Late diagnosis of paediatric HIV infection in south west LondonBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7127.271 (Published 24 January 1998) Cite this as: BMJ 1998;316:271
- Correspondence to: Dr Richardson
- Accepted 29 July 1997
The family clinic at St George's Hospital provides care for HIV positive children throughout south west London. We are increasingly concerned about the late presentation of many children. This is particularly worrying because in 1992 the Department of Health recommended that all women attending antenatal clinics in areas of higher prevalence (such as Greater London) should be offered an HIV test.1 If these guidelines had been effective we would have expected most HIV infected children to be recognised in the perinatal period. To assess the scale of the problem we reviewed the method of presentation of vertically infected children in our area.
Patients, methods, and results
We studied the hospital notes of all children who attended our clinic between 1986 and 1996 and identified 48 children with vertically acquired HIV infection. (None of these children had risk factors for horizontally acquired HIV infection.)
Presentation was defined as perinatal if the child was referred at, or around, the time of birth; asymptomatic if the child was referred after the identification of another infected family member or after the incidental finding of signs suggestive of HIV infection; and symptomatic if the child's initial complaint was a clinical manifestation of HIV infection. Severity of symptoms and immunological status at diagnosis were staged according to the revised CDC classification.2 To determine the effect of the Department of Health guidelines, we compared children born before or during 1992 (n=24) with those born after 1992 (n=24).
Age at presentation for the whole group ranged from birth to 9 years (median 19 months). The table shows that a significantly higher proportion of children were born in London after 1992 (5/24 v 17/24; χ2= 2.1, P<0.001). The mode of presentation and disease stage at diagnosis were similar in the two groups (χ2 for trend <1.0, P>0.2). Twenty-three children (48%; 95% confidence interval 34% to 62%) presented with infections and 16 (33%; 20% to 46%) presented with manifestations of organ involvement such as lymphadenopathy and parotitis. On examination, 31 children (65%; 52% to 78%) had signs of organ involvement.
In our area the Department of Health guidelines on antenatal testing have had no effect on the method of presentation of paediatric HIV infection. Since the guidelines were issued in 1992, the mother's HIV infection had been detected by antenatal testing in only one (6%) of the 17 children born in London.
Although poor, this detection rate is no worse than that calculated from unlinked anonymous testing in London and south east England as a whole.3 In 1995 the estimated proportion of HIV positive women giving birth who were aware of their diagnosis was 13%. The proportion detected by antenatal testing was 4.8%. These figures are particularly disappointing because antenatal diagnosis allows the use of perinatal antiretroviral therapy, an intervention that dramatically reduces the transmission of HIV from mother to child.4 In addition, HIV positive mothers can be advised to avoid breastfeeding as this will also reduce the risk of the infant being infected.
Most HIV positive children in this study were diagnosed after the first year of life. Most presented with symptomatic disease, usually in the form of repeated or opportunistic infections, but signs of organ involvement (such as lymphadenopathy, parotitis, and hepatosplenomegaly) were identified in two thirds of the children. Prospective studies have shown that 80% of vertically infected children show such signs during infancy.5 Wider recognition of these manifestations, together with the awareness that, in London at least, most HIV infected children are of black African origin,3 would probably result in more children being identified before they develop symptoms. Early diagnosis of HIV infection is important because it allows children to benefit from interventions such as prophylaxis against opportunistic infections (especially pneumocystis pneumonia), prompt treatment of established infections, parental education, and social support. Early diagnosis may also be associated with a better response to antiretroviral drugs. It is likely that combination antiretroviral therapy will be most effective in children who start treatment before their immune systems are severely damaged.
We thank Dr Angus Nicoll for his help in the preparation of this article.
Conflict of interest: None.
Contributions: MPR conceived the study, collected and analysed the data, and wrote the first draft of the paper. MS recognised the problem of late diagnosis and supervised the study. Both authors were involved in writing the final version of the paper, and both authors act as guarantors.