Keeping HIV in the index of suspicion

We report seven cases of children whoseHIV (human immunodeficiency virus)diagnosis was made well beyond theneonatal period. These cases serve toremind clinicians to consider HIV in thedifferential diagnosis for children whenappropriate, with the goal of earlierdetection of HIV disease and treatmentto preserve immune function.

Identification of HIV-1 infected women by prenatal testing, the use of antiretroviral therapy in pregnant women and newborns, and the use of cesarean section for gravid women with high viral loads have contributed to a significant decline in perinatal HIV transmission in the United States.^1,2 However, cases of transmission continue to occur, primarily due to lack of prenatal care, failure to screen for HIV during pregnancy, and immigration from countries of high endemicity.³

Seven cases of HIV-1 infection in children 7 to 18 years of age who presented for care between January 2002 and December 2004 are discussed in the following article. These children were not diagnosed by the New York State newborn screening program or by routine testing, despite known HIV infection in the parents. They represent typical presentations of undiagnosed HIV in children.

Discussion

According to the Centers for Disease Control and Prevention (CDC), AIDS (acquired immunodeficiency syndrome) disproportionately affects children from ethnic minority groups. Eighty-four percent of the children diagnosed with AIDS in the US in 2003 were black or Hispanic.⁴ Of the cases presented here, 71% (5/7) were of Hispanic ethnicity. Approximately 60% (4/7) were born abroad and had been residing in the US for less than five years; of these, only one patient was receiving regular medical care in the US prior to diagnosis.

These cases illustrate both the importance of children participating in regular medical care and the need to consider HIV testing in children from countries with a high prevalence of HIV among women of childbearing age. Screening of pregnant women and infants for HIV is not widely available worldwide; practitioners should be particularly vigilant in these populations.

In 1994, the US Public Health Service recommended routine voluntary HIV testing for all women during prenatal care, or at delivery if not performed earlier.² To date, New York and Connecticut are the only states that require universal screening of newborns for HIV.⁵ Physicians should be aware of current HIV testing laws for individual states, as well as their dates of enactment, before assuming that a US-born child and mother have been tested.

• CASE 1

An 18-year-old male ...

... from Haiti whose risk factors included a blood transfusion 5 years prior, maternal illness and death of unknown etiology, and multiple female sexual partners. He was tested for HIV when he presented with his third episode of pneumonia. His previous pneumonias were presumed to be bacterial in origin (no organisms identified), and the patient's symptoms responded to typical antibacterial therapy for community-acquired pneumonia. This child did not have a primary care doctor, and he denied other illnesses or any significant weight loss.

• CASE 2

A 14-year-old male ...

... who was screened for HIV due to his history of sexual encounters with five to 10 females his own age. This child was followed by a general pediatric faculty practice. The parents brought him for medical care and for HIV evaluation, when it was revealed that he was having frequent unsupervised visits with young women in his home.

• CASE 3

A 10-year-old boy ...

... with recurrent otitis media and pharyngitis, who tested positive for HIV at the time of evaluation of lymphadenopathy in the Dominican Republic. This child's mother tested HIV positive in her second pregnancy, when Case 3 was 2 years of age. The mother stated at the time that she had a negative HIV test during her previous pregnancy. Case 3 was placed with relatives during his infancy, and was raised in the Dominican Republic. The mother continued to receive services in a US HIV center along with her two subsequent exposed but HIV-negative children. She suffered significant mental health problems. The mother remained in contact with Case 3 and his guardians during his childhood, but never disclosed her diagnosis until the biopsy evaluation revealed HIV infection.