Personal and Network-Related Factors Associated to Diagnosis Disclosure Reactions for Children and Adolescents Living with HIV.

The process of human immunodeficiency virus (HIV) diagnosis disclosure for vertically infected young people living with HIV has proven decisive for acceptance/adherence to treatment. Herein, we present a cross-sectional study aiming at evaluating how individual and network related variables are associated with reactions to HIV disclosure among them. We used the egocentric approach with a structured questionnaire applied to individuals aged 15-25 years in an HIV referral center in Rio de Janeiro, Brazil. Outcome variable referred to adoption or not of risk behavior after diagnostic disclosure, was classified as "good"/"bad" reactions. Results showed that, of the 80 study participants, 25% reported a "bad reaction" to diagnostic disclosure, an outcome that was more common for patients with at least one friend in their social support network (OR 4.81; 95%CI [1.05-22.07]). In conclusion, a "bad reaction" to HIV serological disclosure may be associated with inadequate structure of the individual's social support network.

RESUMEN: El proceso de divulgación del diagnóstico del virus de inmunodeficiencia humana (VIH) es decisivo para la aceptación/adhesión a tratamiento de los jóvenes infectados verticalmente que viven con VIH. Presentamos un estudio transversal con el objetivo de evaluar cómo variables individuales y de red están asociadas con reacciones a la divulgación del VIH entre ellos. Utilizamos el enfoque egocéntrico por medio de un cuestionario estructurado aplicado a personas de 15-25 años en un Centro de Referencia para VIH en Río de Janeiro, Brasil. La variable de resultado se refiere a la adopción o no de comportamiento de riesgo después de la divulgación del diagnóstico, clasificadas como reacciones "buena"/"mala". Los resultados mostraron que, de los 80 participantes del estudio, el 25% reportó una "mala reacción" a la divulgación diagnóstica. Este resultado fue más común en pacientes con al menos un amigo en su red de apoyo social (OR:4.81; IC95% [1.05-22.07]). Como conclusión, una "mala reacción" a la divulgación serológica del VIH puede estar asociada con una estructura inadecuada de la red de apoyo social del individuo.

HIV Vertical transmission in Rio de Janeiro, Brazil - does the distance matter?

Mother-to-child transmission (MTCT) is the main route of transmission for HIV among under 5 children in Brazil. National data indicate that missed opportunities for HIV prevention of MTCT are still common in antenatal care (ANC). We studied variables related to target process indicators in a cohort of HIV exposed children. We used data from 1996 to 2013 related to HIV exposed uninfected and HIV-infected children attended in an HIV reference hospital in Rio de Janeiro, Brazil. Data were collected from baseline questionnaires applied to all children followed-up in the hospital. Gestational and perinatal history were extracted from the mother's ANC card. Infants were categorized according to dates of first HIV care at the unit (1996-2000, 2001-2006 and 2007-2013). Distances between recorded addresses and the nearest maternity/hospital were measured by Euclidean distance, the shortest car route calculated in Google Maps and the route of the available bus line. Of the 599 children who fulfilled the inclusion criteria, 178 (29.7%) were HIV-infected. Approximately 70% of infants exposed to the virus from 1996-2000 were infected, dropping to 15.2% from 2001-2006 and rebounding to 30.1% from 2007-2013. Birth cohort was associated with ANC, and mothers from 2007-2013 had a lower chance of attending ANC (OR = 0.16; 95%CI 0.08-0.30). In addition, when the distance home-birthplace was higher than 9.5 km, there was a lower chance that the mother had attended ANC (OR = 0.35; 95%CI 0.18-0.68). Birth cohort was associated to HIV and ANC, and our data showed that a reduction of ANC might be related to rebound in HIV cases. There seems to have an association between larger distances from home to the birthplace and absence of ANC, which suggests that ANC was being performed in the tertiary units instead of in the primary care facilities as recommended.

Safety and immune response after two-dose meningococcal C conjugate immunization in HIV-infected children and adolescents in Rio de Janeiro, Brazil.

We aimed to evaluate immunogenicity and adverse events (AEs) after a booster dose of Meningococcal C conjugated (MCC) vaccine in HIV-infected children and adolescents, who had a previous low seroconversion rate after priming with MCC, at a reference HIV-care center in Rio de Janeiro. METHODS: 2-18 years old HIV-infected subjects with CD4+ T-lymphocyte cell (CD4) ≥15%, without active infection or antibiotic use, were enrolled to receive 2 doses of conjugated meningococcal C oligosaccharide-CRM197 12-18 months apart. All patients were evaluated before and 1-2 months after immunization for seroprotection [defined as human serum bactericidal activity (hSBA) titer ≥1:4]. AEs were assessed at 20 min, 3 and 7 days after each dose. Factors independently associated with seroprotection were studied. RESULTS: 156 subjects were enrolled and 137 received a booster MCC dose. 55% were female, and median age was 12 years. Eight-nine percent were receiving combined antiretroviral therapy (cART) at the booster visit (median duration of 7.7 years), 59.9% had undetectable viral load (VL) at baseline, and 56.2% at the booster visit. Seroprotection was achieved in 78.8% (108/137) subjects, with a significantly higher GMT than after the priming dose (p < 0.01). Mild AEs were experienced after a second MCC dose (38%). In logistic regression, undetectable viral load at entry [odds ratio (OR) = 7.1, 95% confidence interval (95%CI): 2.14-23.37], and probably higher CD4 percent at the booster immunization visit (OR): 1.1, 95%CI: 1.01-1.17 were associated with seroprotection after a booster dose of MCC. CONCLUSION: A booster dose of MCC was safe and induced high seroprotection rate even 12-18 months after priming. MCC should be administered after maximum virologic suppression has been achieved. These results support the recommendation of 2-dose of MCC for primary immunization in HIV-infected children and adolescents with restored immune function.

The cascade of care to prevent mother-to-child transmission in Rio de Janeiro, Brazil, 1996-2013: improving but still some way to go.

OBJECTIVE: To describe the cascade of care to HIV mother-to-child transmission (PMTCT) in a Rio de Janeiro reference paediatric clinic and evaluate the main factors possibly associated with HIV transmission. METHODS: Data on antenatal care (ANC), perinatal and neonatal assistance to HIV-infected and HIV-exposed but uninfected children assisted in the clinic from 1996 to 2013 were collected. The cascade of care was graphically demonstrated, and possible factors associated with HIV infection were described using regression models for bivariate and multivariate analysis. We imputed missing values of explanatory variables for the final model. RESULTS: A total of 989 children were included in the analysis: 211 were HIV and 778 HEU. Graphically, the HIV PMTCT cascade of care improved from 1996/2000 to the later periods, but not from 2001/2006 to 2007/2013. The main factor independently associated with the HIV infection over time was breastfeeding. In the period 1996/2000, the lack of antiretroviral use during labour was associated HIV transmission. While in 2001/2007, other modes of delivery but elective Caesarean section, and lack of maternal antiretroviral use during ANC were associated with HIV transmission. In the last period, the main factor associated with transmission was the lack of maternal ANC. CONCLUSIONS: The HIV PMTCT cascade improved over time, but HIV vertical transmission remains a problem, and better access to ANC is needed.

In Utero Exposure to Antiretroviral Drugs: Effect on Birth Weight and Growth Among HIV-exposed Uninfected Children in Brazil.

BACKGROUND: There are concerns about the effects of in utero exposure to antiretroviral drugs (ARVs) on the development of HIV-exposed but uninfected (HEU) children. The aim of this study was to evaluate whether in utero exposure to ARVs is associated with lower birth weight/height and reduced growth during the first 2 years of life. METHODS: This cohort study was conducted among HEU infants born between 1996 and 2010 in Tertiary children's hospital in Rio de Janeiro, Brazil. Weight was measured by mechanical scale, and height was measured by measuring board. Z-scores for weight-for-age (WAZ), length-for-age (LAZ) and weight-for-length were calculated. We modeled trajectories by mixed-effects models and adjusted for mother's age, CD4 cell count, viral load, year of birth and family income. RESULTS: A total of 588 HEU infants were included of whom 155 (26%) were not exposed to ARVs, 114 (19%) were exposed early (first trimester) and 319 (54%) later. WAZ were lower among infants exposed early compared with infants exposed later: adjusted differences were -0.52 (95% confidence interval [CI]: -0.99 to -0.04, P = 0.02) at birth and -0.22 (95% CI: -0.47 to 0.04, P = 0.10) during follow-up. LAZ were lower during follow-up: -0.35 (95% CI: -0.63 to -0.08, P = 0.01). There were no differences in weight-for-length scores. Z-scores of infants exposed late during pregnancy were similar to unexposed infants. CONCLUSIONS: In HEU children, early exposure to ARVs was associated with lower WAZ at birth and lower LAZ up to 2 years of life. Growth of HEU children needs to be monitored closely.

Immunogenicity and safety of meningococcal C conjugate vaccine in children and adolescents infected and uninfected with HIV in Rio de Janeiro, Brazil.

BACKGROUND: We aimed to evaluate the Meningococcal (Neisseria meningitidis) C conjugated (MCC) vaccine seroconversion and adverse events (AEs) in HIV-infected and HIV-uninfected children and adolescents in Rio de Janeiro, Brazil. METHODS: HIV-infected or HIV-uninfected subjects, 2-18 years old, with CD4+ T-lymphocyte cell (CD4) percentage >15%, without active infection or antibiotic use, were enrolled. All patients were evaluated before and 1-2 months after immunization for seroconversion (defined as ≥4-fold titer increase in human serum bactericidal activity) and at 20 minutes, 3 and 7 days after immunization for AEs. Factors associated with seroconversion among HIV-infected group were studied. RESULTS: Two hundred four subjects were enrolled: 154 HIV-infected and 50 HIV-uninfected. Median age was 12 years, and 53% were female. Among the HIV-infected group, 82 (53%) had a history of at least 1 C clinical category of Centers for Diseases Control and Prevention event, and 134 (87%) were using combination antiretroviral therapy. The median nadir CD4 percentage was 13% (0-47%). Seventy-six (37.3%) experienced mild AEs. Seroconversion occurred in 46 of 154 (30%) in the HIV-infected group and in 38 of 50 (76%) in the uninfected group (P < 0.01). Factors associated with seroconversion in the HIV-infected group were as follows: never had a C clinical category event [odds ratio (OR) = 2.1, 95% confidence interval (CI): 1.0-4.4]; undetectable viral load at immunization (OR: 2.4, 95% CI: 1.1-5.2) and higher CD4 nadir/100 cells (OR: 1.1, 95% CI: 1.0-1.2). CONCLUSION: MCC vaccine should be administered to HIV-infected children and adolescents after maximum immunologic and virologic benefits have been achieved with combination antiretroviral therapy. Our data suggest that a single dose of MCC vaccine is insufficient for HIV-infected individuals 2-18 years of age.

Short communication: kidney dysfunction among HIV-infected children in Latin America and the Caribbean.

Renal toxicity is a concern in HIV-infected children receiving antiretrovirals. However, the prevalence [1.7%; 95% confidence interval (CI): 1.0-2.6%] and incidence of kidney dysfunction (0.17 cases/100 person-years; 95% CI: 0.04-0.30) were rare in this multicenter cohort study of 1,032 perinatally HIV-infected Latin American and Caribbean children followed from 2002 to 2011.