Date Published: February 2, 2010
Publisher: Public Library of Science
Author(s): Glenda E. Gray
Abstract: Glenda Gray discusses the implications of a new study that found that almost half of all adolescents hospitalized in Zimbabwe were HIV-infected.
Partial Text: In 2006, the Society for Adolescent Medicine issued its second position paper on HIV/AIDS in adolescents . It noted that although great progress had been made in the scientific understanding, diagnosis and treatment of HIV, and the prevention of perinatal transmission, there was a growing HIV crisis in the developing world. At least half of all new infections in the developing world were amongst youth and young adults, and a substantial number of teenagers and young adults were already living with HIV/AIDS .
Little is also known about the survival of HIV-infected children in Africa beyond 5 years of age. Some studies have estimated that 38% of children will be slow progressors and that the estimated cumulated mortality at 15 years will be 83% . Others estimate a 67% survival at 1 year, 39% at 5 years, and 13% survival at 10 years . Decreased survival of HIV-infected children in Africa to date is attributed to lack of access to antiretroviral therapy (ART), delayed diagnosis, and inadequate management due to lack of expertise and resources.
In this issue of Plos Medicine, Ferrand and colleagues present data on the causes of acute hospitalization in adolescence in Zimbabwe . HIV has become the single most common cause of acute admission and in-hospital death amongst adolescents in Harare. Almost half of all adolescents hospitalized were found to be HIV infected, and most of them were severely immunosuppressed, with the major route of transmission being attributed to perinatal transmission. Those admitted were more likely to be stunted, have pubertal delay, be a maternal orphan, or have an HIV-infected mother as compared to non-HIV admissions. Unlike their HIV-negative counterparts, who were largely admitted for trauma or an acute exacerbation of a chronic medical condition, HIV-infected adolescents were more likely to be admitted for an infection with tuberculosis, pneumonia, cryptococcosis, and septicemia. HIV-infected adolescents were also almost four times more likely to die. The risk of in-hospital death was increased in those HIV-infected adolescents who had underlying chronic complications.
Older children and adolescents are diagnosed late in Africa despite most guardians suspecting their children of being HIV infected before diagnosis . The median age of diagnosis in some studies has been found to be between 11–12 years of age ,, with a delay of 3.5 years (interquartile range, 1–6 years) between the first serious illness and diagnosis of HIV infection. In addition, when these adolescents are diagnosed, they are already below average for height and weight, have moderate to severe immunodeficiency, and have had recurrent infections as well as tuberculosis.
Access to ART will improve health outcomes and long-term survival of any child that is infected early on in life, irrespective of setting. In the developed world, the long-term effects of protease-inhibitor–based combination therapy have shown greater improvements in CD4% in younger children as compared to older children. These findings may reflect greater thymic productivity in pre-adolescent children than in adolescents and adults  or other factors such as poorer treatment adherence in older children.
Disclosure issues abound both in the developed and developing world. However, studies suggest that there are medical benefits to disclosure of HIV infection status to children and adolescents. Children and adolescents who know their HIV status appear more likely to accept medical care and have a higher self-esteem as compared to youth that are unaware of their status ,. Nondisclosure can be associated with anxiety and depression, in addition to being excluded from social support. Reluctance of parents and caregivers to disclose the HIV status to a child or an adolescent is usually based on the fear of discrimination and stigma, toward both the adolescent and the family as a whole ,.
Adolescents with moderate or severe immunosuppression are less likely to have adrenarche as compared to HIV-uninfected children of their own age . However, the median age of sexual debut of adolescents who acquired their infection perinatally in southern Africa is unknown. In a study conducted in the US, amongst 40 HIV-positive adolescents/young adults, it was found that 28% of youth (mean age of 16.6 years), reported being sexually active . When re-interviewed about 2 years later, 41% (mean age 18.3 years), were sexually active. Other studies examining sexual behaviour of adolescents infected with HIV as infants report sexually activity ranging from 18% (mean age of 15.5 years) , to 59% (mean age 18.5 years) in HIV-infected adolescents with hemophilia who ever reported prior sexual intercourse .
There is a substantial burden of HIV infection in adolescents in southern Africa who acquired HIV perinatally. It is evident that they contribute substantially to hospital admissions and in-hospital deaths. There is an urgent need for services that will be able to provide accessible and appropriate HIV testing, counseling, and support, as well as facilitate access to ART and appropriate sexual risk-reduction interventions. The adolescents admitted to hospitals in Harare could have benefited from early diagnosis and concomitant initiation of ART, and this absence of treatment should not continue to be the plight of similar adolescents in our region.