Effect of Concomitant HIV Infection on Presentation and Outcome of Rotavirus Gastroenteritis in Malawian Children

Rotaviruses are the main cause of severe, dehydrating diarrhea in infants and young children throughout the world. By contrast with more-developed countries, in which rotavirus causes few deaths (<40 per year in the United States), an estimated 500,000 to 870,000 deaths annually are caused by rotavirus infection in less-developed countries. Infection with HIV is common among children in many countries in sub-Saharan Africa, and diarrheal disease is a leading cause of illness and death in HIV-infected children in these areas. The objectives of this study were to examine the effect of host HIV infection on the severity of rotavirus disease, and on the duration of fecal shedding of rotavirus and the serum immune response to rotavirus infection. Researchers enrolled 786 inpatients (median age 8 months, 34 percent of whom were HIV-1 infected) and 400 outpatients (median age 9 months, 16 percent of whom were HIV- infected) in the study.

Early rotavirus vaccines seemed to be less effective in tropical settings, but newer vaccines have shown similar levels of protection (80-100 percent) against the most severe outcomes of rotavirus infection in more-developed and less-developed countries. Most rotavirus vaccines in development include live, oral, attenuated strains, and concern exists regarding their use in infants who might be immunocompromised. Specifically, the CDC's Advisory Committee on Immunization Practices recommended that the (now suspended), tetravalent rhesus-human reassortant rotavirus vaccine should not be given to infants born to HIV-infected mothers (unless HIV infection in the infant has been excluded), and suggested further research in this area. Understanding the behavior of natural rotavirus infections in HIV-infected children is an important first step in this process.

In this 2-year hospital-based study of rotavirus gastroenteritis, researchers found that rotavirus was less commonly identified among HIV-infected children than among HIV-negative children. In those with HIV infection, the contribution of rotavirus might have been diluted by the effect of other enteropathogens -- e.g. parasites, bacteria and perhaps viruses such as astroviruses and picobirnaviruses, which have been associated with diarrhea in HIV-infected adults. Researchers were unable to find significant differences in the clinical severity of rotavirus diarrhea between hospitalized children with and without HIV infection. However, significantly more deaths occurred during follow-up after hospital discharge among HIV-infected children than among HIV-negative children, and death was related to low CD4 count on presentation.

In conclusion, rotavirus was detected less frequently among HIV-infected children, who were able to clinically resolve rotavirus infection irrespective of their immune status, and could mount a seroresponse similar to children without HIV infection. The finding of more frequent deaths among HIV-infected children during short-term follow-up after rotavirus infection requires further study, including assessment of the effect of rotavirus on HIV replication. The observation of (clinically inapparent) prolonged shedding in some HIV-infected children also merits further investigation, and would be best addressed in a large, longitudinal study with long-term follow-up.

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