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Chronic comorbidities in children and adolescents with perinatally acquired HIV infection in sub-Saharan Africa in the era of antiretroviral therapy
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Summary
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Globally, 1⋅7 million children are living with HIV, of which 90% are in sub-Saharan Africa. The remarkable scale-up of combination antiretroviral therapy has resulted in increasing numbers of children with HIV surviving to adolescence. Unfortunately, in sub-Saharan Africa, HIV diagnosis is often delayed with children starting antiretroviral therapy late in childhood. There have been increasing reports from low-income settings of children with HIV who have multisystem chronic comorbidities despite antiretroviral therapy. Many of these chronic conditions show clinical phenotypes distinct from those in adults with HIV, and result in disability and reduced quality of life. In this Review, we discuss the spectrum and pathogenesis of comorbidities in children with HIV in sub-Saharan Africa. Prompt diagnosis and treatment of perinatally acquired HIV infection is a priority. Additionally, there is a need for increased awareness of the burden of chronic comorbidities. Diagnostic and therapeutic strategies need to be collectively developed if children with HIV are to achieve their full potential.
Studies from low-income countries have reported a high burden of cardiac abnormalities associated with HIV in children with HIV taking ART. Prevalence estimates from these studies are wide, ranging between 14% and 89%, most likely reflecting differences in measurements and in the selection of participants.
Microalbuminuria is an early marker of glomerular injury and predicts further proteinuria development. Two studies from Tanzania and South Africa reported a variable prevalence of 20% (49 of 240) and 8% (43 of 511), respectively, for microalbuminuria in children with HIV.
Age at ART initiation is an important predictor of bone density. In the Zimbabwean study, children with HIV starting ART after the age of 8 years had, on average, at least 1 standard deviation lower size-adjusted lumbar spine bone density. This level of bone density reduction doubles fracture risk in adults. Given the late average age at ART initiation of CWHIV in sub-Saharan Africa, these findings are concerning.
children with HIV who start ART outside infancy can have subtle to severe neurocognitive deficits.
Children with HIV with advanced immunosuppression before ART initiation, or who started ART at an older age, have an increased risk of cancer compared with those with modest immunosuppression or who began ART in infancy
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