Children HIV infected: experience of 14 years of the Instituto Fernandes Figueira - Fiocruz
In children aids is more severe than in adults. It causes a large variety of complications due to infections, caused by common and oportunistics germs. In general the infected child shows faster progress of the disease and a high mortality rate. It is estimated that 20% ? 40% of infected children are considered as having a higher probability of rapidly progressive disease, and develop aids and die in the early years of childhood. Older children show a slower progress of the disease. Recent international trials have shown the efficacy of combined therapy in pediatric aids. In Brazil there are few studies that demonstrated a significant change in the clinical progress of the disease when combined antiretroviral therapies are utilized (HAART). In this research data on 130 infected children between the ages of 0 ? 18 have been analyzed at the IFF, since 1990 until 2004. Laboratory, clinical and epidemiological data were evaluated. Children were separated in two groups: GROUP 1 ? children who were submitted to mono therapy; GROUP 2 ? children who were submitted to combined therapy (treatment involving two or three different types of antiretroviral therapy, HAART).We demonstrated the clinical course of pediatric aids and were able to estimate the impact of combined therapy in reducing mortality rate and morbidity in this population.A total of 130 children HIV infected were included in this study, during the period 1990-2004. Forty-three were died in the beginning of the study and 87 were follow-up in the DIP/AIDS department at IFF till December 2004. The average age at the time of diagnosis was 35.78 months old (with a variation between 0.3 ? 162.37 months). There was no significant difference in the variables of sex and race. Sixty-six patients were male (50.8%) and 65 were white (50%). The average length of time of their follow up was 59.8 months with a variation between 0.2 ? 188.57 months.Perinatal or vertical transmission was predominant, in 113 cases (86.9%). Fourteen children were infected following an HIV-contaminated blood transfusion, in three children it was not possible to determine the real cause of infection, but in one it could have been caused by breast feeding. In the beginning of children?s follow-up, the majority, 104 (80%) received B and C classification, while 26 received N ? A classification. Out of the 65 patients who had the lymphocytes count T CD4+ in the beginning, 49 had some degree of immunodeficiency (immunosupression category 2 or 3). Only 5 newborn babies who were given the protocol PACTG 076 were infected. Only 35 children (26.9% of the sample) did not follow the vaccine calendar at the IFF. One hundred and fifteen patients (88.4%) were given antiretoviral therapy for at least 12 weeks, 13 died before treatment started and 2 still remain with no formal indication to start ARV. Seventy-three (56.2%) started treatment using combined therapy, and 42 (32.3) of them started with monotherapy. Forty patients were given only one regime of antiretroviral therapy, 23 were given 2 regimens, 15 were given 3 regimens, 13 were given 4 regimens,8 were given 5 regimens, 9 were given 6 and 7 were given 7 regimens. Out of these 40 children who were given only 1 regimens of antiretroviral therapy, 28 started combined (double or triple) therapy. With increasing number of antiretroviral therapy the use of combined was diminished. Regarding the PCP prophylaxis, of the 130 children, 119 (91.5%) utilized it for a period equal or longer than one month, 8 died before it utilization and 3 were given for a period shorter than 4 weeks. Fourteen children (10.8%) were given isoniazida to prevent tuberculosis; 10 children (7.7%) were given claritromicina to MAC prophylaxis; 6 patients (4.6%) were given cetoconazol or fluconazol for recurrent oropharyngeal candidiasis; only 3 patients (2.3%) were given VZIG up to 96 hours following exposure to varicela or herpes zoster virus and 2 individuals (1.5%) were given ganciclovir as secondary CMV prophylaxis. The most frequent clinical manifestation was bacterial pneumonia in 108 patients (83.1%). Following pneumonia, the A category clinical manifestation was more frequent: limphadenopaty in 103 (79.1%), hepatomegaly in 77 (59.2%) and splenomegaly in 64 (49.2%). Recurrent or persistent upper respiratory tract infection was responsible for 47.7% of the sample with 62 patients, and its main represented was otitis media. Children who started ARV treatment with double or triple therapy showed lesser frequency in acquiring aids-related diseases. Most children, 89 (71.2%) had between one and five hospitalizations. The average number of hospitalizations was six. For 60 patients (46.2%) the main cause of hospitalization was pneumonia.One hundred and five out of 130 children developed aids between the ages 0.6 ? 176.6 months old; the average age was 41 months old, the median was 31.5 and standard deviation was 37.17. After the HIV diagnosis the average time for developing aids was 10.18 months, with a variation between 0 ? 72.3 months, median 3.33 months and standard deviation 16.02 months. Of the 42 patients who started antiretroviral treatment with monotherapy, 39 (92.9%) developed aids. Of the 73 who started combined (double or triple) therapy, 54 patients (75%) developed aids. One group of 29 children (27.6%) developed aids before their first birthday, mostly with invasive bacteria-caused infections. In another group, 56 children (53.4%) developed aids between the ages of 23 ? 72 months, and a third group with 20 children (19%) kept free of any aids symptoms till the age of 73 months. Of the 105 patients who developed aids, the estimate survival after diagnosis by the Kaplan-Meier curve were: the first 42 patients who started ARV monotherapy treatment was 83.4% in the first year, 68.1% in the second year, and 54.1% in the fourth year, 32.3% in the seventh year and 12.9% in the ninth year. Of the 73 patients who started combined therapy, life expectancy in the first year was 93.8%, 91.1% in the fourth year, 84.1% in the sixth year and in the fourteenth year the estimate is around 42%. Of the 15 patients who did not start the ARV treatment, it is expected that 50% will be alive after the first year after aids diagnosis, 41.6% in the second year and 16.6% in the third year.The average age of death for the 43 children was 56.21 months, with a variation between 2.87 ? 239.53 months with a standard deviation 53.43 months. Of the 42 patients who started ARV monotherapy treatment 24 died (57.1%) while of the 73 patients who started combined therapy treatment, only 6 (8.2%) died. There was a statistically significant reduction in the mortality rate (p=0.0001) among patients who started anti-retroviral treatment with combined therapy. The main cause of death was pulmonary sepsis.It was noted the increase of cell percentage T CD4+, and the decrease of viral count at the end of the children follow up. In the present study we have demonstrated that the patients who started antiretroviral with HAART, showed a tendency to a lower manifestation of oportunistics diseases and aids-related diseases, and a lower mortality rate. The PCP prophylaxis combined with this therapeutic showed great impact in aids morbidity specially, among children younger than two years old. We also observed a higher life expectancy after aids diagnosis. These facts prove the increase in quality of life among children HIV-infected after the utilization of combined therapy specially, when it includes protease inhibitors.
Advisor:Márcio Neves Bóia; Susie Andries Nogueira
School:Faculdades Oswaldo Cruz
Source Type:Master's Thesis
Keywords:HIV Acquired Immunodeficiency Syndrome Children infected Welfare of the Clhildren
Date of Publication:07/08/2005