Growing up with HIV in resource-rich countries: a case report
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Growing up with HIV in resource-rich countries: a case report Rohan Hazra, M.D. Pediatric, Adolescent and Maternal AIDS Branch Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health Department of Health and Human Services July 25, 2012
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Growing up with HIV in resource-rich countries: a case report. Rohan Hazra, M.D. Pediatric, Adolescent and Maternal AIDS Branch Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health Department of Health and Human Services - PowerPoint PPT Presentation
Transcript of Growing up with HIV in resource-rich countries: a case report
Growing up with HIV in resource-rich countries:
a case reportRohan Hazra, M.D.
Pediatric, Adolescent and Maternal AIDS BranchEunice Kennedy Shriver National Institute of Child Health and Human Development
National Institutes of HealthDepartment of Health and Human Services
July 25, 2012
Case report• 10 year old perinatally HIV-infected male referred
for “salvage therapy.”• Past medical history notable for recently treated
Burkitt’s lymphoma
Overall* ADC* NADC0tan28a566028
0tan28a566028
0tan29a566029
0tan29a566029
0tan1a56601
0tan1a56601
0tan2a56602
0tan2a56602
0tan3a56603
pre-HAART eraHAART era
Canc
ers p
er 1
000
pers
on-y
ears
US children: 0.2/1000
Cancers in HIV-infected children: CDC PSD and LEGACY Cohorts
N=5,735; 37,240 person-years
Twichell, CROI 2010, #859* <.05
Case report• 10 year old perinatally HIV-infected male referred
for “salvage therapy.”• Past medical history notable for recently treated
Burkitt’s lymphoma• Diagnosed with HIV at 2 months of age.• Began ZDV at 33 months of age (CD4 288).
Sequential unsuccessful ART• ZDV/3TC• ZDV/3TC/RTV• ZDV/3TC/NFV• ddI/d4T/NFV• ddI/d4T/NVP• ddI/d4T/RTV• d4T/EFV/RTV/SQV• ddI/APV/LPV/r
Other medical history
• Varicella• h/o +PPD, received INH• Paresthesias with d4T/EFV/RTV/SQV• Pancreatitis with ddI/APV/LPV/r• ADHD diagnosed at 10 years of age
Project CASAH(Child and Adolescent Self-Awareness and Health)
Mellins, J Child Psychol Psychiatr 2009
• Types of psychiatric and substance use disorders in 9-16 year old children affected by HIV in NYC (206 HIV+ and 134 HEU)
• The Diagnostic Interview Schedule for Children (DISC-IV) – caregiver OR youth report
Project CASAH(Child and Adolescent Self-Awareness and Health)
Mellins, J Child Psychol Psychiatr 2009
Psych d
iagno
sis
Anxiet
y diso
rder
Mood d
isorde
r
Behav
ioral
disord
er
ADHD
Substa
nce a
buse
0%
20%
40%
60%
80%
HIV+HEU
*
*
Other studiesP1055 (Gadow, JDBP 2010) and PHACS (Malee, Aids Care 2011)
• P1055: 6-17 y, 319 HIV+, 174 HEU, and 82 negative in HIV+ household
• DSM-based instruments and other surveys
• Psychopathology - no substantial differences between groups
• PHACS: 7-16 y, 295 HIV+, 121 HEU
• Behavioral Assessment System for Children (BASC-2)
When we saw him• Completed therapy for Burkitt’s 7
months ago. Off ARVs during chemotherapy.
• ddI/APV/LPV/r stopped after one month 5 months ago
• CD4: 1%/4, VL 385k• Extensive, multiclass resistance
Response to ARTTDF/ZDV/3TC/LPV/r
0tan28a566028 0tan10a5660100tan28a566028
0tan21a566021
0tan14a566114
0tan7a56617
0tan1a56621
0tan24a566224
0tan17a566317
0tan28a566028
0tan1a56601
0tan3a56603
0tan5a56605
0tan7a56607CD4 count Log VL
Weeks
CD4 Count
Log VL
Complications
• Anemia – ZDV replaced with d4T• Nephrolithiasis• Elevated fasting cholesterol and
triglycerides and lipoatrophy
Hypercholesterolemia Rates in HIV-Infected Children: Cholesterol >200 mg/dL
Euro Pediatr Lipodys Grp, AIDS 2004Carter, JAIDS, 2006Rosso, Eur J Endocrinol 2007Chantry, Pediatrics 2008
Aldrovandi, AIDS 2009 Brewinski, J Trop Pediatr, 2010Dimock, Metabolism 2010Sztam, J Pediatr Gastroentrol Nut, 2011
10 11 12 13 14 15 16 17 180.500
0.600
0.700
0.800
0.900
1.000
1.100
Age (years)
Abso
lute
LS
BMD
(g/c
m2)
Bone Mineral Density by DXAThomas, CROI 2009
10 11 12 13 14 15 16 17 180.500
0.600
0.700
0.800
0.900
1.000
1.100
Age (years)
Abso
lute
LS
BMD
(g/c
m2)
Bone Mineral Density by DXAThomas, CROI 2009
Bone Mineral Density (BMD) in HIV-Infected vs HIV-Uninfected Children by Gender (P1045)
Jacobson D et al, AIDS 2010;24:587-96
• 236 HIV-infected and 143 uninfected youth 7-24 years of age
• Appearance of significant and widening difference in BMD for HIV+ vs HIV- BOYS over course of pubertal progression (adjusted)
• Similar pattern but non-significant differences in GIRLS
HIV -HIV+
HIV -HIV+
Renal Health
• Andiman, PIDJ 2009:2102 children in PACTG 219/219C – renal abnormalities associated with non White race, older age, TDF
• Judd, AIDS 2010:456 children in UK/Ireland CHIPS cohort- decreased renal tubular function associated with prolonged TDF
Insulin ResistanceGeffner, Hormone Research in Pediatrics 2011
• 402 ARV-treated perinatally-infected youth (mean age 12 y, 25% prepubertal)
• 61 (15.2%) – insulin resistance• Association with obesity was stronger than
for any other variable
Young man in his early 20s• Perinatally-acquired
HIV• Cancer• Insulin resistance• High cholesterol• ADHD• History of low bone
density• Renal disease
Young man in his early 20s• Perinatally-acquired
HIV• Cancer• Insulin resistance• High cholesterol• ADHD• History of low bone
density• Renal disease
• High school graduate• Employed• A survivor• Resilient• Potential for a full and
productive adulthood
