Perinatally-Infected HIV Youth Are Prone to Serious Health Events as They Age

The good news? The number of babies infected with HIV during the perinatal stage has been decreasing in the United States over time. The bad news? Children who are infected with HIV either just before or after birth are at much greater risk of experiencing serious health events—and even death—than children who are infected during adolescence, a recent study finds.

A team of scientists from several hospitals and medical colleges including Massachusetts General Hospital and Harvard University’s T. H. Chan School of Public Health, both in Boston, discovered that the earlier a child is infected with HIV, the harder it may be to stay healthy. The researchers investigated data from 2 studies: the Pediatric HIV/AIDS Cohort Study (PHACS) Adolescent Master Protocol (AMP) and the International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT). The first study, PHACS AMP, looked at perinatally HIV-infected youth (PHIVY) aged 7 to 16 years. The IMPAACT study monitored PHIVY who were slightly older, with a mean age of 17.4 years. In all, 1,446 young patients from 12 states, including Puerto Rico, were included in this study. The researchers noted each patient’s viral load and CD4 cell count that were recorded in successive years throughout the 2 studies.

Older children who had been infected with HIV perinatally, and who had spent more years living with higher viral loads and lower CD4 cell counts than younger children, experienced more major health events than their younger counterparts. The older an individual was in the study, the more likely he or she was to have lived with viral loads of 400 copies/mL or more and CD4 counts of 200/uL or less, both of which are predictors of illness. Indeed, the older subjects in the study suffered at higher rates from maladies classified by the Centers for Disease Control and Prevention as stage B and C illnesses.

Stage B illnesses include symptomatic conditions such as thrush, candidiasis, pelvic inflammatory disease, fever, shingles, and diarrhea. Stage C illnesses indicate the presence of AIDS and include Kaposi sarcoma and leukemia. Out of the 29 deaths that occurred in the population studied, 23 occurred in individuals whose CD4 counts were below 200/uL and 24 occurred in individuals whose viral loads were 400 copies/mL or higher. Participants with these high viral loads and low CD4 counts also had higher rates of bacterial pneumonia and serious bacterial infections.

Is it the simple fact of living longer with a higher burden of disease that’s responsible for the increased level of illness in the older adolescents, or are adolescents simply less likely than younger children to adhere to their medication regimens? “It is likely a combination of factors,” Anne M. Neilan, MD, MPH, an infectious disease instructor at Massachusetts General Hospital and a lead author of the study said in an interview with Contagion^®. “Monitoring of viral load remained consistent across age ranges, suggesting ongoing engagement in care. Thus, high overall rates of viremia among participants ages 18 to 30 years are likely attributable to suboptimal medication adherence or acceptance or accumulated viral resistance.”

Sticking to antiretroviral therapy regimens, which became the standard of care in the 1990s, can go a long way toward keeping PHIVY healthy. “It’s important to emphasize that among PHIVY with good HIV control, serious health problems are rare,” says Dr. Neilan. “One of the first reports of AIDS in children was in the early 1980s, by Dr. James Oleske of New Jersey Medical School at Rutgers, who is a co-author of our study. At that point, getting to the age of 4 was a victory, and living until the third decade of life was unimaginable.”

But getting adolescents to stick with their HIV treatment often is a difficult endeavor. “We need to act to strengthen these services for youth, taking into account their developmentally specific needs,” suggests Dr. Neilan. “That might include youth-friendly services that consider the substantial stigma many of these patients face, novel approaches to antiretroviral therapy delivery, and improving support for youth transitioning from pediatric to adult healthcare providers.”