HIV-infected Children In sub-Saharan Africa Research Articles

Treatment failure among Sub-Sahara African children living with HIV: a systematic review and meta-analysis

BackgroundAntiretroviral treatment failure is a global issue, particularly in developing countries such as Sub-Saharan Africa. Prior research findings were highly variable and inconsistent across areas. As a result, the goal of this systematic review and meta-analysis was to determine the pooled prevalence of treatment failure among children receiving antiretroviral medication in Sub-Saharan Africa.MethodsTo find qualifying papers, we searched databases (such as PubMed, Google Scholar, African Journals Online, Scopus, and the Cochrane Library). The data were retrieved using Microsoft Excel and exported to STATA Version 14 for analysis. To check for publication bias, we employed Egger and Begg’s regression tests. A random-effects model was used to assess the pooled prevalence of treatment failure due to high levels of variability.ResultsFollowing the removal of duplicated articles and quality screening, a total of 33 primary articles were determined to be appropriate for inclusion in the final analysis for this study. Overall, the pooled prevalence of treatment failure among HIV-infected children was 25.86% (95% CI: 21.46, 30.26). There is great variety across the included studies, with the majority of them being conducted in Ethiopia. Cameroon had the greatest pooled prevalence of treatment failure among HIV-infected children, at 39.41% (95% CI: 21.54, 57.28), while Ethiopia had the lowest, at 13.77% (95% CI: 10.08, 17.47).ConclusionsThe pooled estimate prevalence of treatment failure among HIV-infected children in Sub-Saharan Africa was high. The implementation of national and international policies and strategies on ART clinic care services should be given special focus in order to reduce treatment failure in children living with HIV/AIDS.Trial registrationThe protocol has been registered in the PROSPERO database under the registration number CRD-429011.

The impact of viraemia on inflammatory biomarkers and CD4+ cell subpopulations in HIV-infected children in sub-Saharan Africa.

To determine the impact of virological control on inflammation and cluster of differentiation 4 depletion among HIV-infected children initiating antiretroviral therapy (ART) in sub-Saharan Africa. Longitudinal cohort study. In a sub-study of the ARROW trial (ISRCTN24791884), we measured longitudinal HIV viral loads, inflammatory biomarkers (C-reactive protein, tumour necrosis factor alpha, interleukin 6 (IL-6), soluble CD14) and (Uganda only) whole blood immunophenotype by flow cytometry in 311 Zimbabwean and Ugandan children followed for median 3.5 years on first-line ART. We classified each viral load measurement as consistent suppression, blip/post-blip, persistent low-level viral load or rebound. We used multi-level models to estimate rates of increase or decrease in laboratory markers, and Poisson regression to estimate the incidence of clinical events. Overall, 42% children experienced viral blips, but these had no significant impact on immune reconstitution or inflammation. Persistent detectable viraemia occurred in one-third of children and prevented further immune reconstitution, but had little impact on inflammatory biomarkers. Virological rebound to ≥5000 copies/ml was associated with arrested immune reconstitution, rising IL-6 and increased risk of clinical disease progression. As viral load testing becomes more available in sub-Saharan Africa, repeat testing algorithms will be required to identify those with virological rebound, who need switching to prevent disease progression, whilst preventing unnecessary second-line regimen initiation in the majority of children with detectable viraemia who remain at low risk of disease progression.

Chapter 8 - NeuroAIDS in children

The human immunodeficiency virus-1 (HIV-1) enters the central nervous system compartment within the first few weeks of systemic HIV infection and may cause a spectrum of neurologic complications. Without combination antiretroviral therapy (cART), 50-90% of all HIV-infected infants and children develop some form of neuroAIDS. Of the estimated 2.3 million children less than 15 years of age who were living in sub-Saharan Africa at the end of 2014, only 30% were receiving cART, suggesting that there is a large burden of neuroAIDS among HIV-infected children in sub-Saharan Africa. There is complex interplay between the disease process itself, the child's immune reaction to the disease, the secondary complications, the side-effects of antiretroviral drugs, and inadequate antiretroviral drug uptake into the central nervous system. In addition there is the layering effect from the multiple socioeconomic challenges for children living in low- and middle-income countries. Adolescents may manifest with a range of neurocognitive sequelae from mild neurocognitive disorder through to severe neurocognitive impairment. Neuroimaging studies on white-matter tracts have identified dysfunction, especially in the frontostriatal networks needed for executive function. Psychiatric symptoms of depression, attention deficit hyperactivity disorder, and behavioral problems are also commonly reported in this age group. Antiretroviral drugs may cause treatment-limiting neurologic and neuropsychiatric adverse reactions. The following chapter addresses the neurologic complications known to be, and suspected of being, associated with HIV infection in children and adolescents.

Prevalence and Risk Factors for Albuminuria among HIV Ivorian Children, Using the Dipstick Method

Context: Human immunodeficiency virus (HIV) infected children are at risk of developing chronic kidney disease defined by decreased glomerular filtration rate and or proteinuria. Studies on the prevalence of and risk factors for proteinuria among HIV-infected children in sub-Saharan Africa are scarce and in Cote d’Ivoire, there is paucity of reported data. We determined the prevalence of and the risk factors for proteinuria among HIV-infected Ivorian children in both ART (antiretroviral therapy)-naïve and ART-exposed children. Method: It was a cross-sectional bi-centric study, conducted from July 2013 to April 2014. Each child’s urine was tested for proteinuria and microalbuminuria using multi test strips and mitral test, respectively. Proteinuria was defined as of significant of 1+ and above on the dipstick or the presence of microalbuminuria ≥ 20 mg/l. Results: Of the 155 HIV-infected children enrolled, there were 78 boys. Sixty seven point seven percent were treated with antiretroviral and 74.1% had treatment duration of less than 5 years. In the first dipstick test, the prevalence of proteinuria was 29% which persisted in 9.7% after 24 hour urinary protein examination. It was significantly different between the 2 groups treated and naïve (2.8% versus 24%). The advanced CDC clinical stage emerged as the main independent determinant of proteinuria. Conclusion: Proteinuria is common in HIV-infected Ivorian children. Screening for proteinuria in HIV-infected children will help in early and treatment, and thus prevention and progression to chronic kidney disease to end-stage kidney disease.

Prevention of Mother-to-Child Transmission of HIV in Yaounde: Barrier to Care

ABSTRACTMost HIV-infected children in Sub-Saharan Africa are born where programs for the prevention of mother-to-child transmission of HIV (PMTCT) exist but are not universally operational. The expansion of PMTCT programs in Cameroon was among the largest in francophone Africa, but despite highly variable estimates of PMTCT uptake (ranging from 20% to 66%), it is clear that not enough HIV-infected pregnant Cameroonian women benefit from treatment to prevent HIV transmission to their children. The reasons why HIV-infected women in Cameroon do not use treatments to prevent this transmission remain partially unidentified. We conducted a qualitative study of the therapeutic itineraries (treatments taken and motivations) followed by HIV-infected pregnant women in Cameroon to understand the barriers to accessing high-quality PMTCT care. Here we construct the therapeutic itinerary for HIV-infected pregnant women, and identify the barriers at each step. Lack of financial independence, personal support, and empowering information were the primary obstacles at multiple steps.

High levels of pre-treatment HIV drug resistance and treatment failure in Nigerian children.

IntroductionPre-treatment HIV drug resistance (PDR) is an increasing problem in sub-Saharan Africa. Children are an especially vulnerable population to develop PDR given that paediatric second-line treatment options are limited. Although monitoring of PDR is important, data on the paediatric prevalence in sub-Saharan Africa and its consequences for treatment outcomes are scarce. We designed a prospective paediatric cohort study to document the prevalence of PDR and its effect on subsequent treatment failure in Nigeria, the country with the second highest number of HIV-infected children in the world.MethodsHIV-1-infected children ≤12 years, who had not been exposed to drugs for the prevention of mother-to-child transmission (PMTCT), were enrolled between 2012 and 2013, and followed up for 24 months in Lagos, Nigeria. Pre-antiretroviral treatment (ART) population-based pol genotypic testing and six-monthly viral load (VL) testing were performed. Logistic regression analysis was used to assess the effect of PDR (World Health Organization (WHO) list for transmitted drug resistance) on subsequent treatment failure (two consecutive VL measurements >1000 cps/ml or death).ResultsOf the total 82 PMTCT-naïve children, 13 (15.9%) had PDR. All 13 children harboured non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations, of whom seven also had nucleoside reverse transcriptase inhibitor resistance. After 24 months, 33% had experienced treatment failure. Treatment failure was associated with PDR and a higher log VL before treatment initiation (adjusted odds ratio (aOR) 7.53 (95%CI 1.61–35.15) and 2.85 (95%CI 1.04–7.78), respectively).DiscussionPDR was present in one out of six Nigerian children. These high numbers corroborate with recent findings in other African countries. The presence of PDR was relevant as it was the strongest predictor of first-line treatment failure.ConclusionsOur findings stress the importance of implementing fully active regimens in children living with HIV. This includes the implementation of protease inhibitor (PI)-based first-line ART, as is recommended by the WHO for all HIV-infected children <3 years of age. Overcoming practical barriers to implement PI-based regimens is essential to ensure optimal treatment for HIV-infected children in sub-Saharan Africa. In countries where individual VL or resistance testing is not possible, more attention should be given to paediatric PDR surveys.

HIV knowledge, stigma, and illness beliefs among pediatric caregivers in Ghana who have not disclosed their child's HIV status

The majority of HIV-infected children in sub-Saharan Africa have not been informed of their HIV status. Caregivers are reluctant to disclose HIV status to their children because of concern about the child’s ability to understand, parental sense of guilt, and fear of social rejection and isolation. We hypothesized that the low prevalence of pediatric HIV disclosure in Ghana is due to lack of accurate HIV information and high HIV stigma among caregivers. This is a preliminary analysis of baseline data of an HIV pediatric disclosure intervention study in Ghana (“Sankofa”). “Sankofa” – is a two-arm randomized controlled clinical trial comparing disclosure intervention plus usual care (intervention arm) vs usual care (control arm) at Korle-Bu Teaching Hospital (KBTH; control arm) and Komfo-Anokye Teaching Hospital (KATH; intervention arm). We enrolled HIV-infected children, ages 7–18 years who do not know their HIV status, and their caregivers. Baseline data of caregivers included demographic characteristics; Brief HIV Knowledge Questionnaire (HIV-KQ-18); Brief Illness Perception Questionnaire; and HIV Stigma Scale. Simple and multivariable linear regression analyses were used to assess the relationship between caregiver characteristics and HIV knowledge, stigma, and illness perception. Two hundred and ninety-eight caregivers were enrolled between January 2013 and July 2014 at the two study sites; KBTH (n = 167) and KATH (n = 131). The median age of caregivers was 41 years; 80.5% of them were female and about 60% of caregivers were HIV-positive. Seventy-eight percent of caregivers were self-employed with low household income. In both unadjusted and adjusted analyses, HIV negative status and lower level of education were associated with poor scores on HIV-KQ. HIV positive status remained significant for higher level of stigma in the adjusted analyses. None of the caregiver’s characteristics predicted caregiver’s illness perception. Intensification of HIV education in schools and targeted community campaigns are needed.

Effect of Age at Antiretroviral Therapy Initiation on Catch-up Growth Within the First 24 Months Among HIV-infected Children in the IeDEA West African Pediatric Cohort.

We described malnutrition and the effect of age at antiretroviral therapy (ART) initiation on catch-up growth over 24 months among HIV-infected children enrolled in the International epidemiologic Databases to Evaluate Aids West African paediatric cohort. Malnutrition was defined at ART initiation (baseline) by a Z score <-2 standard deviations, according to 3 anthropometric indicators: weight-for-age (WAZ) for underweight, height-for-age (HAZ) for stunting and weight-for-height/BMI-for-age (WHZ/BAZ) for wasting. Kaplan-Meier estimates for catch-up growth (Z score ≥-2 standard deviations) on ART, adjusted for gender, immunodeficiency and malnutrition at ART initiation, ART regimen, time period and country, were compared by age at ART initiation. Cox proportional hazards regression models determined predictors of catch-up growth on ART over 24 months. Between 2001 and 2012, 2004 HIV-infected children <10 years of age were included. At ART initiation, 51% were underweight, 48% were stunted and 33% were wasted. The 24-month adjusted estimates for catch-up growth were 69% [95% confidence interval (CI): 57-80], 61% (95% CI: 47-70) and 90% (95% CI: 76-95) for WAZ, HAZ and WHZ/BAZ, respectively. Adjusted catch-up growth was more likely for children <5 years of age at ART initiation compared with children ≥5 years for WAZ, HAZ (P < 0.001) and WHZ/BAZ (P = 0.026). Malnutrition among these children is an additional burden that has to be urgently managed. Despite a significant growth improvement after 24 months on ART, especially in children <5 years, a substantial proportion of children still never achieved catch-up growth. Nutritional care should be part of the global healthcare of HIV-infected children in sub-Saharan Africa.

"If I take my medicine, I will be strong: " evaluation of a pediatric HIV disclosure intervention in Namibia.

Background:Despite known benefits, only a small proportion of HIV-infected children in sub-Saharan Africa know their status and limited disclosure interventions exist. Namibia's Ministry of Health and Social Services developed and implemented a multipronged intervention to support health care workers (HCWs) and caregivers in the disclosure process.Methods:The intervention included a staged disclosure cartoon book, child and caregiver readiness assessment tools, a monitoring form to track progress over visits, and HCW training curriculum. We conducted qualitative interviews with 35 HCWs and 46 caregivers of HIV-positive children at 4 high volume HIV clinics. Interviews elicited detailed information about intervention uptake and impact. HCWs also participated in a self-efficacy survey.Results:The intervention improved HCW and caregiver confidence and communication skills in pediatric disclosure. The most valuable intervention component was the disclosure cartoon book, which provided structure, language, and guidance for a gradual disclosure process. HCWs reported it greatly reduced caregiver resistance to disclosure. Both caregivers and HCWs reported improved knowledge and ability to support the pediatric patient, improved child understanding of how HIV medications work, increased child hopefulness for their future, and improved child adherence to care and treatment. HCW self-efficacy surveys found that HCWs who received training felt more confident in their ability to engage in the disclosure process.Conclusions:HCWs and caregivers highly endorsed the intervention. Given the urgency to address pediatric HIV disclosure in Africa, and the utility and low cost of the locally-produced disclosure tool, this approach may be useful in other similar settings.

Renal abnormalities among HIV-infected, antiretroviral naive children, Harare, Zimbabwe: a cross-sectional study.

BackgroundData on the prevalence of renal and urine abnormalities among HIV-infected children in Sub-Saharan Africa are limited. We set out to determine the prevalence of proteinuria; low estimated glomerular filtration rate (eGFR), urinary tract infection and associated factors among HIV-infected antiretroviral therapy (ART) naive children, aged 2–12 years, attending the paediatric HIV clinic at a tertiary hospital in Harare.MethodsConsecutive ART naive children attending the clinic between June and October 2009 were recruited. Detailed medical history was obtained and a complete physical examination was performed. Children were screened for urinary tract infection and for significant persistent proteinuria. Serum creatinine was used to estimate GFR using the modified Counahan-Barratt formula. The Student’s t-test was used to analyse continuous variables and the chi-square or Fisher’s exact test was used to analyse categorical data. Logistic regression was performed to assess the relationship between study factors and urine abnormalities, persistent proteinuria and the eGFR.ResultsTwo hundred and twenty children were enrolled into the study. The median age was 90 months (Q1=65.5; Q3=116.5). The prevalence of urinary tract infection was 9.5%. Escherichia coli was the predominant organism. There was uniform resistance to cotrimoxazole. Persistent proteinuria (urine protein to creatinine ratio greater than 0.2, a week apart) was found in 5% of the children. Seventy-five children (34.6%) had mild to moderate renal impairment shown by a low eGFR (30 to <90ml/min/1.73m2). Persistent proteinuria was more likely to be found in children who were wasted, weight-for-height (WHZ) z-score <−2 (p=0.0005). Children with WHO clinical stage 4 were more likely to have a low eGFR than children with less advanced stages (OR 2.68; CI 1.24-5.80). Urine abnormalities were more likely to be observed in children with WHO clinical stages 3 and 4 (OR 2.20; CI 1.06-4.60).ConclusionThere is significant renal impairment among HIV-infected, ART naive children aged 2–12 years attending the outpatient paediatric HIV clinic at Harare Central Hospital. The abnormalities are more likely to occur in children with advanced HIV/AIDS. Screening for renal impairment and urinary tract infections in HIV-infected children before initiation of ART and regularly thereafter would be helpful in their management. Keywords: HIV, renal disease, persistent proteinuria, glomerular filtration rate, urinary tract infection

Risk Factors for Pre-Treatment Mortality among HIV-Infected Children in Rural Zambia: A Cohort Study

BackgroundMany HIV-infected children in sub-Saharan Africa enter care at a late stage of disease. As preparation of the child and family for antiretroviral therapy (ART) can take several clinic visits, some children die prior to ART initiation. This study was undertaken to determine mortality rates and clinical predictors of mortality during the period prior to ART initiation.MethodsA prospective cohort study of HIV-infected treatment-naïve children was conducted between September 2007 and September 2010 at the HIV clinic at Macha Hospital in rural Southern Province, Zambia. HIV-infected children younger than 16 years of age who were treatment-naïve at study enrollment were eligible for analysis. Mortality rates prior to ART initiation were calculated and risk factors for mortality were evaluated.Results351 children were included in the study, of whom 210 (59.8%) were eligible for ART at study enrollment. Among children ineligible for ART at enrollment, 6 children died (mortality rate: 0.33; 95% CI:0.15, 0.74). Among children eligible at enrollment, 21 children died before initiation of ART and their mortality rate (2.73 per 100 person-years; 95% CI:1.78, 4.18) was significantly higher than among children ineligible for ART (incidence rate ratio: 8.20; 95% CI:3.20, 24.83). In both groups, mortality was highest in the first three months of follow-up. Factors associated with mortality included younger age, anemia and lower weight-for-age z-score at study enrollment.ConclusionsThese results underscore the need to increase efforts to identify HIV-infected children at an earlier age and stage of disease progression so they can enroll in HIV care and treatment programs prior to becoming eligible for ART and these deaths can be prevented.

HIV-Infected Children in Rural Zambia Achieve Good Immunologic and Virologic Outcomes Two Years after Initiating Antiretroviral Therapy

BackgroundMany HIV-infected children in sub-Saharan Africa reside in rural areas, yet most research on treatment outcomes has been conducted in urban centers. Rural clinics and residents may face unique barriers to care and treatment.MethodsA prospective cohort study of HIV-infected children was conducted between September 2007 and September 2010 at the rural HIV clinic in Macha, Zambia. HIV-infected children younger than 16 years of age at study enrollment who received antiretroviral therapy (ART) during the study were eligible. Treatment outcomes during the first two years of ART, including mortality, immunologic status, and virologic suppression, were assessed and risk factors for mortality and virologic suppression were evaluated.ResultsA total of 69 children entered the study receiving ART and 198 initiated ART after study enrollment. The cumulative probabilities of death among children starting ART after study enrollment were 9.0% and 14.4% at 6 and 24 months after ART initiation. Younger age, higher viral load, lower CD4+ T-cell percentage and lower weight-for-age z-scores at ART initiation were associated with higher risk of mortality. The mean CD4+ T-cell percentage increased from 16.3% at treatment initiation to 29.3% and 35.0% at 6 and 24 months. The proportion of children with undetectable viral load increased to 88.5% and 77.8% at 6 and 24 months. Children with longer travel times (≥5 hours) and those taking nevirapine at ART initiation, as well as children who were non-adherent, were less likely to achieve virologic suppression after 6 months of ART.ConclusionsHIV-infected children receiving treatment in a rural clinic experienced sustained immunologic and virologic improvements. Children with longer travel times were less likely to achieve virologic suppression, supporting the need for decentralized models of ART delivery.

Kidney function of HIV‐infected children in Lagos, Nigeria: using Filler's serum cystatin C‐based formula

BackgroundLimited data is available on kidney function in HIV-infected children in sub-Saharan Africa. In addition, malnutrition in these children further reduces the utility of diagnostic methods such as creatinine-based estimates of glomerular filtration rate. We determined the serum cystatin C level and estimated glomerular filtration rate of 60 antiretroviral-naïve, HIV-infected children and 60 apparently healthy age and sex matched children.MethodsSerum cystatin C level was measured using enzyme-linked immunosorbent assay technique, while glomerular filtration rate was estimated using Filler's serum cystatin C formula. Student t test, Mann Whitney U test, Pearson chi square and Fisher's exact test were used, where appropriate, to test difference between groups.ResultsCompared to the controls, the HIV-infected group had significantly higher median (interquartile range) serum cystatin C levels {0.77 (0.29) mg/l versus 0.66 (0.20) mg/l; p = 0.025} and a higher proportion of children with serum cystatin C level >1 mg/l {10 (16.7%) versus one (1.7%); p = 0.004}. The HIV-infected children had a mean (± SD) eGFR of 96.8 (± 36.1) ml/min/1.73 m2 compared with 110.5 (± 27.8) ml/min/1.73 m2 in the controls (p = 0.021). After controlling for age, sex and body mass index, only the study group (HIV infected versus control) remained a significant predictor of serum cystatin C level (β = -0.216, p = 0.021). The proportion of HIV-infected children with eGFR <60 ml/min/1.73 m2 was eight (13.3%) versus none (0%) in the control group (p = 0.006). However, the serum cystatin C level, eGFR and proportions of children with serum cystatin C level >1 mg/l and eGFR <60 ml/min/1.73 m2 were not significantly different between the HIV-infected children with advanced disease and those with milder disease.ConclusionsHIV-infected children in Nigeria have higher serum cystatin C level and lower eGFR compared to age and sex matched controls.

Adherence to isoniazid prophylaxis among HIV-infected children: a randomized controlled trial comparing two dosing schedules.

BackgroundTuberculosis contributes significantly to morbidity and mortality among HIV-infected children in sub-Saharan Africa. Isoniazid prophylaxis can reduce tuberculosis incidence in this population. However, for the treatment to be effective, adherence to the medication must be optimized. We investigated adherence to isoniazid prophylaxis administered daily, compared to three times a week, and predictors of adherence amongst HIV-infected children.MethodsWe investigated adherence to study medication in a two centre, randomized trial comparing daily to three times a week dosing of isoniazid. The study was conducted at two tertiary paediatric care centres in Cape Town, South Africa. Over a 5 year period, we followed 324 HIV-infected children aged ≥ 8 weeks. Adherence information based on pill counts was available for 276 children. Percentage adherence was calculated by counting the number of pills returned. Adherence ≥ 90% was considered to be optimal. Analysis was done using summary and repeated measures, comparing adherence to the two dosing schedules. Mean percentage adherence (per child during follow-up time) was used to compare the mean of each group as well as the proportion of children achieving an adherence of ≥ 90% in each group. For repeated measures, percentage adherence (per child per visit) was dichotomized at 90%. A logistic regression model with generalized estimating equations, to account for within-individual correlation, was used to evaluate the impact of the dosing schedule. Adjustments were made for potential confounders and we assessed potential baseline and time-varying adherence determinants.ResultsThe overall adherence to isoniazid was excellent, with a mean adherence of 94.7% (95% confidence interval [CI] 93.5-95.9); similar mean adherence was achieved by the group taking daily medication (93.8%; 95% CI 92.1-95.6) and by the three times a week group (95.5%; 95% CI 93.8-97.2). Two-hundred and seventeen (78.6%) children achieved a mean adherence of ≥ 90%. Adherence was similar for daily and three times a week dosing schedules in univariate (odds ratio [OR] 0.88; 95% CI 0.66-1.17; P = 0.38) and multivariate (adjusted OR 0.85; 95% CI 0.64-1.11; P = 0.23) models. Children from overcrowded homes were less adherent (adjusted OR 0.71; 95% CI 0.54-0.95; P = 0.02). Age at study visit was predictive of adherence, with better adherence achieved in children older than 4 years (adjusted OR 1.96; 95% CI 1.16-3.32; P = 0.01).ConclusionAdherence to isoniazid was excellent regardless of the dosing schedule used. Intermittent dosing of isoniazid prophylaxis can be considered as an alternative to daily dosing, without compromising adherence or efficacy.Trial registrationClinical Trials NCT00330304

HIV in children: take a moment to make a difference!

You may not know it, but there are 5.5 million HIV-infected people in Africa. More important for paediatric radiologists to know is that there are nearly 2 million HIV-infected children in sub-Saharan Africa. In my home country, South Africa, there are 360,000 HIV-infected children. Now you understand why we have dedicated seven articles in this minisymposium to HIV in children. You may not believe that this affects you as a European or North American radiologist, but if the resurgence of tuberculosis is anything to go by, HIV should be a major concern to you too. The mass migration from Africa, increasing urban poverty and worsening social conditions in parts of cities of many developed nations make Africa at your doorstep. The majority of adults with HIV infection are of childbearing age, and of these, three-quarters are women. This, in turn, translates to both a medical and a social disaster for children. Not only are the bread-winners ill and not able to care for their children, but mothers transmit the disease during pregnancy, delivery and breast feeding to their children. Additionally, parents who are not treated and die leave orphans behind (many of whom are infected with the virus). There are currently over 11 million AIDS orphans! Imaging in HIV infection and AIDS requires skills ranging from interpretation of plain radiographs to MRI scanning of the central nervous system. Children with HIV infection are susceptible to both common and unusual infections, sometimes simultaneously. The radiologist also needs to distinguish changes resulting from HIV infection itself, such as brain shrinkage or cardiomegaly. Furthermore, neurological damage, chronic illness and superinfection compound each other with a variety of complications, such as aspiration and cardiac failure. Neoplasms, such as lymphoma, present radiologically in similar ways to some infections such as TB, when lymphadenopathy can no longer be used as a distinguishing imaging feature. The patient’s condition also affects the diseases that they are most susceptible to, and depending on CD4 levels the composition of a radiological differential diagnosis changes. Moreover, the institution of highly active antiretroviral therapy further complicates image interpretation, especially when the body is able to mount an immune response, resulting in the phenomenon of immune reconstitution inflammatory syndrome (IRIS). Without information from the clinician, the radiologist can become lost in identifying multiple radiological signs without any coherent conclusion and without being able to assist the clinician to manage the patient. Children may be on prophylaxis for pneumocystis, making that an unlikely diagnosis. There may be newonset pyrexia and the suggestion of fungal disease. Coexistent skin lesions may allow the rare diagnosis of Kaposi sarcoma in the lung to be made on radiographic findings. The clinician may depend on radiological identification of lymphadenopathy to start anti-TB treatment. The CD4 count may make some infections or neoplasms less likely and others more likely. Imaging is also useful for follow-up. Disease progression, resolution of acute infections, response to treatment and success of interventions for some complications can be determined this way. Because HIV predominantly affects children in the developing world, imaging research should be geared towards low-cost solutions. However, high-end imaging in Pediatr Radiol (2009) 39:525–526 DOI 10.1007/s00247-009-1279-5

Risk factors and cumulative incidence of anaemia among human immunodeficiency virus-infected children in Uganda.

Anaemia has not been well characterised among HIV-infected children in sub-Saharan Africa. Baseline prevalence and cumulative incidence of anaemia (haemoglobin < 110 g/L) were 91.7% and 100% and, for moderate anaemia (haemoglobin < 90 g/L), were 35.1% and 58.4%, respectively, among 225 HIV-infected children followed from 9 to 36 months of age. Hospitalisation, suspected tuberculosis, malaria and height-for-age Z-score <-2 were significantly associated with moderate anaemia. Moderate anaemia and weight-for-height Z-score <-2 were associated with mortality. Anaemia is common and associated with increased mortality in HIV-infected children.