HIV This Week

Causes of acute hospitalization in adolescence: burden and spectrum of HIV-related morbidity in a country with an early-onset and severe HIV epidemic: a prospective survey.

Ferrand RA, Bandason T, Musvaire P, Larke N, Nathoo K, Mujuru H, Ndhlovu CE, Munyati S, Cowan FM, Gibb DM, Corbett EL. PLoS Med. 2010;7:e1000178.

Survival to older childhood with untreated, vertically acquired HIV infection, which was previously considered extremely unusual, is increasingly well described. However, the overall impact on adolescent health in settings with high HIV seroprevalence has not previously been investigated. In this study adolescents (aged 10-18 y) systematically recruited from acute admissions to the two public hospitals in Harare, Zimbabwe, answered a questionnaire and underwent standard investigations including HIV testing, with consent. Pre-set case-definitions defined cause of admission and underlying chronic conditions. Participation was 94%. 139 (46%) of 301 participants were HIV-positive (median age of diagnosis 12 y: interquartile range [IQR] 11-14 y), median CD4 count = 151; IQR 57-328 cells/microl), but only four (1.3%) were herpes simplex virus-2 (HSV-2) positive. Age (median 13 y: IQR 11-16 y) and sex (57% male) did not differ by HIV status, but HIV-infected participants were significantly more likely to be stunted (z-score<-2: 52% versus 23%, p<0.001), have pubertal delay (15% versus 2%, p<0.001), and be maternal orphans or have an HIV-infected mother (73% versus 17%, p<0.001). 69% of HIV-positive and 19% of HIV-negative admissions were for infections, most commonly tuberculosis and pneumonia. 84 (28%) participants had underlying heart, lung, or other chronic diseases. Case fatality rates were significantly higher for HIV-related admissions (22% versus 7%, p<0.001), and significantly associated with advanced HIV, pubertal immaturity, and chronic conditions. HIV is the commonest cause of adolescent hospitalisation in Harare, mainly due to adult-spectrum opportunistic infections plus a high burden of chronic complications of paediatric HIV. Low HSV-2 prevalence and high maternal orphanhood rates provide further evidence of long-term survival following mother-to-child transmission. Better recognition of this growing phenomenon is needed to promote earlier HIV diagnosis and care.

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http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000178

Editor’s note: Zimbabwe, a few years ahead of other countries in the region, may be the proverbial ‘canary in the mine’, alerting us to what will become increasingly evident – the unrecognised numbers of adolescents with HIV infection who were infected through mother-to-child (vertical) transmission. Adolescents (10 to 18 years) get lost in our epidemiological and clinical categories of <15 years and 15 to 49 years. Adolescents also get lost in our service provision, with freestanding services and youth-friendly clinics for adolescents rare in many settings. Legal barriers may prevent young people from learning their HIV status without guardian consent. Provider-initiated HIV testing and counselling offered to all adolescents in high HIV prevalence countries would go a long way to overcoming late diagnosis (the median age is 11 to 12 years), delayed antiretroviral treatment, blunted growth, and slow pubertal development. But to really make a difference in their growth, health, and survival, adolescents with HIV infection shouldn’t have to wait until they are sick to find out they have HIV. There is no time to lose – a considerable epidemic of long time survivors of vertical transmission is expected during the coming decade and strategic planning must start now or speed up rapidly. The later the diagnosis is made, the higher is the mortality.