Thai national guidelines for the use of antiretroviral therapy in pediatric HIV infection in 2010.

With better knowledge and availability of antiretroviral treatments, the Thai National HIV Guidelines Working Group has issued treatment guidelines for children in Thailand in March 2010. The most important aspects of these new guidelines are detailed below. ART should be initiated in infants less than 12 months of age at any CD4 level regardless of symptoms and in all children at CDC clinical stage B and C or WHO clinical stages 3 and 4. For children with no or mild symptoms consider CD4-guided thresholds of CD4 <25% (children aged one to five years) or CD4 <350 cells/mm3 (children 5 years or older). The preferred first-line regimen in children aged < 3 years is AZT+3TC+NVP. For children >3 years of age the preferred regimen is AZT+3TC+EFV. If an infant has previously been exposed to NVP perinatally, use AZT+3TC+LPV/r as empirical first regimen. In adolescents, consider TDF+3TC+EFV. The preferred ARV treatment in children who failed first line regimens of 2NRTI+NNRTI (Salvage treatment) comprises 2NRTI (guided by genotype) +LPV/r, and an alternative regimen is 2NRTI (guided by genotype) +ATV/ r (use in cases with dyslipidemia who are six years or older). In cases with extensive NRTI resistance with no effective NRTI option available, double boosted PI with LPV/r+SQV or LPV/r+IDV can be considered. Consultation with an expert is recommended. Laboratory monitoring is recommended for CD4 and every six months. Viral load at least at 6 and 12 months after initiation or change of regimen, then yearly thereafter. More frequent viral load monitoring is advised for cases with unsuccessful virologic response, infants, children with imperfect adherence, or those using of third line regimens. Toxicity monitoring depends on the drug received, at least every six months, and more often as clinically indicated. These include, but are not limited to, complete blood count, renal function tests, liver function tests, urinanalysis, and lipid profiles. Therapeutic drug monitoring is recommended in cases that have ARV-related toxicity, receiving non-standard dosing or regimens, using double boosted PI, and in those with renal or hepatic impairment.

Growth, developmental, and behavioral outcomes of HIV-affected preschool children in Thailand.

In order to determine growth, developmental, and behavioral outcomes of Thai HIV-affected preschool children, a cross-sectional study was performed at Chiang Mai University Hospital. Thirty HIV-affected children aged 3 to 5 years and 35 of age-matched control with their respective caregivers participated. There was no difference in growth and behavioral outcome, as measured by a standardized Child Behavioral Checklist, between the two groups. Cognitive functioning, as measured by a Thai intellectual assessment score, was significantly lower in the HIV-affected group (p = 0.03). Twenty percent of the HIV-affected group had below average level IQ (< or = 89) compared to 11% in the control. The risk factors were low caregivers' family income and being brought up by relatives as opposed to biological parents. An early intervention program for these children should be promoted as a result.

A mediastinal mass resembling lymphoma: an unusual manifestation of probable case of invasive zygomycosis in an immunocompetent child.

A 2-year-old girl presented with prolonged fever and progressive dyspnea for 3 weeks. A chest radiograph revealed a left lung infiltrate and associated pleural effusion. Echocardiography revealed a large posterior mediastinal mass extending to the left atrial wall and massive pericardial effusion. The presumptive diagnosis was lymphoma. At operation, a large brownish-yellow mass was noted at the posterior mediastinum, with matted hilar, and subcarinal lymph nodes. Pericardial and pleural effusions with left lung consolidation were also noted. Histopathological examination of biopsy specimens revealed a granulomatous inflammatory reaction with a diffuse eosinophilic infiltrate and broad septated fungal hyphae with right angle branching compatible with zygomycosis. Surgical removal of the mass could not be performed due to the adjacent great vessels and carina. She subsequently died from airway obstruction and respiratory failure ten days later.

An in-house HIV DNA PCR assay for early diagnosis of HIV infection in children in Thailand.

Eighty-five venous blood specimens were collected at 4, 6 or 9 months of age from asymptomatic human immunodeficiency virus (HIV)-exposed infants and from symptomatic HIV-infected infants on admission to the hospital. The specimens were tested by in-house HIV deoxyribonucleic acid (DNA) nested polymerase chain reaction (PCR) and the commercial Amplicor HIV-1 DNA test. In order to determine the accuracy of the tests, the results were compared with the HIV infection status of the children. In-house HIV DNA PCR and the commercial Amplicor HIV-1 DNA test had overall sensitivity of 95.2 per cent and 100 per cent and an overall specificity of 100 per cent and 98.4 per cent, respectively. In the analysis of 62 HIV-exposed infants who received perinatal HIV prevention intervention, in-house HIV DNA PCR yielded 100 per cent sensitivity, specificity, positive predictive value and negative predictive value. The authors concluded that in-house HIV DNA PCR has comparable sensitivity and specificity to the Amplicor HIV-1 DNA test in detecting the HIV infection status of children born to HIV-infected mothers. The in-house HIV DNA PCR, which costs US $10 per test, should be considered in developing countries for the early diagnosis of HIV-1 infection in children.