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Brief Reports Indian Pediatrics 2002; 39:372-375 |
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HIV Seropositivity in Hospitalized Children with High Clinical Likelihood of AIDS |
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Ever since HIV was first registered in India in 1986, its growth appears to be exponential. In August 1999, National AIDS Control Organization (NACO) reported 2.5% prevalence of HIV seropositivity(1). Of the 35,20,179 persons screened, 88, 064 were seropositive. Of the 8,220 AIDS cases in India, 319 (3.8%) were below 14 years of age. Antenatal mothers had a seropositivity of 11.27% and perinatal transmission rate was 0.08%(1). The vertical transmission rate reported by NACO comes under a lot of scrutiny as most other studies report it to be 15-40%(2-3). Recent work from Mumbai reports the vertical transmission to be 24%(4). The state of UP has a sero-prevalence of 0.1% in its low risk population(5) and the prevlence in high risk individuals, is expected to be higher. Moreover there is a scarcity of data on the prevalence of HIV infection in hospitalized children. Hence this study was undertaken to determine the prevalence of HIV infection in hospitalized children with clinically high likelihood of Acquired Immuno Deficiency Syndrome (AIDS). Subjects and Methods This study was carried out between August 1997 to February 1999. The cases were selected from hospitalized children in the age group of 3 mo - 12 years. The selection of cases was based on the WHO clinical criteria for diagnosis of AIDS in children in developing countries(6). Inclusion criteria were presence of one of the following: (a) 3 major; (b) 2 major and 2 minor; and (c) 2 major and 1 minor criteria. The criteria were modified to include repeated chest infections as a minor criterion(7). In children less than 18 months of age only (a) and (b) were taken as the inclusion criteria. After written consent from parents, the children were subjected to detailed history, physical examination relevant investigations and HIV screening. Both the parents were questioned separately in the vernacular and any discrepancy led to combined questioning. Those who had not heard of AIDS were regarded as unaware of HIV. Separated serum (from 4 ml of the venous blood) was stored at 2º-8º C. Samples were tested for HIV 1 and HIV 2 antibodies by INNOELISA (INNIGENETICS NV, Belgium). If tested negative, the child was labeled as HIV negative, and if tested positive then it was confirmed by a second ELISA using a different kit. If second ELISA was positive, then a confirmatory Western Blot (WB) was done at National Institute of Communicable Diseases, New Delhi. If WB was positive then the child was labeled as HIV positive. If the first ELISA was equivocal then a second ELISA was performed. If the second ELISA was equivocal, then ELISA was repeated 2 weeks later. If this ELISA tested negative, then the child was labeled as HIV negative. Parents of all children less than 1 year of age were also screened for HIV infection. Results Of the 122 children screened, only 1 child was seropostive. The majority (58.9%) of these children were in the 1-5 year age group. The rest were equally distributed between 3 months to 1 year, and 5 to 12 years. Male to female ratio was 1.3:1. Of the total, 100 (81.9%) belonged to lower socioeconomic status, and none of their parents were aware of HIV. Parents of 15 of the rest 22 cases belonging to the middle socioeconomic status were at least aware of HIV. Only fathers of 6 patients had high-risk occupation or behavior. Fifteen patients had 3 major criteria, 70 had 2 major and 2 minor criteria and 37 had 2 major and 1 minor criteria. Of the toal, 100 (81.9%), 76 (62.3%) and 38 (31.1%) cases presented with the major criteria failure to thrive, fever more than 1 month and diarrhea more than 1 month, respectively. Among the minor criteria cough more than 1 month (45.9%) was the most common presentation, followed by generalized lymphadenopathy (10.7%) and generalized dermatitis (4.1%). Oropharyngeal candidiasis and recurrent respiratory infections were present in 4.92% each. Mean weight for height was 58.06 ± 14.51% and height for age was 86.48 ± 6.84% indicating severe wasting with stunting in the selected group. Tuberculosis was confirmed in 42 patients (34.4%) and 28 (23%) had CSF proven tubercular meningitis. On screening, one child was found to be HIV seropositive. This was a 2-year old male child admitted with failure to thrive, fever for more than 1 month, and oroparyngeal candidiasis. There was a history of sexual promiscuity in the father, but the parents were sero-negative. The child had repeated chest infections with previous admissions in private nursing homes. Weight for height was 54% but height for age was 94%. Cerebrospinal fluid examination and miliary mottling on chest radiography confirmed initial clinical diagnosis of TBM stage III. As per WHO classification, this patient had 2 major and 1 minor criteria for diagnosis of AIDS. Discussion The recently published data by NACO of 2.5% prevalence in the general population comes under scrutiny(1). In our study of high likelihood hospitalized children, the small size notwithstanding, we find a prevalence of less than 1%. This is in sharp contrast to the 15% prevalence reported in clinically suspected hospitalized children from Mumbai(8). Vertical transmission is ruled out in the index case as the parents were HIV negative. The child had received parenteral infusions and injections in private hospitals. Hence the most probable route of transmission was parenteral, which was found to be the most incriminated route in a study from New Delhi(9). Merchant et al reported vertical transmission in 86.6% and transmission through blood in 11.57%(10). The major WHO clinical criteria of failure to thrive, fever >1 month, and diarrhea of >1 month are widely prevalent due to endmic diseases. Tuberculosis and malnutrition, which are rampant in India, can also produce similar clinical findings. If the presence of 2 major and 2 minor criteria is diagnostic of AIDS, our data should have revealed higher rates of seropositivity. Less than 1% seropositivity for HIV, that too in a child fulfilling only 2 major and 1 minor WHO criteria, in the present study questions the sensitivity and specificity of the criteria. A recent report from Mumbai, showed that of the 28 confirmed cases of HIV, only 6 fulfilled the WHO criteria(11). There are conflicting reports regarding sensitivity and specificity of the WHO criteria. Even in Africa with 30% seroprevalence(12) a sensitivity of 37-40% and specificity between 26-59% has been reported. The cause for low sensitivity in the African studies could be due to non-inclusion of pulmonary disease in the WHO criteria. In areas where seroprevalence is low, application of the WHO criteria without establishing seropositivity will lead to an unacceptable high false positive diagnosis. Here we raise the question whether screening should be based on WHO criteria only. How-ever, with <1% seropositivity we conclude, that the presence of HIV infection in our area is low. Multicentric studies are required to evaluate the effectiveness and to suggest modifications to these criteria so as to increase their sensitivity in the diagnosis of AIDS. Contributors: SL, TS, AM and SA were involved in the design of the study, data collection, analysis, and drafting of the paper. SA will act as the guarantor of the paper. Funding: None. Competing interests: None stated.
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