Can the Burden of Pneumonia among HIV-Infected Children Be Reduced?
Jeena, Prakash Mohan, Bulletin of the World Health Organization
Of the approximately 2.1 million children who are infected with human immuno-deficiency virus type 1 (HIV-1), (1) more than 80% will develop a respiratory illness sometime during the course of their disease. (2) The prevalence of HIV-1 infection among African children admitted for very severe pneumonia (under the WHO case definition) varies from 55% to 65% and is associated with a case fatality rate of 20% to 34%; three- to six-times higher than children who are not infected with HIV. (3,4) In infancy, pneumonia caused by Pneumocystis jiroveci is often the first HIV/AIDS indicator disease that prompts HIV testing and, consequently, early antiretroviral treatment for those infected. (5)
Approximately 2 million children less than 5 years of age die of pneumonia each year in countries with a high prevalence of HIV. The standard case management guidelines for pneumonia recommended by WHO for use in areas with low HIV burdens are less effective in areas where HIV burdens are high. (6) Modifications to these guidelines have been suggested, but their use, as reported in a recently published study of children with very severe pneumonia, resulted in a 45% treatment failure rate among HIV-infected infants in tertiary care settings. (4) Polymicrobial infections with Staphylococcus aureus, nontyphoidal Salmonella spp. and other Gram-negative pathogens, Mycobacterium tuberculosis, P. jiroveci, cytomegalovirus and other viruses were commonly seen among the treatment failures and carried a greater than 10-fold risk of a poorer outcome. Randomized controlled studies of alternative antimicrobial agents that are active against some of the pathogens identified among these treatment failures are urgently required.
A second major challenge for standard case management in the HIV era is to develop a management guideline to care for the largest group of HIV-affected children: HIV-exposed but HIV-uninfected children, who are at increased risk of acquiring pneumonia. Such children, who live in close contact with HIV-infected persons who persistently harbour a multitude of different pathogens, are at higher risk of pneumonia treatment failure than HIV-unexposed control children; however, the risk of an adverse outcome is lower than for HIV-infected children. (7) Studies on the impact of pneumonia on HIV-exposed but HIV-uninfected children are essential.
The other major intervention to reduce pneumonia-related morbidity and mortality among HIV-infected children requires the implementation of preventive strategies. Routine immunizations against Streptococcus pneumoniae, Haemophilus influenzae and varicella are safe and effective in HIV-infected children, even though their primary immunological response is inferior and they experience faster decay in immunological memory. Despite the lower efficacy of the conjugate pneumococcal (65% versus 83%) and H. …