The outcomes of COVID-19 pneumonia in children-clinical, radiographic, and pulmonary function assessment.

OBJECTIVES: The goal of this study was to assess the pulmonary sequelae of COVID-19 pneumonia in children. STUDY DESIGN: Children (0-18 years old) diagnosed with COVID-19 pneumonia hospitalized between March 2020 and March 2021 were included in this observational study. All children underwent follow-up visits 3 months postdischarge, and if any abnormalities were stated, a second visit after the next 3 months was scheduled. Clinical assessment included medical history, physical examination, lung ultrasound (LUS) using a standardized protocol, and pulmonary function tests (PFTs). PFTs results were compared with healthy children. RESULTS: Forty-one patients with COVID-19 pneumonia (severe disease n = 3, mechanical ventilation, n = 0) were included in the study. Persistent symptoms were reported by seven (17.1%) children, the most common was decreased exercise tolerance (57.1%), dyspnea (42.9%), and cough (42.9%). The most prevalent abnormalities in LUS were coalescent B-lines (37%) and small subpleural consolidations (29%). The extent of LUS abnormalities was significantly greater at the first than at the second follow-up visit (p = 0.03). There were no significant differences in PFTs results neither between the study group and healthy children nor between the two follow-up visits in the study group. CONCLUSIONS: Our study shows that children might experience long-term sequelae following COVID-19 pneumonia. In the majority of cases, these are mild and resolve over time.

The prevalence and predictors of pulmonary lesions in paediatric patients with coronavirus disease 2019 - a brief report.

Purpose: There are currently only scarce data available describing imaging manifestations in children with COVID-19. The aim of this study was to analyse pulmonary lesions on chest radiography (CXR) in paediatric patients infected with SARS-CoV-2 and to compare the CXR results with clinical and laboratory data. Material and methods: In this prospective single-centre study we included 118 consecutive paediatric patients with COVID-19. CXR was performed in 107 patients. Clinical and laboratory evaluations were performed on the same day as CXR, immediately (0 to 2 days) after the COVID-19 diagnosis had been established. Results: Pulmonary lesions were found in 24/107 (23%) children, including 14/24 (58%) with bilateral abnormalities. Compared to patients with normal CXR, children presenting with pulmonary lesions were significantly younger (7.0 ± 4.5 vs. 9.5 ± 4.5 years, p = 0.03) and more commonly presented with an elevated D-dimer level (6/24, 25% vs. 5/81, 7%; p = 0.008). Almost half (46%) of the children with pulmonary lesions were asymptomatic, and 11/60 (18%) of all asymptomatic patients presented with abnormal CXR. Conclusions: Pulmonary lesions in the course of COVID-19 are more common in younger children and those presenting with an elevated D-dimer level. A significant proportion of asymptomatic COVID-19 patients develop CXR abnormalities.

Analysis of Preventable Risk Factors for Toxoplasma gondii Infection in Pregnant Women: Case-Control Study.

BACKGROUND: Toxoplasma gondii (TG) is a parasitic protozoon that may cause miscarriages or birth defects if the infection occurs during pregnancy. The study's aim was to evaluate the risk factors associated with TG infection in pregnant women. MATERIALS: Medical charts for all 273 pregnant women with suspected TG infection consecutively admitted to the Hospital of Warsaw between 2019 and 2020 were retrospectively analyzed. The presumptive TG diagnosis was verified by a serologic assessment of IgM and IgG titers, and IgG affinity tests. RESULTS: The median age was 32 years (range: 19-42 years). The diagnosis of primary TG infection was confirmed in 74/273 (27.1%) women. In 114/273 (41.8%) there was evidence of past infection. In 71/273 (26%) women, an infection was excluded. In 172/273 (62%) women the recommended testing for other infectious diseases putting fetus development at risk was performed correctly. Logistic regression model analysis revealed that living in rural areas and eating raw meat were independent factors associated with increased risk of TG infection during pregnancy (OR 2.89, 95% CI: 1.42-5.9, p = 0.004; and OR 2.07, 95% CI: 1.03-4.18, p = 0.04, respectively). CONCLUSIONS: The independent risk factors for TG infection during pregnancy include living in rural areas and eating raw meat. The physician's educational role here is crucial for the efficient prevention of congenital toxoplasmosis.

Paediatric COVID-19 mortality: a database analysis of the impact of health resource disparity.

BACKGROUND: The impact of the COVID-19 pandemic on paediatric populations varied between high-income countries (HICs) versus low-income to middle-income countries (LMICs). We sought to investigate differences in paediatric clinical outcomes and identify factors contributing to disparity between countries. METHODS: The International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC) COVID-19 database was queried to include children under 19 years of age admitted to hospital from January 2020 to April 2021 with suspected or confirmed COVID-19 diagnosis. Univariate and multivariable analysis of contributing factors for mortality were assessed by country group (HICs vs LMICs) as defined by the World Bank criteria. RESULTS: A total of 12 860 children (3819 from 21 HICs and 9041 from 15 LMICs) participated in this study. Of these, 8961 were laboratory-confirmed and 3899 suspected COVID-19 cases. About 52% of LMICs children were black, and more than 40% were infants and adolescent. Overall in-hospital mortality rate (95% CI) was 3.3% [=(3.0% to 3.6%), higher in LMICs than HICs (4.0% (3.6% to 4.4%) and 1.7% (1.3% to 2.1%), respectively). There were significant differences between country income groups in intervention profile, with higher use of antibiotics, antivirals, corticosteroids, prone positioning, high flow nasal cannula, non-invasive and invasive mechanical ventilation in HICs. Out of the 439 mechanically ventilated children, mortality occurred in 106 (24.1%) subjects, which was higher in LMICs than HICs (89 (43.6%) vs 17 (7.2%) respectively). Pre-existing infectious comorbidities (tuberculosis and HIV) and some complications (bacterial pneumonia, acute respiratory distress syndrome and myocarditis) were significantly higher in LMICs compared with HICs. On multivariable analysis, LMIC as country income group was associated with increased risk of mortality (adjusted HR 4.73 (3.16 to 7.10)). CONCLUSION: Mortality and morbidities were higher in LMICs than HICs, and it may be attributable to differences in patient demographics, complications and access to supportive and treatment modalities.

Clinical and Epidemiological Characteristics of 1283 Pediatric Patients with Coronavirus Disease 2019 during the First and Second Waves of the Pandemic-Results of the Pediatric Part of a Multicenter Polish Register SARSTer.

This prospective multicenter cohort study aimed to analyze the epidemiological and clinical characteristics of coronavirus disease 2019 (COVID-19) in children. The study, based on the pediatric part of the Polish SARSTer register, included 1283 children (0 to 18 years) who were diagnosed with COVID-19 between 1 March 2020 and 31 December 2020. Household contact was reported in 56% of cases, more frequently in younger children. Fever was the most common symptom (46%). The youngest children (0-5 years) more frequently presented with fever, rhinitis and diarrhea. Teenagers more often complained of headache, sore throat, anosmia/ageusia and weakness. One fifth of patients were reported to be asymptomatic. Pneumonia was diagnosed in 12% of patients, more frequently in younger children. During the second wave patients were younger than during the first wave (median age 53 vs. 102 months, p < 0.0001) and required longer hospitalization (p < 0.0001). Significantly fewer asymptomatic patients were noted and pneumonia as well as gastrointestinal symptoms were more common. The epidemiological characteristics of pediatric patients and the clinical presentation of COVID-19 are age-related. Younger children were more frequently infected by close relatives, more often suffered from pneumonia and gastrointestinal symptoms and required hospitalization. Clinical courses differed significantly during the first two waves of the pandemic.

Comparison of clinical severity and epidemiological spectrum between coronavirus disease 2019 and influenza in children.

Data on the novel coronavirus disease 2019 (COVID-19) in children are limited, and studies from Europe are scarce. We analyzed the clinical severity and epidemiologic aspects of COVID-19 in consecutive children aged 0-18 years, referred with a suspicion of COVID-19 between February 1, and April 15, 2020. RT-PCR on a nasopharyngeal swab was used to confirm COVID-19. 319 children met the criteria of a suspected case. COVID-19 was diagnosed in 15/319 (4.7%) patients (8 male; mean age 10.5 years). All of them had household contact with an infected relative. Five (33.3%) patients were asymptomatic. In 9/15 (60.0%) children, the course of the disease was mild, and in 1/15 (6.7%), it was moderate, with the following symptoms: fever (46.7%), cough (40%), diarrhea (20%), vomiting (13.3%), rhinitis (6.7%), and shortness of breath (6.7%). In the COVID-19-negative patients, other infections were confirmed, including influenza in 32/319 (10%). The clinical course of COVID-19 and influenza differed significantly based on the clinical presentation. In conclusion, the clinical course of COVID-19 in children is usually mild or asymptomatic. In children suspected of having COVID-19, other infections should not be overlooked. The main risk factor for COVID-19 in children is household contact with an infected relative.

SARS-CoV-2 testing and infection control strategies in European paediatric emergency departments during the first wave of the pandemic.

Between February and May 2020, during the first wave of the COVID-19 pandemic, paediatric emergency departments in 12 European countries were prospectively surveyed on their implementation of SARS-CoV-2 disease (COVID-19) testing and infection control strategies. All participating departments (23) implemented standardised case definitions, testing guidelines, early triage and infection control strategies early in the outbreak. Patient testing criteria initially focused on suspect cases and later began to include screening, mainly for hospital admissions. Long turnaround times for test results likely put additional strain on healthcare resources.Conclusion: Shortening turnaround times for SARS-CoV-2 tests should be a priority. Specific paediatric testing criteria are needed. What is Known: • WHO and public health authorities issued case definitions, testing and infection control recommendations for COVID-19 in January. • SARS-CoV-2 testing was made available across Europe in February. What is New: • Paediatric emergency departments implemented COVID-19-specific procedures rapidly, including case definitions, testing guidelines and early triage. • A third of surveyed departments waited more than 24 h for SARS-CoV-2 test to be reported, resulting in additional strain on resources.

Prevalence and predictors of liver disease in HIV-infected children and adolescents.

Liver disease in HIV-infected patients may result from the infection itself, antiretroviral treatment or comorbidities. In this study, we analysed liver disease in 79 HIV-infected children and adolescents aged 14.0 ± 5.1 years. All the patients were receiving combination antiretroviral therapy (cART), with a mean duration of 11.5 ± 4.7 years. Six patients (8%) had detectable HIV viral load, and 8/79 (10%) of the participants were coinfected with hepatitis B or C virus (HCV, 6/8 or HBV, 2/8). Liver disease was defined as an elevation of any of the following parameters: alanine or aspartate aminotransferase (ALT and AST), total bilirubin, and gamma glutamyl transferase (GGTP). For the noninvasive evaluation of liver fibrosis, the AST-to-Platelet Ratio Index (APRI) and Fibrosis-4 (FIB-4) were calculated. Liver disease was diagnosed in 20/79 (25%) of the patients, including 13/71 (18%) of participants without coinfection and 7/8 (88%) with coinfection (p < 0.0001). All of the liver markers except bilirubin were significantly higher in the coinfected group. APRI scores indicated significant fibrosis in 5/8 (63%) of patients with coinfection. HBV or HCV coinfection and detectable HIV viral load were independently positively associated with APRI (p = 0.0001, and p = 0.0001) and FIB-4 (p = 0.001, and p = 0.002, respectively). In conclusion, liver disease in HIV-infected children and adolescents results mainly from HBV or HCV coinfection. Effective antiretroviral treatment is protective against hepatic abnormalities.

[Evaluation of antibody response to HPV vaccination in HIV infected girls]. / Ocena skutecznosci szczepienia przeciwko HPV dziewczat zakazonych HIV na podstawie badania obecnosci przeciwcial poszczepiennych.

BACKGROUND: HIV-infected women have an increased prevalence of HPV infections and high risk of cervical cancer. HPV vaccines seem to be a successive method of prevention in immunocompetent women. AIM: To evaluate HPV vaccination effectiveness based on the presence of HPV antibodies in HIV infected girls and to establish factors, which influence vaccination effectiveness. PATIENTS AND METHODS: Post vaccination antibodies were evaluated in 17 HIV -infected girls who received 3 doses of quadrivalent (types 6/11/16/18) HPV vaccine at the mean age of 11,5 years (range 9-17 yr). HPV antibodies were checked 1 month to 2 years (mean 18 months) after the third vaccine dose by ELISA HPV IgG assay (Dia.Pro Diagnostic Bioprobes). All patients have been receiving combined antiretroviral treatment (cART). Analyzed factors included: age at HIV diagnosis, age at the first vaccine dose, Centers for Disease Control and Prevention (CDC) classification at diagnosis, at vaccination and at evaluation. RESULTS: HPV antibodies were present in all 17 (100%) patients. HIV-infection was diagnosed at the mean age of 3,5 years (range 1 month--10.5 years). Nadir clinical CDC category: 7/17 patients (41%)--A, 5/17 (29,5%)--B, 5/29 (29.5%)--C. Nadir CDC count pointed moderate immunosuppression in 8/17 (47%) children and severe in 9/17 (53%). At vaccination 15/17 girls had CDC classification N1/A1, 2/17 (11.7%) were classified N2. At evaluation all girls had CDC classification N1 or A1. CONCLUSIONS. HPV vaccination in HIV infected girls resulted in successful antibody response. Immune recovery due to cART resulted in a good vaccine response, even in children with prior severe immunodeficiency.

[Lipodystrophy in HIV infected children]. / Lipodystrofia u dzieci zakazonych HIV.

UNLABELLED: The important side effect of antiretroviral treatment (ART) are metabolical disturbances and lipodystrophy. The consequences can be early atherosclerosis or ischemic heart disease. The aim of this study was to estimation of prevalence of lipodystrophy in HIV infected children on HAART risk factors and methods of its diagnosis. MATERIAL AND METHODS: Between 2002-2005 year 52 children (aged 3-18 years) were included into study. There were 28 boys and 24 girls. An anamnesis was taken and physical examination was done every 6-12 weeks. Laboratory tests included: label of triglycerides, cholesterol with fractions, glucose. In 49 patients body composition based on Bioelectrical Impedance Analysis (BIA) and in 51 thicknesses of skin folds were measured. Patients were analyzed according to age, sex, Z score for Body Mass Index, clinical and immunological stage of HIV antiretroviral treatment (time, schemas, drugs) and its efficacy. RESULTS: Lipodystrophy was found in 24 (46%) children (12 girls and 12 boys), mean age 9.68 years. Lipatrophy was recognized in 7, lipohipertrophy in 1 and the mixed form in 16 of cases. Children with lipodystrophy had complains much more frequently (96% vs. 64%) (p = 0.01). They had also thinner skin fold over/on the triceps (p = 0.02). Remaining skin folds were similar. Comparison of family history, age, sex, Z score for BMI, body composition based on BIA, clinical and immunological stage, efficacy of ART did not bring any significant statistical differences. All children with lipodystrophy were treated with D4T more frequently with DDI and RTV none of them received ZDV, rarely 3TC. Statistical differences were significant. In lipodystrophy group there were increased levels of triglicerydes much more frequently (79% vs. 39%) (p = 0.037). Remaining lipid abnormalities were also more frequent in that group, statistical differences were insignificant. CONCLUSIONS: 1. Lipodystrophy in observed group was very frequent. Clinical signs were recognized in 46%, hyperlipidemia in 73% of cases. Dominant was the mixed form. 2. The risk factor is treatment with D4T DDI, RTV. 3. The high risk of lipodystrophy in effective treated children changes opinion about therapeutical success and should require new therapeutical options. 4. Measurement of skin folds is useful method, but body composition based on BIA is not useful test for diagnosis of lipodystrophy.

[20-years experiences of HIV infected children's care]. / 20-letnie doswiadczenie w opiece nad dziecmi zakazonymi HIV.

OBJECTIVE: The aim was to present the 20-years experiences of medical care of children borne to HIV(+) mothers and HIV infected children. METHODS: Between 1987 and 2006 year 305 children borne to HIV(+) mother were investigated. The risk of vertical transmission was estimated. We analyzed routs of HIV transmission, the reasons of HIV diagnosis, HIV staging at diagnosis, HBV and HCV coinfection, ART treatment and its efficacy. MAIN OBSERVATIONS AND RESULTS: HIV infection was confirmed: 75 cases of vertical HIV infection and 8 children infected in other ways. 260 children were borne after 1994 year (the date of introducing recommendation of the use of ART to reduce perinatal transmission of HIV). 158 of them received prophylaxis of vertical HIV infection. The risk of HIV vertical in children receiving prophylaxis was 5% comparing to 45.6% risk in children without prophylaxis regimens. 66 children receive ART regimen. The efficacy of treatment was: viral 85%, immunological: 89% and clinical: 85% improvement. CONCLUSIONS: HIV testing should be offered to every women in the child-bearing age. Current prophylaxis, which suppress maternal VL HIV below detection level, decrease the risk of vertical HIV transmission to 0-1%. The child born to HIV(+) mother requires early diagnostics of HIV, HBV, HCV infections. Because of rapid progression of the disease, the HIV infected child should be diagnosed and treated since the first year of life. Properly treated children reach to mature age.

[HIV infection in children in Poland - clinical advancement at time of diagnosis]. / Zakazenie HIV u dzieci w polsce - zaawansowanie kliniczne choroby w momencie rozpoznania.

UNLABELLED: At the end of 2006, there were about 130 children with confirmed HIV infection in Poland, 90% of them being infected vertically. AIM: to present the causes, the diagnostic procedure of HIV infection and the assessment of clinical staging at diagnosis of vertical infection in a child. MATERIALS AND METHODS: between 1987-2006 there were 86 HIV infected children (45 male, 41 female) treated in our Department. 78 children had been infected vertically, 8 by other route. Reasons for HIV testing in children and clinical staging at diagnosis were analysed in vertically infected children. The patients were divided into two groups: I - diagnosed because of clinical signs and symptoms, II - because of knowledge of HIV positive status in family members. RESULTS: there were 22/79 children in group I and 56/79 in group II. Vertical HIV infection diagnosis was confirmed at the age from 1 month to 11 years, the mean age was: 26 months - in group I, 25 months - in group II. During the first year of life HIV infection was diagnosed in 36 children (33% of them having AIDS, 36% severe immunodeficiency), at the age of 12-35 months in 22 children (23% of them having AIDS, 32% severe immunodeficiency) and above 35 months in 20 children (15% of them having AIDS, 35% severe immunodeficiency), respectively. Children diagnosed because of clinical manifestations were more likely to have AIDS (p<0.01) and severe immunodeficiency (p<0.07). CONCLUSIONS: early diagnosis in children relies on the knowledge on the mother's HIV infection positive status. In Poland vertical HIV infection diagnosis is established late (mean: above 2 years), often at the advanced stage of the disease.

[Tuberculosis in HIV infected children]. / Gruzlica u dzieci zakazonych HIV.

UNLABELLED: Tuberculosis (TB) is important threat in HIV-infected people. Although there is slow but constant decline TB-infections among adults and children in Poland, about 30% HIV-(+) adults is coinfected with TB. There were 12 cases of TB in HIV(+) children diagnosed in Department of Pediatric Infectious Diseases in 1994-2005. The aim was analysis of reasons for TB diagnostic tests in HIV (+) children, coinfection HIV and TB and efficacy of anti TB treatment. TB diagnostics was performed in 23 children because of clinical indications (15/23) and conversion or excessive skin tests (8/23). There were bacteriological and radiological exams done in all cases of TB suspicion. When active TB was diagnosed there were 4 tuberculostatic drugs used (6-12 months). In latent or unlocalized TB-INH was used for 12 months. RESULTS: 12 cases of TB infection were diagnosed: active TB--4, BCG-itis--1, latent--1 and unlocalized TB--6. In 10 cases TB infection was excluded. All cases of tuberculostatic treatment was successful. 5/12 cases are presently treated. CONCLUSIONS: Skin test is lonely, generally used method of TB control in HIV (+) children without clinical manifestations of TB. There is a necessity of diagnosis and chemoprophylaxis in all cases of conversion or enlarged (above 10 mm, vesicularis) skin test. TB diagnosis is an indication for HIV diagnostics.

[Mumps--an underestimated disease]. / Swinka--niedoceniona choroba.

UNLABELLED: In countries, where vaccination against mumps is not obligatory, epidemic increase in morbidity is observed every 4-5 years. In Poland vaccination had not been obligatory until 2004. Year 2004 was an epidemic year--135,178 cases were reported. In 2005 (up to 31.07.05) 64,062 cases were noted and many hospitalizations. The aim was analysis of clinical course of mumps in children hospitalized between 1.01.04 and 31.07.05. MATERIAL AND METHODS: 292 children in age from 11 months to 16 years, 90 (30,8%) girls and 202 (69,2%) boys. Diagnosis of mumps was based on typical clinical picture, history of exposure and amylase activity in serum and urine. 111/292 (38%) children were referred to the hospital with suspicion of meningitis: in 68/292 (23,3%) lymphocytic meningitis was diagnosed (49 boys and 19 girls) and in 43 meningeal signs were not observed. Orchitis was observed in 48/202 (23,76%) boys 12-16 years old, in 3 of them both testes were affected. In 3 boys meningitis and orchitis were diagnosed, in one of them with encephalitic symptoms. 73/292 (25%) children were admitted to the hospital because of emesis and dehydration. 43/292 were hospitalized with suspicion of meningitis. 15 children were admitted because of high fever with poor response for antipyretics. In two children unilateral deafness was observed. In two children edema of subcutaneous tissue of upper chest. In remaining cases mumps was diagnosed in children with hematologic and oncologic diseases, kidney failure, congenital defects. CONCLUSIONS: Complications of mumps and need for hospitalization in children with mumps still are problems of public health. The only method of prophylaxis is accurate vaccination pragramme.

[Lipodystrophy in HIV infected children]. / Lipodystrofia u dzieci zakazonych HIV.

UNLABELLED: Lipodystrophies are rare diseases with abnormal distribution of fat tissue and/or with metabolic changes. The consequence of metabolic abnormalities may be early atherosclerosis or ischaemic heart disease. During the last years lipodystrophy has been more often recognized in HIV infected, antiretroviral treated people. THE AIM was to estimate the prevalence of lipodystrophy in HIV infected children receiving Highly Active Antiretroviral Therapy (HAART). MATERIAL AND METHODS: 40 children (age 3-16 years) were included in the study. An anamnesis (current complaints and family history) was taken and physical examination was carried out. Laboratory tests included: triglycerides, cholesterol and fractions, glucose. RESULTS: Medium time of HAART was 4 years. Lipodystrophy was found in 9/40 children. Metabolic abnormalities and clinical manifestations were observed in all children with lipodystrophy. All of them were treated with Zerit, more often with Videx and Kaletra. 5/9 patients with and 5/31 without lipodystrophy had AIDS. Abnormal serum lipid concentrations were observed in 27/31 children without clinical symptoms of lipodystrophy. There was no significant connection with family history and current clinical stage. CONCLUSIONS: Advance of disease and HAART treatment (especially with Zerit, Videx and Kaletra) increases the risk of this syndrome. Metabolic abnormalities in HAART treated children are frequent, also in children without clinical manifestations of lipodystrophy. Estimated risk of metabolic abnormalities in children should influence the choice of therapeutic schedule or its modification.

Occurrence of Clostridium difficile in fecal samples of HIV-infected children in Poland.

The prevalence of Clostridium difficile and its toxins (A and B) in HIV-positive children in Poland was investigated in a group of 18 children, aged 6 months to 8 1/2 years. Stool samples were tested using an antigen detection method for toxin A/B, cytotoxicity-neutralization and culture. In 3 cases (17%) C. difficile toxins were detected in both stool samples and strains recovered from culture. The three strains isolated were shown by PCR methods to contain toxins A and B genes. All children had been treated previously with antimicrobial and antiviral agents. All three C. difficile-positive children had mild diarrhea that resolved without specific therapy. Further studies involving a large number of children and molecular analyses of isolated C. difficile strains are necessary to determine the frequency and rate of carriage of C. difficile strains among HIV-positive children in Poland.

Diagnosis and management of children born to HIV infected mothers in Poland.

OBJECTIVE: The aim of this study was to describe the management of children born to HIV positive mothers in Poland. MATERIAL AND METHODS: Between 1987 to 2003, 218 children of HIV positive mothers were admitted to the Department of Children's Infectious Diseases of the Medical University in Warsaw. Currently recommended management of newborn infants and the routine schedule of diagnostic procedures of children born to HIV positive mothers were discussed. Children, who were in the programme of HIV mother to child transmission (MTCT) prophylaxis, are followed up from birth. Their psychosomatic development is evaluated. They also follow a modified vaccination schedule. RESULTS: From 1994 to 2003 the prevention programme of vertical transmission was carried out in 107 children. The risk of vertical transmission in this group was 2%. CONCLUSIONS: Children born to HIV infected mothers need to be diagnosed, to receive antiretroviral therapy initiated at the moment of diagnosis of HIV infection and to be under specialized care.