Blood donors in Kenya: a comparison of voluntary and family replacement donors based on a population-based survey.

BACKGROUND AND OBJECTIVES: Blood safety and sufficiency are major challenges in Kenya and other sub-Saharan African countries forcing many countries to rely on family replacement donors (FRD). We analysed data from a national AIDS indicator survey to describe blood donors in Kenya and potential risks of transfusion transmissible infections (TTI) comparing voluntary donors and FRD. MATERIALS AND METHODS: A population-based, cross-sectional survey was conducted in 2007 among 15- to 64-year-olds. Consenting participants were interviewed about blood donation history and were tested for HIV, HSV-2 and syphilis. RESULTS: Of the 17,940 people surveyed, 445 (2·3%) reported donating blood in the prior 12 months. Sixty-four per cent were voluntary donors, and the rest were FRD. Compared to FRD, the majority of voluntary donors were <25 years old (59% versus 18%), from the highest wealth quintile (57% versus 42%) and single (64% versus 23%). In addition, voluntary donors were less likely to have been sexually active than replacement donors (43% versus 13%). HIV prevalence was lower among voluntary donors than among FRD (2·6% versus 7·4%, P-value=0·07). CONCLUSIONS: The majority of blood donors in Kenya are voluntary with lower potential risk of TTI.

Quantification of print, radio and television exposure among previous blood donors in Kenya: an opportunity for encouraging repeat donation in a resource-limited setting?

Blood services in sub-Saharan Africa experience blood shortages and low retention of voluntary, non-remunerated donors. To boost collections by encouraging repeat donations, the Kenya National Blood Transfusion Service is exploring the likelihood of reaching previous donors through targeted print, radio and television advertising. We analysed data from a national AIDS Indicator Survey to determine whether previous donors have significant exposure to media. Respondents reporting history of blood donation had significantly higher exposure to print, radio and television media than those without history of blood donation. Targeted media campaigns encouraging repeat donation are likely to reach previous donors even in resource-limited settings.

Reduced risk of transfusion-transmitted HIV in Kenya through centrally co-ordinated blood centres, stringent donor selection and effective p24 antigen-HIV antibody screening.

BACKGROUND: Following a 1994 study showing a high rate of transfusion-associated HIV, Kenya implemented WHO blood safety recommendations including: organizing the Kenya National Blood Transfusion Service (NBTS), stringent blood donor selection, and universal screening with fourth-generation p24 antigen and HIV antibody assays. Here, we estimate the risk of transfusion-associated HIV transmission in Kenya resulting from NBTS laboratory error and consider the potential safety benefit of instituting pooled nucleic acid testing (NAT) to reduce window period transmission. METHODS: From November to December 2008 in one NBTS regional centre, and from March to June 2009 in all six NBTS regional centres, every third unit of blood screened negative for HIV by the national algorithm was selected. Dried blood spots were prepared and sent to a reference laboratory for further testing, including NAT. Test results from the reference laboratory and NBTS were compared. Risk of transfusion-associated HIV transmission owing to laboratory error and the estimated yield of implementing NAT were calculated. FINDINGS: No cases of laboratory error were detected in 12,435 units tested. We estimate that during the study period, the percentage of units reactive for HIV by NAT but non-reactive by the national algorithm was 0·0% (95% exact binomial confidence interval, 0·00-0·024%). INTERPRETATION: By adopting WHO blood safety strategies for resource-limited settings, Kenya has substantially reduced the risk of transfusion-associated HIV infection. As the national testing and donor selection algorithm is effective, implementing NAT is unlikely to add a significant safety benefit. These findings should encourage other countries in the region to fully adopt the WHO strategies.

Provider-initiated HIV testing and counselling for TB patients and suspects in Nairobi, Kenya.

SETTING: Integrated tuberculosis (TB) and human immunodeficiency virus (HIV) services in a resource-constrained setting. OBJECTIVE: Pilot provider-initiated HIV testing and counselling (PITC) for TB patients and suspects. DESIGN: Through partnerships, resources were mobilised to establish and support services. After community sensitisation and staff training, PITC was introduced to TB patients and then to TB suspects from December 2003 to December 2005. RESULTS: Of 5457 TB suspects who received PITC, 89% underwent HIV testing. Although not statistically significant, TB suspects with TB disease had an HIV prevalence of 61% compared to 63% for those without. Of the 614 suspects who declined HIV testing, 402 (65%) had TB disease. Of 2283 patients referred for cotrimoxazole prophylaxis, 1951 (86%) were enrolled, and of 1727 patients assessed for antiretroviral treatment (ART), 1618 (94%) were eligible and 1441 (83%) started treatment. CONCLUSIONS: PITC represents a paradigm shift and is feasible and acceptable to TB patients and TB suspects. Clear directives are nevertheless required to change practice. When offered to TB suspects, PITC identifies large numbers of persons requiring HIV care. Community sensitisation, staff training, multitasking and access to HIV care contributed to a high acceptance of HIV testing. Kenya is using this experience to inform national response and advocate wide PITC implementation in settings faced with the TB-HIV epidemic.

Care of children with HIV infection and AIDS in Africa.

PIP: HIV/AIDS is a major cause of pediatric morbidity and mortality, especially in Africa. The UN Joint Program on HIV/AIDS (UNAIDS) estimates that 85% of the 2.6 million children with HIV infection are from sub-Saharan Africa. About 650,000 children are living with HIV/AIDS and approximately 1000 infected infants are born every day in Africa. Since few of the 7 million infected African women have access to HIV testing and counseling, not to mention interventions such as AZT to reduce the risk of HIV transmission to their infants, the high incidence of HIV-infected children in Africa will likely continue for some time. The countries of east and southern Africa and several countries in west Africa have the highest HIV prevalence rates in the world. The development of cost-effective strategies to provide care and improve the quality of life of HIV-infected infants and children in Africa should be a priority area for increased research and support. The authors describe progress in understanding the natural history of HIV infection in African children, review strategies for managing HIV-infected children in resource-poor settings, and discuss issues of community response and counseling for children.^ieng

Beta 2-microglobulin, HIV-1 p24 antibody and acid-dissociated HIV-1 p24 antigen levels: predictive markers for vertical transmission of HIV-1 in pregnant Ugandan women.

OBJECTIVES: To evaluate the clinical utility of plasma beta 2-microglobulin (beta 2M) levels, acid-dissociated HIV-1 p24 antigen, and HIV-1 p24-antibody titers in predicting HIV-1 vertical transmission in 227 HIV-1-infected Ugandan pregnant women. DESIGN: Plasma beta 2M levels, acid-dissociated HIV-1 p24-antigen positivity, and HIV-1 p24-antibody titers were determined using commercial enzyme immunoassays (EIA) in a Ugandan cohort of 52 HIV-1-seropositive transmitting mothers, 175 HIV-1-seropositive non-transmitting mothers, and 52 seronegative mothers within 6 weeks prior to delivery. RESULTS: Transmitter mothers had significantly higher plasma concentrations of beta 2M (1.80 +/- 1.13 mg/l) than non-transmitter seropositive mothers (1.32 +/- 0.81 mg/l; P = 0.0013). Similarly, a significantly higher proportion of transmitter mothers had detectable p24 antigen than non-transmitter mothers [six out of 51 (11.8%) versus six out of 173 (3.5%); P = 0.03]. Compared with the vertical transmission rate of 23% in the seropositive group, the positive predictive values of a beta 2M level > 1.5 mg/l or detectable HIV-1 p24 antigen for vertical transmission were 34 and 50%, respectively. Five of six (83.3%) seropositive mothers with both a beta 2M level > 1.5 mg/l and detectable p24 antigenemia transmitted HIV-1 infection to their infants compared with 25 of 124 (20.2%) seropositive mothers with values below the cut-off values for both tests (P = 0.00249). However, beta 2M was not found to be a significant independent predictor of vertical transmission when analyzed in a multivariate model with p24 antigenemia. There was no significant difference in HIV-1 p24-antibody titers in transmitter mothers versus non-transmitter mothers (P = 0.299). CONCLUSION: beta 2M levels and acid-dissociated HIV-1 p24-antigen assays may be used to predict which HIV-1-infected pregnant women are at greatest risk for vertical transmission. However, only the p24-antigen test was independently predictive of vertical transmission and its clinical utility is limited.

Detection of human immunodeficiency virus type 1 (HIV-1) DNA and p24 antigen in breast milk of HIV-1-infected Ugandan women and vertical transmission.

OBJECTIVE: To determine the correlation between the detection of human immunodeficiency virus type 1 (HIV-1) in breast milk, the duration of breastfeeding, and vertical transmission of HIV-1 infection in Ugandan women. METHODS: A prospective study of HIV-1 infection in pregnant Ugandan women and their infants has been ongoing since 1990 with follow-up of mother-infant pairs for at least 2 years. Expressed breast milk specimens were collected from 201 HIV-1-seropositive and 86 HIV-1-seronegative Ugandan women approximately 6 weeks after delivery. The presence of HIV-1 DNA in the cellular fraction of the breast milk was detected by polymerase chain reaction (PCR), and HIV-1 p24 antigen was detected in the cell-free breast milk supernatant using p24 antigen enzyme immunoassay (EIA) after immune complex dissociation (ICD). The duration of breastfeeding and the clinical status of the mothers and their children were recorded. HIV-1 EIA, Western blot, PCR, or p24 antigen detection were used for the determination of the HIV-1 infection status of the children. RESULTS: Of the 201 HIV-1-infected women studied, 47 had HIV-1-infected children, 143 had children who seroreverted, and 11 had children of indeterminate status. Breast milk supernatants were available for ICD p24 antigen testing from 188 of the HIV-1-infected women and none had detectable p24 antigen. Breast milk cell pellets were available and contained amplifiable DNA in 125 of the HIV-1-infected women (20 transmitters, 104 nontransmitters, 1 indeterminate). HIV-1 DNA was detected by PCR in 72% (75/104) of nontransmitters and 80% (16/20) of the transmitters. The duration of breastfeeding by transmitter mothers (15.8 months) was not significantly different from nontransmitter mothers (14.4 months). CONCLUSIONS: No correlation was found between the detection of HIV-1 in breast milk or the duration of breastfeeding and transmission of HIV-1 infection in this study of Ugandan women.

Effects of malaria infection in human immunodeficiency virus type 1-infected Ugandan children.

BACKGROUND: Malaria causes severe morbidity and mortality in many areas of Africa where HIV-1 infection is also prevalent. Immunosuppression is associated with both diseases but most reports do not find significant interactions between them. METHODS: A collaborative study of HIV-1 infection in Ugandan women and their infants was established between the Ministry of Health, Makerere University, Kampala, and Case Western Reserve University in 1988. Four hundred fifty-eight infants, including 77 HIV-1-infected, 232 seroreverter and 125 control children born to HIV-1-negative mothers and 24 of indeterminate status were followed closely from birth for 4 years. Data on these infants were reviewed with respect to episodes of general illness and infections, suspected and confirmed episodes of malaria, onset and frequency of malaria, use of chloroquine and occurrence of selected illnesses after episodes of febrile illnesses. Thick and thin blood smears for malaria were obtained from children with fever. RESULTS: There was no association between occurrence of febrile illnesses and childrens' HIV-1 category. The relative rates of occurrence were 1.0 (95% confidence interval (CI), 0.8 to 1.2) and 1.1 (95% CI 0.9 to 1.4) for the HIV seroreverter and control children compared with the HIV-infected children. Although there was no association (P = 0.83) between HIV-1 status and a smear being taken during a febrile episode, there was an increase in smears positive for malaria parasitemia among seroreverter (risk ratio, 1.5; 95% CI 1.1 to 1.9) and control infants (risk ratio, 1.6; 95% CI 1.2 to 2.2) compared with HIV-1-infected infants. The level of parasitemia was similar in each group. A greater proportion of malaria episodes among the HIV-infected group than among the control groups resulted in hospitalizations (P = 0.001) and blood transfusions (P = 0.02). There was a positive association between time to clinical AIDS and absence of malaria (adjusted for follow-up age) in infected children (P = 0.02). Use of chloroquine was similarly high in each HIV-1 category (80%). CONCLUSIONS: In this group of HIV-infected children there was no significant increase in malarial episodes as compared with their HIV-negative controls. The results suggest a possibility that malaria may offer some protection against HIV-1 progression or that chloroquine used to treat malaria may have a direct effect against the HIV-1 virus.

PIP: A prospective study of 458 infants from Kampala, Uganda, who were followed from birth to 48 months of age, documented a reduced risk of malaria in children infected with HIV-1. Included in the analysis were 77 HIV-infected children, 232 seroreverters, 125 HIV-negative children born to uninfected mothers, and 24 children of indeterminate HIV status. Thick and thin blood smears for malaria were obtained from children with fever. 51% of all children had at least 1 positive malaria smear during the study period, for a total of 653 documented malaria episodes. HIV-infected children had 3.5 episodes of malaria per 100 child months of observation compared with 5.0 episodes among seroreverters and 5.5 episodes among seronegative children. The relative rates of occurrence of malaria were 1.0 (95% confidence interval [CI], 0.8-1.2) in seroreverters and 1.1 (95% CI, 0.9-1.4) There was an increase in smears positive for malaria parasitemia among seroreverters (risk ratio, 1.5; 95% CI, 1.1-1.9) and HIV-negative controls (risk ratio, 1.6; 95% CI, 1.2-2.2) compared with HIV-infected children. Parasitemia levels during episodes of malaria were not significantly different between groups. Although the HIV-infected children had fewer episodes of malaria, they had a greater percentage of severe malaria episodes than controls and more frequent hospitalizations and blood transfusions per acute malarial episode. Within the HIV-positive group, mortality and progression to AIDS were delayed (although not significantly) among children who had malaria compared with those without malaria. It is possible that HIV-1 suppresses Plasmodium infection by creating a milieu that is suboptimal for parasite growth.

Risk factors for malaria among expatriates living in Kampala, Uganda: the need for adherence to chemoprophylactic regimens.

This investigation was conducted in response to a report of an increased number of malaria cases among United States Embassy personnel in Kampala, Uganda in the spring of 1992. The objectives of the investigation were to determine if an outbreak had occurred, to identify potential risk factors for malaria in this population, and to assess the effectiveness of various chemoprophylactic regimens. The risk of developing malaria during the first half of 1992 was more than six times greater than during the same time period in 1991 (relative risk [RR] = 6.6, 95% confidence interval [CI] = 1.6-27.8) and almost seven times greater than all the previous six years combined (RR = 6.8, 95% CI = 2.9-15.9). In this outbreak, children and young adults less than 20 years of age had more than a three-fold increase in risk (RR = 3.7, 95% CI = 0.7-19.8) than those in the 20-39-year-old age group. African-Americans had a six-fold increased risk compared with Caucasians (RR = 6.0, 95% CI = 1.6-22.7). Those who did not take any drug prophylaxis were 10 times more likely to develop malaria (RR = 10.0, 95% CI = 2.7-37.0) than those who took mefloquine, doxycycline, or chloroquine plus proguanil. In this setting, weekly mefloquine was 82% more effective, and chloroquine plus proguanil was 92% more effective than weekly chloroquine alone. This outbreak underscores the need for compliance with appropriate chemoprophylactic regimens in preventing malaria infection.

Neurodevelopmental outcomes of Ugandan infants with HIV infection: an application of growth curve analysis.

Neurodevelopmental outcomes of human immunodeficiency virus Type 1 (HIV-1)-infected infants of non-drug-using mothers were assessed in a controlled, prospective study from birth to 24 months with 3 groups: 61 infants of HIV-infected mothers, 234 uninfected infants of HIV-infected mothers (seroreverters), and 115 uninfected infants of uninfected mothers. Compared with seroreverters and uninfected infants, HIV-infected infants demonstrated lower mental and motor development on the Bayley Scales and greater deceleration in their rate of motor development. HIV-infected infants with abnormal neurologic exams had lower motor and mental test scores and lower rates of motor Bayley Scales scores than their HIV-infected counterparts with normal neurologic exams. Contrary to prediction, no group differences in mean performance or growth rates were found on visual information processing on the Fagan Test of Infant Intelligence.

Differential of HIV prevalence in women and men who attended sexually transmitted disease clinics at HIV sentinel surveillance sites in Kenya, 1990-2001.

Several studies in sub-Saharan Africa have reported that HIV prevalence in young women is higher than in young men. We used data from Kenya HIV sentinel surveillance conducted from 1990 to 2001 among sexually transmitted disease (STD) patients (15-49 years old) to investigate consistency of gender differentials over time and their risk factors. Of the 15,889 STD patients, the HIV prevalence ranged from 16.0% in 1990 to 41.8% in 1997. The odds ratios (ORs) of HIV infection for women compared to men decreased by age; women 15-24 years were nearly twice as likely as men of the same ages to be HIV infected (OR 1.7 [1.5-2.0]), but risk in those >44 years was almost equal (OR 0.8 [95% CI 0.7-1.2]). The odds of HIV infection for women compared to men were twice in unmarried patients (OR 2.1 [95% CI 1.8-2.3]). This association persisted after controlling for age groups or marital status, residence, level of education, and presence of STD syndromes. This pattern had been consistent over 12 years. Adolescent women with symptoms of STDs should be a focus for the HIV/STD intervention programmes because of their high risk for HIV.

Human immunodeficiency virus and AIDS in Uganda.

HIV-1 infection, initially described as "slim disease", was first recognized in Uganda in 1982, and is now a predominant health problem. Approximately 1.5 million Ugandans are now infected, largely through heterosexual transmission. In many areas half of adult deaths are now caused by HIV. Seroprevalence rates in urban antenatal clinics have been dropping in the last several years, as have rates in young adults in two rural community cohorts where the epidemic is long established. Tuberculosis cases and admissions have increased dramatically. Among the clinical manifestations of HIV in Uganda, epidemic Kaposi sarcoma, cryptococcal meningitis, suspected toxoplasmosis and cardiomyopathy, as well as atypical or extrapulmonary tuberculosis are seen with increasing frequency. Mother to child transmission of HIV accounts for about 10% of total cases, with a transmission rate of 26% in two studies. Epidemiological and clinical research programs are well developed in Uganda, especially in areas of tuberculosis, maternal and paediatric HIV infection and sexually transmitted infections. Societal openness, a multisectoral approach by the government and innovative programmes, including large-scale HIV testing and counselling and the pioneering work of The AIDS Support Organization (TASO), distinguish the Ugandan response to the epidemic.

PIP: In 1982 the first cases of "slim disease" in Uganda were identified in Rakai District. This disease was not recognized as AIDS until 1985. AIDS is now a serious public health problem for Ugandans. Currently, about 1.5 million Ugandans have HIV infection, acquired mainly via heterosexual transmission; about 10% acquired HIV infection via the mother-child transmission route. In two studies, the mother-child HIV transmission rate reached 26%. 400,000-450,000 Ugandans have died from HIV/AIDS. HIV/AIDS is associated with the death of about 50% of adults in some areas of Uganda. Between 1993 and 1995, there has been a significant decrease in HIV seroprevalence among pregnant women in Kampala as well as in two rural communities. Cases and hospital admissions of tuberculosis (TB) have risen markedly in Uganda. Clinical manifestations of HIV infection include Kaposi's sarcoma, cryptococcal meningitis, toxoplasmosis, cardiomyopathy, and atypical or extrapulmonary TB. Uganda has well-developed HIV-focused epidemiologic and clinical research programs, particularly those addressing TB, maternal-child HIV transmission, and sexually transmitted diseases (STDs). The response to the HIV/AIDS epidemic in Uganda has been unique. The government has openly addressed it since the late 1980s, and this has opened the doors to the creation of innovative services for education, testing, and counseling and care for AIDS patients. Both the government and nongovernmental organizations have developed extensive HIV prevention programs. The AIDS Support Organization provides counseling and care for more than 35,000 persons with HIV/AIDS and has trained hundreds of counselors. Two possible reasons for the decline in the HIV seroprevalence that is now emerging in Uganda include: the AIDS epidemic either has reached a natural plateau or behavioral change has made a difference, improved treatment of STDs, and increasing availability and use of condoms has contributed to the reduction in HIV seroprevalence.

Evidence for population level declines in adult HIV prevalence in Kenya.

The HIV/AIDS epidemic in Kenya has been tracked through annual sentinel surveillance in antenatal clinics since 1990. The system started with 13 sites and now has over 35. Behaviours have been measured through national Demographic and Health Surveys in 1993, 1998, and 2003. The surveillance data indicate that prevalence has declined substantially starting in 1998 in five of the original 13 sites and starting in 2000 in another four sites. No decline is evident in the other five original sites although the 2004 estimate is the lowest recorded. Nationally, adult prevalence has declined from 10% in the late 1990s to under 7% today. Surveys indicate that both age at first sex and use of condoms are rising and that the percentage of adults with multiple partners is falling. It is clear that HIV prevalence is now declining in Kenya in a pattern similar to that seen in Uganda but seven or eight years later. Although the coverage of preventive interventions has expanded rapidly since 2000 this expansion was too late to account for the beginnings of the decline in prevalence. More work is needed to understand fully the causes of this decline, but it is encouraging to see Kenya join the small list of countries experiencing significant declines in HIV prevalence.

Declines in HIV prevalence can be associated with changing sexual behaviour in Uganda, urban Kenya, Zimbabwe, and urban Haiti.

OBJECTIVE: To determine whether observed changes in HIV prevalence in countries with generalised HIV epidemics are associated with changes in sexual risk behaviour. METHODS: A mathematical model was developed to explore the relation between prevalence recorded at antenatal clinics (ANCs) and the pattern of incidence of infection throughout the population. To create a null model a range of assumptions about sexual behaviour, natural history of infection, and sampling biases in ANC populations were explored to determine which factors maximised declines in prevalence in the absence of behaviour change. Modelled prevalence, where possible based on locally collected behavioural data, was compared with the observed prevalence data in urban Haiti, urban Kenya, urban Cote d'Ivoire, Malawi, Zimbabwe, Rwanda, Uganda, and urban Ethiopia. RESULTS: Recent downturns in prevalence observed in urban Kenya, Zimbabwe, and urban Haiti, like Uganda before them, could only be replicated in the model through reductions in risk associated with changes in behaviour. In contrast, prevalence trends in urban Cote d'Ivoire, Malawi, urban Ethiopia, and Rwanda show no signs of changed sexual behaviour. CONCLUSIONS: Changes in patterns of HIV prevalence in urban Kenya, Zimbabwe, and urban Haiti are quite recent and caution is required because of doubts over the accuracy and representativeness of these estimates. Nonetheless, the observed changes are consistent with behaviour change and not the natural course of the HIV epidemic.

Diagnosing HIV.

PIP: Although 40% of infants with HIV die by age 12 months and more than half by age 2 years, proper care can increase the length and quality of life in infected children. Laboratory diagnosis is not accurate until the child is 18 months old, so clinical diagnosis is often used. Because treatment of childhood illnesses would be the same in the presence or absence of HIV, diagnosis merely identifies those children who require closer monitoring. Health workers must also consider the implications of an HIV diagnosis on a child's family. Common symptoms of HIV in infants to 6 months old are severe bacterial infections, swollen lymph glands, enlarged liver and spleen, failure to thrive, and persistent fungal infections. In babies 6-15 months old, growth faltering is common, and persistent diarrhea and respiratory infections are frequent. The usual symptoms are seen in children over 15 months old. Because infections in HIV-positive children are often common illnesses which simply last longer and are more difficult to cure, key points for care are maintaining good nutrition, treating illnesses as early as possible, emphasizing early diagnosis for tuberculosis, using oral rehydration therapy during bouts of diarrhea, monitoring growth, treating the child as normally as possible, and providing appropriate pain relief. The World Health Organization has developed guidelines for the clinical diagnosis of HIV in children based on cardinal findings, characteristic findings, associated findings, and epidemiological risk factors.^ieng

[Children and HIV. Diagnosis of HIV]. / Les enfants et le VIH. Diagnostic du VIH.

PIP: About 40% of newborns infected with HIV do not live to their first birthday. More than half of those die around 2 months old. The remaining HIV-infected newborns survive the opportunistic infections appearing at a young age, then their health improves, and they survive to around age 6. HIV can be diagnosed after a laboratory test and/or based on clinical signs and symptoms. The latter is less precise than the HIV test but the HIV test is either very expensive or the laboratory is not equipped to test for HIV. For infants younger than 18 months, a positive HIV test is not reliable. All infants of HIV- positive mothers are born with maternal HIV antibodies that remain active for 12-18 months. The main advantages of diagnosing HIV in an infant are that opportunistic infections can be identified and treated quickly and that health workers can detect potentially fatal childhood infections very early. Good care of the HIV-infected child includes good nutrition, rapid treatment of childhood infections, appropriate vaccination, early diagnosis and treatment of tuberculosis among family members, oral rehydration therapy, growth monitoring, treating the child like a normal child (e.g., playing), and providing comfort. It is important to explain to the family that, with good care, the HIV-infected child can survive a long time. The mother and other family members need counseling and support. Older HIV-infected children would need special treatment. HIV-positive infants tend to be of low birth weight. Symptoms (e.g., bacterial infections and lymphadenopathy) begin to appear around 2-3 months. Around 6-15 months, HIV-related signs include growth problems (first growth stoppage then weight loss), chronic diarrhea, and tuberculosis (difficult to diagnose, however). Symptoms for children older than 15 months include the aforementioned symptoms plus itchy eruptions, enlarged lymph nodes, chronic cough, and development difficulties (e.g., learning to walk or speak later than usual).^ieng

Growth failure as a prognostic indicator of mortality in pediatric HIV infection.

OBJECTIVE: To study the effect of perinatally acquired human immunodeficiency virus (HIV) on somatic growth and examine the relationship of nutritional status to mortality in HIV-infected infants. METHOD: Pregnant women attending the antenatal clinic at Mulago hospital in Kampala, Uganda, were enrolled. All live-born babies born to HIV-1 seropositive (HIV+) women, and to every fourth age-matched HIV-1 seronegative (HIV-) woman, were followed for 25 months. RESULTS: The mean weight-for-age and length-for-age curves of HIV+ children were significantly lower than those of HIV- controls and seroeverters. Forty-five (54%) of the 84 HIV+ infants died before their second birthday, as compared with a 1.6% and 5.6% mortality in HIV- and seroeverters. HIV+ infants with an average weight-for-age Z-score below -1.5 in the first year of life have a nearly fivefold risk of dying before 25 months of age compared with noninfected controls. CONCLUSION: Perinatally acquired HIV infection is associated with early and progressive growth failure. The severity of growth failure is associated with an increased risk of mortality. The effect of early, aggressive nutritional intervention in delaying HIV progression and mortality should be evaluated by controlled intervention studies.

HIV-1 ICD p24 antigen detection in ugandan infants: use in early diagnosis of infection and as a marker of disease progression.

The objective of this study was to determine the use of immune-complex dissociated (ICD) p24 antigen detection for the diagnosis and prognosis of HIV-1 infection in Ugandan children. Plasma collected prospectively from children born to HIV-1 infected Ugandan women was stored and later analyzed for the presence of neutralizable HIV-1 p24 antigen using the Coulter ICD p24 antigen and neutralization kits. HIV-1 infection status, disease progression, and survival of the children were determined. Specimens from 311 children born to HIV-1 infected women, including 138 HIV-1 infected children, and 113 children born to negative women were tested. Sixty-nine (50%) infected children were p24 antigen positive at least once. For early HIV-1 diagnosis, the specificity and positive predictive value of the assay were consistently high (>95% and >83% respectively), but the sensitivity was low (6-53%), especially in the first months of life. The presence of p24 antigenemia in the first two years of life was associated with poor survival (20%) by 80 months of age compared with infected children without antigenemia (43%, P < 0.001). Early detection of p24 antigen (6 months, P < 0.001). The data suggest that ICD p24 antigen detection is not a sensitive method for the determination of infant HIV-1 status in our cohort of HIV-1 infected Ugandan children tested in the first two years of life. There was a strong correlation, however, between the presence and time of onset of p24 antigenemia and mortality among HIV-1 infected children.