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Background and Purpose: Paediatric HIV/AIDS remains a significant challenge in developing countries. We describe the effectiveness of interventions in HIV-infected children attending Paediatric Infectious Diseases Clinics in Jamaica., Methods: One hundred and ninety-seven HIV-infected children were followed prospectively in multicentre ambulatory clinics between September 1, 2002 and August 31, 2005, in the Kingston Paediatric and Perinatal HIV/AIDS Programme, Jamaica, and their outcomes described., Results: Median follow-up was 23 child-months (interquartile range [IQR] 12-31) with 12 children (6.0%) lost to follow-up and deaths (n=13) occurred at 4.64 per 100 child-years of follow-up. Median age was 5.0 years (IQR 2.2-8.1) and 32.1% had Centers for Disease Control and Prevention (CDC) category C disease at enrollment; 62% were ever on antiretroviral therapy (ART) with median duration of 15.4 months (IQR 5.5-25.5); 85% initiated ART with zidovudine/lamivudine/nevirapine. Mean weight-for-height 0.13 +/- 1.02 (mean difference -1.71 [95% Confidence interval (CI) -2.73, -0.69]; p = 0.001) and body mass index-for-age 0.05 +/- 1.11 (mean difference -1.11, [CI -1.79, -0.43]; p = 0.002); z scores increased after 24 months on ART; however, children remained stunted. Reductions in the incidence of hospitalizations (mean diff 30.95, [CI 3.12, 58.78]; p = 0.03) and in episodes of pneumonia, culture-positive sepsis and tuberculosis occurred in those on ART., Conclusions: A successfully implemented ambulatory model for paediatric HIV care in Jamaica has improved the quality of life and survival of HIV-infected children.

Background: In a few Caribbean islands, prevention of mother-to-child transmission (pMTCT) of HIV with zidovudine prophylaxis has reduced transmission rates from 27 - 44% to 5.5 - 9 %., Objectives: To highlight the uptake of interventions, preliminary outcomes and challenges in caring for HIV-exposed infants in a pMTCT HIVprogramme in a resource-limited setting., Method: A cohort of HIV-infected pregnant women were identified at the leading maternity centres in Greater Kingston through HIV counselling and testing and enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme. Antiretroviralprophylaxis with zidovudine or nevirapine was given to the HIV-positive women and their newborns along with formula feeding. Some infants were enrolled retrospectively and followed irrespective of whether they had or had not received antiretroviral prophylaxis. A multidisciplinary team at the paediatric centres supervised protocol-driven management of the infants. Infants were followed for clinical progress and definitive HIV-infection status was to be confirmed at 18 months of age by ELISA or the Determine Rapid Test., Results: During September 1, 2002 through August 31, 2003, 132 HIV-exposed infants were identified. For those infants prospectively enrolled (78), 97% received antiretroviral prophylaxis and 90% were not breastfed For all HIV-exposed children, 90% received cotrimoxazole prophylaxis and 88% continued follow-up care. Ninety-two per cent of all the infants remained asymptomatic and five died; of these deaths one is possibly HIV-related (severe sepsis at 11 weeks). This infant was retrospectively identified, had received no antiretroviral prophylaxis and was breastfed The main programme challenges, which were overcome, included the impact of stigma, compliance with antiretroviral chemoprophylaxis, breast-milk substitution and follow-up care. Financial constraints and laboratory quality assurance issues limited early diagnosis of HIV infection., Conclusion: Despite the challenges, the expected outcome is to prevent 50 new cases of HIV/AIDS in children living in Greater Kingston per year (300 over six years).

Nevirapine is one of the first line antiretroviral agents used in the treatment of HIV/AIDS as well as for prophylaxis against mother-to-child transmission of HIV As antiretroviral medication becomes more available it is important for physicians to recognize the major clinical toxicities of these medications. We report a HIV-infected infant who developed a rash with systemic symptoms in association with nevirapine administration.

Background: The study describes a cohort of HIV-infected Jamaican children receiving antiretroviral therapy (ART) and reports the outcome., Method: An observational prospective study was conducted on HIV-infected Jamaican children receiving anti retroviral drug therapy (ART). The outcome measures, weight, height, hospital admissions and length of stay were compared at initiation and within six months of commencing ART., Results: There were 37 (33.6%) of 110 HIV-infected children receiving ART during 2001 to 2003. The median age at commencement was six years (age range 1-16 years) with 54.1% (20) males and 48% AIDS orphans. Care was home-based for 68 % of all cases with the University Hospital of the West Indies managing 27 (73%) and the Bustamante Hospital for Children 10 (27%). The distribution by Centers for Disease Control and Prevention (CDC) clinical class was C (severely symptomatic), 22 (59.5%); B (moderately symptomatic), 8 (21.6%); A (mildly symptomatic), 6 (16.2%) and N (asymptomatic), one (2.7%). Among 14 (36%) children with CD4 counts, 8 (57%) were CDC immune class 2 (moderate immunodeficiency) and 6 (43%) were class 3 (severe immunodeficiency). After commencing ART the mean difference in admissions was--1.5+/-2.55 admissions (95% CI -2.3, -0.6; p < 0.001) and in length of stay was -12.9+/-21 day (95% CI -19.9, -0.5.9; p < 0.001). Antiretroviral therapy resulted in a mean weight gain of 2.8 kg+/-4.9 kg (95% CI 1.0, 4.5; p < 0.003) and a mean gain in height of 1.7 cm+/-2.6 cm (95% CI 0.6, 2.8; p < 0.003). Five children required second line therapy., Conclusion: The introduction of antiretroviral therapy has resulted in improved outcomes and is being initiated in older children cared for mainly at home. Limitations in accessing affordable second line agents underscore the need for compliance with first line therapy.

Background: In the face of the continuing pandemic of HIV/AIDS, the burden of the disease is now largest in the resource-poor developing world. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has listed the adult prevalence rate for the Caribbean as second only to Sub-Saharan Africa., Objective: To document the socio-demographic characteristics of paediatric and perinatal HIV/AIDS in Kingston, Jamaica., Methods: A cohort of HIV-infected pregnant women were identified at the leading maternity centres in Kingston and St Catherine and were enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme. Infants born to mothers within the programme were prospectively enrolled. Infants and children identified after delivery, whether HIV-exposed or infected, were also enrolled (retrospective group). All were followed according to standardized protocols., Results: We report on a total of 239 children, 78 (prospective group) and 161 (retrospective group). Among the retrospective group, 68% were classified as infected. For the prospective group, the patients were recruited within twenty-four hours of birth in 98.7% of cases, whereas in the retrospective group, the median age of recruitment was 2.6 years. The median age of the mother was 27 years and that of the father was 33 years. There were seven teenage mothers. Twenty-six per cent of the children were in institutional care. Family size ranged from one to nine children--the median was two children. For those parents where occupation was reported, the majority held semi-skilled or unskilled jobs. Patients attended their regional clinics., Conclusion: HIV/AIDS represents a significant human and financial burden on a developing country such as Jamaica and this underscores the need for urgent and sustained interventions to stem the epidemic.

Reported sexual assault in Jamaica is highest among children and adolescents. The risk of HIV transmission after sexual assault, although small, may be significant in certain circumstances, and it is therefore reasonable that post-exposure prophylaxis should be offered. These HIV transmission rates are similar to those of healthcare workers after occupational exposure to known HIV-infected blood for which routine post-exposure prophylaxis is recommended. We present a case series of children/adolescents with HIV/AIDS post-sexual assault and make the case for post-exposure prophylaxis for HIV infection following sexual assault.

Background: Nursing care has been the "grass roots" of healthcare management even before nursing became a profession. Literature on the nursing experience with HIV is minimal and so it is challenging to comment on, or to compare experiences., Purpose: This paper highlights the nursing interventions as a key feature in the ongoing development and success of a prevention of mother-to-child HIV transmission (pMTCT) programme in a resource-limited setting., Method: In the Kingston Paediatric and Perinatal HIV/AIDS Programme, the nurses and midwives were carefully selected and then trained in the management of preventing mother-to-child transmission (pMTCT) of HIV/AIDS, voluntary counselling and testing and the identification and nursing management of paediatric and perinatal HIV/AIDS. The sites of the programme included three large maternity centres and four paediatric centres, with several feeder clinics for pregnant women. A nurse coordinator supervised the interventions at each site. A multidisciplinary team followed protocol-driven management for the care of pregnant HIV-positive women and children. There was strong collaboration with the Jamaican government and other agencies., Results: The nursing interventions served to: sensitize and encourage other healthcare workers in the care of persons living with HIV/AIDS; sensitize persons in the community about the disease; improve the comfort level of women and families with accessing healthcare; enable prospective data collection for programme assessment and research purposes and to enhance multidisciplinary collaboration to widen the scope of patient care and prevent duplication of healthcare services., Conclusion: Nursing intervention is a vital part of a pMTCT HIV programme; however, ongoing education and training of the entire healthcare team needs to be continued in order to strengthen the programme. It is hoped that much of what is done in the Kingston Paediatric and Perinatal HIV/AIDS Programme will become integrated in the nursing management of maternal and child health nationally.

Objective: To document the frequency of Centers for Disease Control and Prevention (CDC)-defined clinical conditions, opportunistic and co-infections among children with HIV/AIDS., Methods: This prospective, observational study reports the findings of 110 HIV-infected children followed in multicentre ambulatory clinics during September 1, 2002, to August 31, 2003, from the 239 children enrolled in the Kingston Paediatric and Perinatal HIV/AIDS Programme, Jamaica. We describe the clinico-pathologic characteristics of these children with HIV/AIDS, using the CDC criteria., Results: The client distribution by clinic site was as follows: the University Hospital of the West Indies, 71 (64.6%), Bustamante Hospital for Children, 23 (20.9%), Comprehensive Health Centre 13 (11.8/%) and Spanish Town Hospital, 3 (2.7%). The median age of the 110 children with HIV/AIDS was 6.0 years (range 0.9-17.5). Mode of transmission was primarily mother-to-child (88.0%) and only 4% maternal/infant pairs received antiretroviralprophylaxis. Grouped by CDC category: 17 (15.4%) were asymptomatic (N), 22 (20.0%) mildly symptomatic (A), 30 (27.3%) moderately symptomatic (B) and 41 (37.3%) severely symptomatic (C). The most common CDC-defining symptoms were lymphadenopathy (12, 42.8%) and asymptomatic (6, 21.4%) in category N; lymphadenopathy (30, 29.7%), dermatitis (20, 19.8%) and persistent or recurrent upper respiratory tract infections (20, 19.8%) in category A; bacterial sepsis (18, 34.6%) and recurrent diarrhoea (11, 21.2%) in category B; and wasting (28, 30.0%), encephalopathy (26, 27.9%), and serious bacterial infections (15, 16.1%) in category C; Pulmonary tuberculosis (7, 7.5%) and Pneumocystis (jiroveci) carinii pneumonia; (5, 5.4%) were the most frequent opportunistic infections. Streptococcus pneumoniae (10, 30.3%) was the most common invasive bacterial pathogen causing sepsis and Escherichia coli (14, 34.2%) was the most common bacterial pathogen causing urinary tract infections, among the cohort. Thirty-three per cent commenced antiretroviral drugs (ARVs). There were 57 hospitalizations and five deaths., Conclusions: The study is an important step toward documentation of the natural history of paediatric HIV/AIDS in a primarily ARV-naive population from a developing country. It promotes training in paediatric HIV management as we move toward affordable access to antiretroviral agents in the wider Caribbean and the implementation of clinical trials.