Bienvenida

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Bienvenida
Bienvenue
Welkom
Welcome
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SIDA Pediátrico en República Dominicana

• Dra. Solange Soto
• Dr. Erwin Cruz Bournigal
• Dr. Eddy Pérez Then

Clinica Infantil Dr. Robert Reid Cabral (CIRRC),
Sto. Dgo. Rep. Dom. Fogarty International
Research Center and Training Program, University
of Miami, USA. Centro Nacional de
Investigaciones en Salud Materno Infantil
(CENISMI), Sto. Dgo., Rep. Dom. CENISMI, Sto.
Dgo., Fogarty International Research Center and
Training Program, University of Miami, USA.
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Introducción

• 1er caso de SIDA Pediátrico fue reportado en Rep.
  Dom., en el año 1985 por el Dr. Erwin Cruz B. y
  cols.
• 1985 se inicia el seguimiento a niños(as) VIH
  referidos al Servicio de Alérgia e Inmunología
  CIRRC.
• 1999 inicio del Programa para la Reducción de la
  Transmisión Vertical en Rep. Dom. por la
  DIGECITSS.

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Casos de VIH/SIDA referidos al Servicio de
Alérgia e Inmunología de la CIRRC, 1985-2003
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Caracteristica sociodemográfica y estado de los
padres de los niños VIH/SIDA referidos al
Servicio de Alergia e Inmunología de la CIRRC,
1985-2003
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Caracteristica sociodemográfica y estado de los
padres de los niños VIH/SIDA referidos al
Servicio de Alergia e Inmunología de la CIRRC,
1985-2003
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Modo de Transmisión del VIH en los niños
Seropositivos referidos al Servicio de Alergia e
Inmunología del 1985-2003
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Cuadro 3Signos y Síntomas de los niños VIH/SIDA
seropositivos mayores de 18 meses referidos al
Servicio de Alergia e Inmunología de la CIRRC,
1985-2003
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Patologia más frecuente al momento del
diagnóstico en niños positivos al VIH referidos
al servicio de Alérgia e Inmunologia CIRRC,
1985-2003
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Casos de tuberculosis en los niños VIH/SIDA
seropositivos referidos al Servicio de Alergia e
Inmunología de la CIRRC, 1997-2002
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Gracias
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Antiretroviral therapy in infected Haitian
children Bois G., Wright P.F., Wilson G.,Noel
F., Darius N.,Verdier R.I., Deshamps M.M.,
Fitzgerald.D, Johnson W.D., Pape J.WLes
Centres GHESKIO, Port-au-Prince, Haiti and Weill
Medical College of Cornell University, New York,
Ny, USASponsored by the United Nations
Childrens Fund (UNICEF ), and Global Funds
(GPATM)
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Background

• Prevalence of HIV among pregnant women 2,9
  (2003)
• 400 HIV infected children have been followed at
  GHESKIO Centers over the last five years
• 25 of them would qualify for antiretroviral
  treatment, based on the CDC criteria

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Survival of HIV-infected Infants
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Objectives

• Reduce AIDS morbidity and mortality
• Improve quality of life
• Develop national guidelines for the care of
  HIV-infected Haitian Children

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ART in Haitian ChildrenGHESKIO Population

• 124 HIV infected children are on ART
• 29 children treated with highly active ART since
  October 2002 (UNICEF )
• 95 children placed on ART since May 2003 ( Global
  Fund)

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UNICEF Project (29 children )

• Age range 2- 15 years old
• 13 girls and 16 boys
• All presumed infected at birth
• 19 of the 29 are orphans only 1 child with both
  parents alive
• 14 of the 29 had received previous antiviral
  therapy, (mostly mono or bi therapy) which had
  been stopped due to economic reasons

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Procedure
Comprehensive pediatric care
Immunization
Multidisciplinary Team Approach
Treatment and prevention of opportunistic
infection
Psychological Support
Nutritional Support
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Schedule Events
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ART Initiation criteria

• Based on CDC Criteria
• Clinical stages B and C
• Immunological Stages 2 and 3

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ART Regimens

• AZT 3TC Nevirapine
• AZT 3TC Efavirenz
• Nevirapine was replaced by nelfinavir in one
  case due to severe rash

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CLINICAL AND IMMUNOLOGICAL STAGESN 29 children
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Baseline Characteristics
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12 month follow up
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Kaplan Meier Estimate of Survival at 12 months
among 29 children treated with ART
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Conclusion

• Implementing antiretroviral therapy in Haitian
  HIV infected children demands an intensive
  multidisciplinary approach, but can clearly have
  an impact.
• HAART provides meaningful therapeutic benefits
  that can be documented by clinical and immune
  improvement of those children

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THE IMPACT OF HIV INFECTION ON THE DEVELOPMENT OF
PRESCHOOL DOMINICAN CHILDREN
M. Hernandez-Reif1, R. Mendoza2, R. Castillo2, G.
Zhang4, G. Shor-Posner3 1Touch Research
Institute, University of Miami School of
Medicine 2CENISMI/Robert Reid Cabral Childrens
Hospital, Santo Domingo, DR 3Division of Disease
Prevention, Dept of Psychiatry and Behavioral
Sciences, University of Miami School of Medicine
4Miami-Dade County Health Department/Florida
Department of Health
Supported by NIH/NCCAM R21 AT01160 and
NIH/Fogarty D43 TW00017 (GSP)
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BACKGROUND
HIV/AIDS is becoming the leading infectious cause
for developmental delays in children.
HIV vertically infected children show

• Structural anomalies in the brain via CT Scans
  (including brain atrophy, calcification,
  ventricular enlargement) (Blanchette et al. 2001,
  Canadian study).

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BACKGROUND, cont

• Delayed pubertal onset and pubertal maturation
  (Buchacz et al. 2003, large USA study).

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BACKGROUND, cont

• Delayed motor learning in HIV children on HAART
  (von Giesen et al. 2003, German Study).

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BACKGROUND, cont

• Greater delays in motor and mental development
  occur within the first 30 months of life in
  children infected vertically (Smith et al. 2000,
  NIH National Study).

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BACKGROUND, cont

• The Dominican Republic has the 2nd highest
  incidence of HIV-1 infected children in the
  Caribbean
• Antiretrovirals are not yet widely available in
  the Dominican Republic.

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PURPOSE

• To evaluate the developmental profile of
  preschool children with HIV/AIDS living in the
  Dominican Republic who are not receiving
  antiretrovirals.

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METHODS
Participants (Preliminary data Final sample
will be 54 children) 29 HIV Dominican children
receiving care at the Robert Reid Cabral
Childrens Hospital

• Age 3-7 years old
• 59 Females

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INSTRUMENT
DEVELOPMENTAL PROFILE-II (Alpern, Bell Shearer,
2000)

• 186 items that assess childs functional
  developmental age
• Interview and direct testing approaches
• Sensitive to Ethnic Socioeconomic (SES) Biases

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RESULTS
IQ Equivalence Academic Age/Chronological Age

• Counting (1, 2, 3)
• Aware that different activities occur at
  different times of day (meals)
• After listening to a short story can answer
  simple questions
• Can draw a picture of a person (at least the head)

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ACADEMIC
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IQ RESULTS

• Approximately 40 of the children were not
  enrolled in school
• 97 of the children had IQ scores below the
  normal IQ score for children their age (Mean IQ
  77)
• 23 of the children scored in the mild mental
  retardation range (IQ 55-70)

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PHYSICAL

• Throw a ball
• Turn a door knob
• Hop on one foot
• Jump
• Cut a circle using scissors and paper

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PHYSICAL
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SOCIAL

• Plays games (hide-and-seek, etc.)
• Uses thank you and youre welcome
• Recognizes emotions in others (mad, angry)
• Tells secrets to friends

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SOCIAL
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COMMUNICATIVE

• Knows first and last name when asked
• Can sing a short song (30 words)
• Can tell a short story (Little Red Riding Hood)
• Displays age using fingers
• Recognizes and can read some words (older
  children)

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COMMUNICATIVE
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SELF-HELP

• Can put on own shoes, dress self
• Awakens without bladder or bowel accident
• Puts toys or things away when asked
• Can fix him/herself something simple to eat
• Can brush or comb hair

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SELF-HELP
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CONCLUSIONS

• IQ 97 Average
• 25 Mild Mental Retardation

• Effects might relate to
• HIV virus in the brain
• Lack of school enrollment (40)
• Lower SES
• And/or invalid IQ test

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CONCLUSIONS

• 40 showed delays in physical development
• 24 revealed delays in self-help
• Despite their HIV status, the majority of the
  children appeared to be capable of caring for
  themselves

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CONCLUSIONS

• About 30 were delayed in social development
• About 90 were delayed in communication skills
• Effects might be related to
• HIV virus
• SES
• Sensitivity of DP-II

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GENDER DIFFERENCES
Male children showed more physical and social
delays than girls
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CONCLUSIONS
Findings should be considered with caution until

• Replicated with a larger sample size
• Compared with normative data HIV seropositive
  Dominican children

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CONCLUSIONS

• Overall findings suggest
• Dominican children infected with HIV not
  receiving antiretrovirals show developmental
  delays in several domains.

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