); however, abnormal neurological signs and significant gross motor difficulties persisted.

Asunto(s)

Complejo SIDA Demencia/prevención & control , Fármacos Anti-VIH/uso terapéutico , Discapacidades del Desarrollo/etiología , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , VIH-1/efectos de los fármacos , Complejo SIDA Demencia/tratamiento farmacológico , Terapia Antirretroviral Altamente Activa , Recuento de Linfocito CD4 , Distribución de Chi-Cuadrado , Desarrollo Infantil , Preescolar , Discapacidades del Desarrollo/prevención & control , Femenino , Estudios de Seguimiento , Infecciones por VIH/inmunología , Infecciones por VIH/transmisión , VIH-1/inmunología , Humanos , Lactante , Transmisión Vertical de Enfermedad Infecciosa , Masculino , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Carga Viral

RESUMEN

OBJECTIVE: To measure the extent of underdosing of antiretroviral drugs in children. DESIGN: Multicentre cohort study. SETTING: Clinical centres in hospitals in the United Kingdom and Ireland in the collaborative HIV paediatric study (CHIPS). PARTICIPANTS: 615 HIV infected children aged 2-12 years receiving antiretrovirals. MAIN OUTCOME MEASURES: Doses relative to weight and height compared with current recommended doses in 2004 European guidelines. RESULTS: The CHIPS cohort of 934 children comprises 80% of diagnosed HIV infected children in the UK and Ireland between January 1997 and March 2005, of which 66% (615) aged 2-12 years were prescribed antiretrovirals. Actual doses standardised to weight or surface area varied widely across individual drugs, antiretroviral class, and calendar time, with children underdosed (prescribed less than 90% of current recommended doses) from 6-62% child time at risk. Three serious issues in prescribing antiretrovirals, which may also be relevant to paediatric prescribing in general, were identified. Firstly, dosing was inadequate before incorrect recommendations at licensing were later revised when important pharmacokinetic results emerged. Secondly, guidelines stating dosage alternatives (by weight/surface area) for the same drug led to different and inconsistent doses. And, thirdly, ongoing growth was not adjusted for. CONCLUSIONS: Largely inadvertently, HIV infected children in the United Kingdom and Ireland have been underdosed with antiretrovirals, highlighting problems applicable throughout paediatric prescribing.

Asunto(s)

Fármacos Anti-VIH/administración & dosificación , Antirretrovirales/administración & dosificación , Infecciones por VIH/tratamiento farmacológico , Estatura , Peso Corporal , Niño , Preescolar , Estudios de Cohortes , Humanos , Lactante , Irlanda , Reino Unido

RESUMEN

OBJECTIVES: Highly active antiretroviral therapy (HAART) has extended survival of HIV-infected children into adulthood, raising concerns about long-term metabolic changes in childhood. METHODS: A longitudinal study of metabolite levels in paediatric HIV-infected patients before and after starting HAART (January 2000 to June 2003). The effects of HAART on nonfasting blood levels of total (TC), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) cholesterol, cholesterol ratio and lactate were analysed using mixed-effects regression. RESULTS: A total of 146 children attended 1208 appointments (median 6.7/child). Of these, 99 (68%) were African. At baseline, 75 (51%) were on HAART and had higher TC (4.19 vs 3.49 mmol/L, P<0.0001), HDL (1.03 vs 0.82 mmol/L, P<0.0001), and LDL (2.54 vs 2.11 mmol/L, P=0.0003) than those not on HAART. Metabolites increased with time on HAART exposure and then stabilized. At 2 years, TC had increased by 0.93 mmol/L (P<0.0001), with 29 children (20%) having repeated TC levels above the 95th centile. LDL and HDL had increased by 0.69 and 0.31 mmol/L at 2 years, respectively (both P<0.0001). Lactates declined with increasing age (-0.06 mmol/L/year, P=0.0001). CONCLUSIONS: This is the first cohort study to demonstrate significant elevations of HDL as well as LDL in children on HAART. This rise in cardio-protective HDL may represent a positive effect of treatment.

Asunto(s)

Fármacos Anti-VIH/farmacología , Terapia Antirretroviral Altamente Activa , Infecciones por VIH/tratamiento farmacológico , VIH-1 , Lípidos/sangre , Adolescente , Fármacos Anti-VIH/administración & dosificación , Niño , Preescolar , HDL-Colesterol/sangre , LDL-Colesterol/sangre , Esquema de Medicación , Femenino , Infecciones por VIH/sangre , Infecciones por VIH/virología , Humanos , Lactante , Ácido Láctico/sangre , Masculino , Estudios Retrospectivos , Carga Viral

RESUMEN

PURPOSE OF REVIEW: Advances in the management of children with vertical HIV-1 infection in the developing and developed worlds are discussed in reference to literature published in 2003/4. Studies in mother-to-child transmission are beyond the scope of this review. RECENT FINDINGS: Improvements in mortality and morbidity from HIV-1 infection following combination antiretroviral therapy are extremely encouraging. There is an increase in the understanding of the immune response to HIV-1 in infants and children and a possible future role for immunomodulatory therapies. Preliminary data are available on the timing of initiation of antiretroviral therapy, the optimization of drug combinations and the clinical interpretation of genotypic resistance testing and therapeutic drug monitoring. Evidence is emerging that early antiretroviral therapy can protect the central nervous system in infants. In resource-limited settings, mortality and morbidity remain extremely high but low-cost health interventions such as prophylactic co-trimoxazole can reduce mortality prior to the expansion of antiretroviral therapy programmes. SUMMARY: Further randomized controlled trials assessing antiretroviral therapy combinations with a sustained virological/immunological response with minimal toxicities are required. The roles of therapeutic drug monitoring and resistance testing require further elucidation. The expansion of antiretroviral therapy programmes is essential for children with HIV living in resource-limited settings.

Asunto(s)

Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/mortalidad , Fármacos Anti-VIH/administración & dosificación , Niño , Preescolar , Quimioterapia Combinada , VIH-1/efectos de los fármacos , Humanos , Lactante , Recién Nacido , Resultado del Tratamiento

RESUMEN

Brothers 9 and 14 years of age presented in London with fever and skin lesions after a safari in East Africa. Malaria films were negative, but trypanosomes were seen in blood films and chancre fluid. Sleeping sickness should be considered in children returning from East Africa.

Asunto(s)

Suramina/administración & dosificación , Viaje , Tripanocidas/administración & dosificación , Trypanosoma brucei rhodesiense/aislamiento & purificación , Tripanosomiasis Africana/diagnóstico , Tripanosomiasis Africana/tratamiento farmacológico , Adolescente , Animales , Niño , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Estudios de Seguimiento , Humanos , Úlcera de la Pierna/patología , Úlcera de la Pierna/terapia , Londres , Masculino , Índice de Severidad de la Enfermedad , Hermanos , Tanzanía , Resultado del Tratamiento

RESUMEN

PURPOSE: To describe the presentation of cytomegalovirus retinitis (CMVR) in a series of infants. METHODS: Immunocompromised infants with either HIV or systemic cytomegalovirus (CMV) were examined for CMVR. Ocular involvement was recorded and monitored by digital imaging. RESULTS: Five infants were detected to have CMVR. All the infants demonstrated changes within the macula. One infant progressed from a fine granular pattern to fulminant CMVR. CONCLUSION: Infants under a year with CMVR have a predilection for the disease to present at the macula, in contrast to the presentation in adults, which tends to involve more peripheral parts of the retina.

Asunto(s)

Retinitis por Citomegalovirus/patología , Infecciones Oportunistas Relacionadas con el SIDA/inmunología , Infecciones Oportunistas Relacionadas con el SIDA/patología , Infecciones Oportunistas Relacionadas con el SIDA/virología , Retinitis por Citomegalovirus/inmunología , Retinitis por Citomegalovirus/virología , Femenino , Humanos , Huésped Inmunocomprometido , Lactante , Recién Nacido , Mácula Lútea/patología , Masculino , Carga Viral

Asunto(s)

Infecciones por VIH/diagnóstico , VIH-1/aislamiento & purificación , Reacción en Cadena de la Polimerasa/métodos , ARN Viral/análisis , Reacciones Falso Negativas , Reacciones Falso Positivas , Femenino , Humanos , Lactante , Masculino , Sensibilidad y Especificidad

Asunto(s)

Infecciones por VIH , Pediatría , Adolescente , Adulto , Fármacos Anti-VIH/uso terapéutico , Niño , Preescolar , Quimioterapia Combinada , Femenino , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , VIH-1 , Humanos , Lactante , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Embarazo , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Inhibidores de la Transcriptasa Inversa/uso terapéutico

Asunto(s)

Infecciones por VIH/prevención & control , Recursos en Salud , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Atención Perinatal , Atención Prenatal , Países en Desarrollo , Femenino , Infecciones por VIH/transmisión , Humanos , Lactante , Recién Nacido , Atención Perinatal/economía , Atención Perinatal/métodos , Embarazo , Atención Prenatal/economía , Atención Prenatal/métodos , Riesgo

RESUMEN

AIMS OF THE GUIDELINES: These guidelines, drawn up by a multidisciplinary group of clinicians and lay workers active in the management of pregnant women infected with HIV, aim to give up-to-date information on interventions to reduce the risk of mother to child transmission of the virus. The evidence on the use of interventions to prevent mother to child transmission of HIV has been graded according to the strength of the data as per the definitions of the US Agency for Health Care Policy and Research [1]. Weighted evidence on the use of combination antiretroviral therapy (ART) for the treatment of HIV infection per se is presented in the BHIVA guidelines for adults [2,3]. The highest level evidence (i.e. randomised controlled trials (RCTs) or large, well conducted meta-analyses) is only available for formula feeding, prelabour caesarean section and zidovudine monotherapy. The need to treat mothers for HIV infection has led to the widespread use of ART in pregnancy which in turn results in new questions such as how to deliver when the mother, on therapy, has no detectable plasma viraemia with the most sensitive assays. In addressing many common and/or difficult clinical scenarios in the absence of 'best evidence' the guidelines rely heavily on 'expert opinion'. Recommendations for management are given in the section on clinical scenarios, and summarized in Table 3. An expanded version of these guidelines with an appendix on safety and toxicity data is available on the BHIVA website http://www.bhiva.org. The authors are available to discuss individual cases.

Asunto(s)

Infecciones por VIH/terapia , Infecciones por VIH/transmisión , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Complicaciones Infecciosas del Embarazo/terapia , Adulto , Fármacos Anti-VIH/efectos adversos , Fármacos Anti-VIH/uso terapéutico , Terapia Antirretroviral Altamente Activa , Lactancia Materna , Parto Obstétrico/métodos , Parto Obstétrico/normas , Medicina Basada en la Evidencia , Servicios de Planificación Familiar/métodos , Servicios de Planificación Familiar/normas , Femenino , Feto/efectos de los fármacos , Infecciones por VIH/diagnóstico , Humanos , Alimentos Infantiles , Recién Nacido , Embarazo , Complicaciones Infecciosas del Embarazo/diagnóstico , Atención Prenatal/métodos , Atención Prenatal/normas , Prevención Primaria/métodos , Prevención Primaria/normas , Proyectos de Investigación/normas , Factores de Riesgo , Salud de la Mujer

Asunto(s)

Infecciones por VIH/transmisión , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Sexo Seguro , Femenino , Humanos , Lactante , Recién Nacido , Tamizaje Masivo , Embarazo , Tercer Trimestre del Embarazo , Factores de Riesgo

RESUMEN

OBJECTIVES: The outcome of Pneumocystis carinii pneumonia (PCP) in HIV-infected infants is poor, and the role of cytomegalovirus (CMV) co-infection in the course and outcome of PCP is unclear. This study describes the prevalence, clinical characteristics, management and changes in survival over time of vertically HIV-infected infants developing PCP and/or CMV infection. METHODS: Data on children with HIV, born in the UK and Ireland and reported to the National Study of HIV in Pregnancy and Childhood, with PCP and/or CMV were combined with clinical information collected from reporting paediatricians. RESULTS: By April 1998, 340 vertically HIV-infected children had been reported, of whom 93 had PCP and/or CMV, as their first AIDS indicator disease; 85 (91%) were infants. Among infants with PCP, 79% were born to mothers not diagnosed as HIV infected, and there was an independent and statistically significant association with breast-feeding, being black African, and developing CMV disease. Median survival after PCP and/or CMV was significantly better in those born between 1993 and 1998 compared with those born before 1993 (P = 0.009), and worse than after other AIDS diagnoses (P = 0.01). Infants with dual infection were more likely to be ventilated (P = 0.003) and receive corticosteroids (P = 0.002) than those with PCP alone. CONCLUSION: Although survival from PCP and CMV has improved over time, these remain serious and potentially fatal infections among infants in whom maternal HIV status is not recognized in pregnancy. Breast-feeding increases the risk of combined PCP and CMV infection, which is associated with severe disease.

Asunto(s)

Infecciones Oportunistas Relacionadas con el SIDA/epidemiología , Infecciones por Citomegalovirus/epidemiología , Infecciones por VIH/transmisión , Transmisión Vertical de Enfermedad Infecciosa , Neumonía por Pneumocystis/epidemiología , Complicaciones Infecciosas del Embarazo , Infecciones Oportunistas Relacionadas con el SIDA/mortalidad , Negro o Afroamericano , Población Negra , Lactancia Materna , Infecciones por Citomegalovirus/mortalidad , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/epidemiología , Humanos , Incidencia , Lactante , Recién Nacido , Irlanda/epidemiología , Neumonía por Pneumocystis/mortalidad , Embarazo , Factores de Riesgo , Tasa de Supervivencia , Reino Unido/epidemiología , Población Blanca

RESUMEN

Given as a single dose to the mother during labour, nevirapine can protect the neonate from HIV-1 infection for up to 7 days. However, after maternal nevirapine therapy during pregnancy, neonatal plasma concentrations of nevirapine decline more rapidly, suggesting in-utero liver enzyme induction.

Asunto(s)

Fármacos Anti-VIH/farmacocinética , Infecciones por VIH/prevención & control , VIH-1 , Trabajo de Parto , Nevirapina/farmacocinética , Fármacos Anti-VIH/sangre , Fármacos Anti-VIH/uso terapéutico , Esquema de Medicación , Femenino , Sangre Fetal , Semivida , Humanos , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Intercambio Materno-Fetal , Tasa de Depuración Metabólica , Nevirapina/sangre , Nevirapina/uso terapéutico , Embarazo

RESUMEN

OBJECTIVES: To ascertain current practices in the diagnosis and management of HIV and pregnancy in the North Thames Region. METHODS: Postal survey using a self-completed questionnaire sent to the head of all of the Region's 34 units involved in the care of HIV. The survey asked questions on current policy around HIV and pregnancy in the HIV units and associated antenatal clinics and was linked to a case-note survey of pregnant, HIV-positive women in the last 2 years. RESULTS: Over 50% of the responding antenatal units recommended the HIV test by March 1999. Most HIV units were offering a range of antiretroviral regimens in pregnancy, although a minority (33%) did not offer triple therapy. Elective Caesarean section was the recommended mode of delivery for most women (90%) irrespective of drug therapy or viral load. Most infants were being tested for HIV infection by a combination of PCR, viral culture and antibody testing to 18 months of age. All the infants (19) followed to 6 months of age in the case-note survey were PCR negative. Reporting rates to the National Survey of HIV in Pregnancy were high (87%) but poor for the Drug Exposure Register (33%). CONCLUSIONS: Management of HIV and pregnancy in the North Thames units showed a large amount of consistency with regard to testing policies and management. However, there were a few units that did not offer therapy appropriate for advanced disease despite the recommendations of national bodies and a few units still did not recommend HIV testing to all women.

Asunto(s)

Infecciones por VIH/diagnóstico , Centros de Salud Materno-Infantil , Pautas de la Práctica en Medicina , Complicaciones Infecciosas del Embarazo/diagnóstico , Inglaterra , Femenino , Encuestas de Atención de la Salud , Humanos , Embarazo , Atención Prenatal , Encuestas y Cuestionarios

RESUMEN

A survey of antibody responses to human herpesvirus 8 (HHV-8) was undertaken to examine the mode of transmission of this virus to children born to mothers with HIV. Methods. Serum samples from a cohort of 92 mother-infant pairs and a cross-sectional cohort of 100 children (median age, 4 years) were tested. In the cohort of mother-infant pairs, 14 infants were HIV-infected, 72 were not and the HIV status was unknown for 6. In the cohort of children 70 were HIV-infected and 30 were vertically exposed but uninfected. Serologic responses to two HHV-8 antigens, latency-associated nuclear antigen and the structural antigen encoded by open reading frame 65 were detected by immunofluorescent antibody test and enzyme-linked immunoassay. Results were confirmed by Western blot. Results. All HHV-8-seropositive mothers were African (17 of 92, 18.5%). Six of their infants were HHV-8-seronegative and 11 had at least 1 HHV-8-seropositive sample. One of the 11 infants tested only at birth had a lower antibody titer than the mother; the remaining 10 infants had decreasing titers up to 7 months of age and 6 became seronegative. No infants born to HHV-8-seronegative mothers had antibodies to the virus. The seroprevalence to HHV-8 was 6% in the cohort of children. All had African mothers and their median age was greater than that of the cohort (8.4 vs. 4.0 years). Five were coinfected with HIV. Conclusions. HHV-8 was not vertically transmitted by any of the HIV-coinfected mothers. Acquisition of antibody to HHV-8 occurred in older children, implying a horizontal route of transmission.

Asunto(s)

Transmisión de Enfermedad Infecciosa , Infecciones por Herpesviridae/transmisión , Herpesvirus Humano 8/inmunología , Complicaciones Infecciosas del Embarazo/virología , Adulto , Anticuerpos Antivirales/sangre , Niño , Preescolar , Estudios de Cohortes , Estudios Transversales , Ensayo de Inmunoadsorción Enzimática , Femenino , Técnica del Anticuerpo Fluorescente , Infecciones por VIH/complicaciones , Infecciones por Herpesviridae/complicaciones , Infecciones por Herpesviridae/virología , Humanos , Lactante , Transmisión Vertical de Enfermedad Infecciosa , Embarazo

RESUMEN

The aim of antiretroviral therapy in pregnancy is to deliver a healthy uninfected child to a healthy mother, without prejudicing the future treatment opportunities of the mother. The use of zidovudine monotherapy rapidly became standard practice once it had been shown to reduce by 67% mother to child transmission in women with CD4+ lymphocyte counts above 200 x 10(6)/l. High rates of transmission are seen when maternal disease is advanced (high viral load, low CD4+ lymphocyte counts) despite zidovudine. In these women highly active antiretroviral therapy gives the best prospect for prolonged health and it is anticipated that reducing plasma viral load below the limits of detection will further reduce transmission rates. However, safety data for antiretroviral therapy in pregnancy are limited and each additional treatment exposes a significant proportion of uninfected infants to potential long term hazards. Where maternal therapy is not indicated and the sole objective of treatment is to reduce mother to child transmission, recent data suggest that short course zidovudine (especially in conjunction with prelabour caesarean section) is a reasonable option. This may minimise the emergence of viruses with reduced sensitivity to zidovudine and preserve maternal options for later therapy.

Asunto(s)

Fármacos Anti-VIH/uso terapéutico , Guías como Asunto , Infecciones por VIH/tratamiento farmacológico , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Recuento de Linfocito CD4 , Femenino , Infecciones por VIH/transmisión , Humanos , Atención Posnatal/organización & administración , Atención Preconceptiva/organización & administración , Embarazo , Atención Prenatal/organización & administración , Sociedades Médicas , Viremia/transmisión