Integration versus disintegration: a grounded theory study of adolescent and young adult development in the context of perinatally-acquired HIV infection.

Adolescents/young adults with perinatally-acquired HIV infection experience a number of issues that impact developmental tasks. No study to date has described the process by which this occurs. The purpose of this grounded theory study was to describe the process by which HIV infection impacts adolescent/young adult development. Interviews were conducted and analyzed with 25 participants age 18 to 24. Six core categories emerged that were used to generate a theory, integration versus disintegration, that describes how perinatal HIV impacts participants' development. The results of this study provide unique clinical considerations for pediatric and adult clinicians providing care for this population.

Breastfeeding in women with HIV infection: A qualitative study of barriers and facilitators.

BACKGROUND: Until recently, breastfeeding has been contraindicated for women living with HIV (WHIV) in the U.S. However, given the numerous health benefits of breastfeeding, recommendations have changed to support parental choice to breastfeed through shared decision-making. Although specific guidelines for managing the care of these women and their infants are not yet available, various approaches have been successful without infants acquiring HIV from their virologically suppressed mothers, thus, establishing breastfeeding as a viable option for the rising number of interested WHIV. This descriptive qualitative study aimed to identify factors influencing infant feeding choices decisions among WHIV in a multiethnic and multicultural population. METHODS AND FINDINGS: A qualitative description design was used. WHIV who had given birth within 6 months were recruited using purposeful sampling. Data were collected using a semistructured interview guide in the participant's preferred language. Content analysis was used, and barriers and facilitators were separated and used to generate the themes and categories. In total, 20 participants were interviewed, and from these interviews, 11 barriers and 14 facilitators that influenced the decision to breastfeed were identified. Major barriers were related to the interference with daily activities, fear of transmission, lack of a standardized approach to education, and maternal concerns. Key facilitators included the benefits and advantages of breastmilk, access to more scientific research information on breastfeeding in the context of HIV, advice from a lactation consultant, emotional connection and attachment with the child, support from family and partners, empowering and supporting autonomy and decision-making about infant feeding, providing feeding choices, access to the lived experiences of women who have successfully breastfed their infants, and collaborative relationship with the physician and other healthcare providers. CONCLUSION: The study identified barriers and facilitators to breastfeeding among WHIV that may influence their infant feeding decision-making process. More research is needed to guide the standardization of institutional policies and develop strategies to support breastfeeding in this population.

Growth and body composition of uninfected children exposed to human immunodeficiency virus: comparison with a contemporary cohort and United States National Standards.

OBJECTIVE: To compare growth and body composition of uninfected children exposed to HIV with a contemporary HIV-unexposed group and to US references. STUDY DESIGN: Uninfected children exposed to HIV under 2 years were enrolled into a longitudinal observational study and unexposed children under 2 years of age in a cross-sectional evaluation. Weights, lengths, head circumferences, skinfold thicknesses, and arm and thigh circumferences were measured and adjusted for age using Centers for Disease Control and National Health and Nutrition Examination Survey standards. Uninfected children exposed to HIV were compared with an unexposed nearest-neighbor matched comparison group. Uninfected children exposed to HIV were compared by age to Centers for Disease Control standards for growth measures and National Health and Nutrition Examination Survey standards for body composition. RESULTS: One hundred eleven uninfected children exposed to HIV and 82 children not exposed to HIV were evaluated. For the matched comparison for both groups, the mean age was 10 months, 59% were male, and 73% were African American. No statistical differences were found in anthropometric measurements between uninfected children who were or were not exposed to HIV. Uninfected children exposed to HIV were smaller than US standards at birth with mean (SD) weight-for-age and weight-for-length z-scores of -0.39 (1.06); P = .002 and -0.35 (1.04); P = .005, respectively. Over the first 2 years of life, there was a trend toward increasing weight-for-age z-score, length-for-age z-score, and weight-for-length z-score in uninfected children exposed to HIV. Subscapular and triceps skinfolds among uninfected children exposed to HIV were lower than national standards and there was a trend that mid-upper arm circumference decreased over time. CONCLUSIONS: Growth and body composition of uninfected children who were or were not exposed to HIV were similar. Uninfected children exposed to HIV weigh less at birth and show a pattern of slightly accelerated growth in the first 2 years of life. Uninfected children exposed to HIV had less subcutaneous fat and decreasing mid-upper arm circumference over time when compared with US standards.

Has highly active antiretroviral therapy increased the time to seroreversion in HIV exposed but uninfected children?

BACKGROUND: Since the introduction of highly active antiretroviral therapy (HAART) for prevention of mother-to-child transmission of human immunodeficiency virus (HIV) in pregnancy in the United States, the time of seroreversion in infants born to HIV-infected mothers has not been documented. The objective of this study was to determine the timing of clearance of HIV antibodies and to identify any associated biological and clinical factors. METHODS: A retrospective analysis of infants who remained uninfected after perinatal HIV exposure was performed. Infant and maternal medical records from January 2000 to December 2007 were reviewed and the time of seroreversion was estimated using methods for censored survival data. RESULTS: In total, 744 infants were included in the study, with prenatal data available for 551 mothers. The median age of seroreversion was 13.9 months, and 14% of infants remained seropositive after 18 months, 4.3% after 21 months, and 1.2% after 24 months. Earlier age of seroreversion was associated with higher immunoglobulin G (IgG) levels at 3-7 months of age (P = .0029) and a higher rate of IgG change over the next 6 months of life (P = .003). Infants born by vaginal delivery were more likely to serorevert at a younger age (P = .0052), and maternal exposure to protease inhibitors was associated with a later age of seroreversion (P = .026). CONCLUSIONS: Clearance of HIV antibodies in uninfected infants was found to occur at a later age than has been previously reported. Fourteen percent of the infants had persistence of HIV antibodies at or beyond 18 months of age.

Proteinuria in children infected with the human immunodeficiency virus.

OBJECTIVES: To determine the prevalence of proteinuria in a large cohort of children infected with the human immunodeficiency virus (HIV) and their longitudinal progression during treatment with highly active antiretroviral therapy. STUDY DESIGN: In a retrospective cohort study, 286 children infected with HIV were monitored with quantitative assays of proteinuria from January 1998 through January 2007, with monitoring of viral load, lymphocyte profiles, kidney function, and mortality rates. Proteinuria was quantitated by urine protein to creatinine ratio (Upr/cr). RESULTS: Ninety-four (33%) had proteinuria at baseline. Of these, 32 (11.2%) had nephrotic range proteinuria (Upr/cr > or = 1.0). Initial screening was at 11 +/- 0.3 years of age, with an average follow-up of 5.6 +/- 0.1 years. The mortality rate was significantly greater in those with proteinuria. During the period of observation, 15 patients with nephrotic proteinuria died or had development of end-stage renal disease, and 16 showed improvement. Of those with intermediate range proteinuria (Upr/cr > or = 0.2 < 1.0), 3 progressed to nephrotic range proteinuria, and 39 (63%) showed resolution of the proteinuria (Upr/cr < 0.2). Improvement in proteinuria was correlated with decreasing viral load (r = 0.5; P < .01). CONCLUSIONS: Control of viral load with highly active antiretroviral therapy appears to prevent the progression of HIV-associated renal disease and improve survival rates in infected children.

Impaired CCR7 expression on plasmacytoid dendritic cells of HIV-infected children and adolescents with immunologic and virologic failure.

BACKGROUND: Defects of plasmacytoid (p) and myeloid (m) dendritic cells (DCs) occur in HIV infection. The aim of this study was to evaluate the maturation and function of DCs in children with perinatal HIV infection who were on antiretroviral therapy. MATERIALS AND METHODS: Twenty HIV-infected children (median age = 12.9 years) classified as immunologic/virologic responders and failures were evaluated in a whole-blood assay with resiquimod (RSQ), a potent agonist to Toll-like receptors 7 and 8, as the DC stimulant. RESULTS: In comparison to controls, pDC and mDC numbers were decreased in patients, but RSQ stimulation resulted in upregulation of CD83, CD80, and tumor necrosis factor-alpha in both DC subsets and upregulation of interferon (IFN)-alpha in pDCs. Patients with immunologic and virologic failure demonstrated a selective impairment in upregulation of lymph node homing marker CCR7 in pDCs. Plasma virus load was negatively correlated with IFNalpha and CCR7 expression, whereas CD4 percentage correlated only with CCR7 expression in pDCs. CONCLUSIONS: A novel defect of pDCs, impaired CCR7 upregulation, is described in association with immunologic or virologic failure. This deficiency could impair homing of pDCs to lymph nodes, leading to secondary defects of mDC maturation and poor T-cell activation.