The Body Covers: The 45th Annual Meeting of the Infectious Diseases Society of America
IDSA 2007 Study Summaries: An Interview With Christos Karatzios, M.D.
October 6, 2007
Welcome. This is Bonnie Goldman, Editorial Director of The Body PRO. I'm in San Diego at IDSA 2007, one of the year's HIV conferences. Right now, I'm in the poster session where researchers are standing in front of their posters. There's nothing like hearing the results of research directly from those who actually conducted the research. It is these women and men who are transforming HIV treatment and care. In this podcast, the researchers will introduce themselves and then summarize their study. After their summary, I'll ask a few questions.
Hi. My name is Chris Karatzios. I'm an attending physician in pediatrics and infectious diseases and HIV physician in Montreal at the Montreal Children's Hospital, McGill University Health Centre. I went down to Miami in 2005 and did a fellowship under the tutelage of Gwendolyn Scott at the University of Miami.
What we did is, we asked the question: What do the children who were infected perinatally and are now surviving into adolescence, look like, medically and psychosocially? This is a population of HIV-infected people that is actually shrinking. Most of the young people that are getting infected right now are getting infected sexually, and not perinatally.
What we did is, we took all the children age 13 to 24 years of age in 2005, and we looked at what they looked like in 2005. This is what this study came out with. It's called "The Clinical and Psychosocial Characteristics of Adolescents with HIV Infection Acquired Early in Life."1
The inclusion criteria: They had to be HIV infected; they had to be infected early in life; and they had to have been aged between 13 and 24, and taken care of at the University of Miami Pediatric Clinic. We looked at their height and weight at the end of 2005. We looked at clinical variables. How many hospitalizations in 2005? What medications were they on, if they had any HIV disease problems, and if they had any sexually transmitted infections.
Then we looked at their lab abnormalities, if they had any. We looked at all the resistance testing that they did in the past, and saw what kind of mutations their HIV had. Then we would look at their viral load and their CD4 count.
We also looked at their CDC [U.S. Centers for Disease Control and Prevention] disease classification -- what they started off with, their worst classification -- and we compared them in 2005.
Meaning their baseline?
Not their baseline. Because when you describe an HIV individual ... let's say a 6-month-old presents to your clinic with PCP [Pneumocystis carinii pneumonia]. They are automatically given a C3. Clinical diagnosis is C, which is the worst classification; 3 is the worst immune classification. But that stays with them throughout their years. If they are 20 years old and they have been very well controlled, they are still called a C3, because they have got the potential to drop back to a C3.
However, maybe they are completely asymptomatic, and they are an N1. Maybe it's best if we tag, every time there's a major change in their status, if we tag an extra little thing to the C3. So, C3/N1 would probably be a better term to describe some of these patients.
We looked at their psychosocial variables: their family life, their education, their personal practices. We looked at their IQ. The study showed that most of the kids were not undetectable. They did have detectable viremia. But most of the kids -- 80%, almost -- they were immune reconstituted. They were not immune suppressed. If we compared how many of them did better immunologically than clinically, if we looked at clinical status, the percentage that went from a C to either a B, A, or N was 60%. The percentage that went from an immune status of 3 to 2, or 3, improving, was 73%.
Major resistance was seen to HIV. Ten percent were multidrug resistant. If we looked at their medical characteristics, one third had neurological disease, with HIV encephalopathy and cognitive dysfunction and developmental delay making up the majority of the problems. Thirty percent of the kids had an opportunistic infection, but they weren't the classic ones, because the kids were immune reconstituted.
Could you describe what they were?
Yes. They were candida, oral candidiasis, HSV [birth-acquired herpes], and a lot of the children had dermatophyte infections: tinea, fungal infections of their skin.
Psychiatric illness also was a major problem. Thirty-four percent of the children had a psychiatric illness, with ADHD [Attention Deficit Hyperactivity Disorder], depression and anxiety making up the most of these diagnoses. If we look at the children who did have a psychiatric illness, 72% were receiving help for this, either medication or psychiatric therapy, or both.
Looking at the growth parameters: Even if we looked at children who were above 18 years of age, a lot of them, actually -- not most -- but a lot of them were very short and did not exhibit any catch-up growth. That's probably because most of this cohort did not receive HAART until after 1996 or 1997.
So there is a correlation between low growth and HIV disease?
Yes. In many reports, and in the literature, it's very rampant. You can see this, that there is a growth delay.
Looking at the psychosocial variables: 60% lived with people other than their biological parents; 80% were orphaned by at least one parent. Most of them were in school, about 98%. About 12% were in special education classes. A minority were employed, 11%.
However, the most important thing that I want to reiterate is that only about 65% were using barrier protection. Two children actually did get pregnant; two adolescents did get pregnant, because only 40% actually disclosed status.
Some of them used marijuana. About 12% of those patients were either using marijuana or alcohol. In Florida, there is a law that if you do not disclose your HIV status to your sexual partner, you go to jail. So five children got into trouble with the law. Three of those five actually went to jail, because their partners actually sued.
Are these males or females?
Two were females, one was a male ... interestingly enough. But by the age of 13, though, in this cohort, 94% knew that they were HIV positive. But again, only 38% disclosed their status.
The intelligence quotient: Half of the kids had IQs below normal. I would say a great number of them actually had it in the moderate to severe mental retardation range.
Is there any idea what that was due to?
Well, this study was just a descriptive study. We have done a study that has not presented at this IDSA, looking back 10 years and answering those questions. Is it the fact that HIV does something to their brain at an early age, and affects them irreversibly, affects their IQ irreversibly? They have got a lot of problems. They have got a lot of psychiatric problems. They have got a lot of HIV encephalopathy. You know, HIV does replicate in the brain, as well.
This wasn't due to HIV meds? Because many of these kids weren't on treatment.
They weren't on treatment earlier on, no. We actually looked back at their IQs and they were always low, compared to the general population. The mean IQ was 78.3, plus or minus 15, standard deviation. If you compare it nationally, it's 99, plus or minus 15. Whether the two groups are statistically significant ... probably not, because our cohort is only 165 patients. But if we were to have more patients, and look at them across the board in North America, we would probably see a difference.
So the major conclusions were that these adolescents infected perinatally before 1992 are surviving with major medical problems. One third suffer from neurological disease. One third suffer from a psychiatric illness. Almost 50% are below normal for height. Major resistance is seen in their HIV. Most of them have detectable viremia, but only about 18% are severely immune suppressed.
They are also surviving with major psychosocial problems. Sixty percent of them do not live with their biological parents. Eighty percent are orphaned. Their IQs are lower than the national mean.
More than one third of sexually active perinatally infected patients in this study do not use condoms, and two thirds do not actually disclose their HIV status.
So, a pretty horrifying descriptive study.
Yes. It's almost a lost generation. You wonder how they are going to contribute to society in the future.
They are dealing with so many issues.
They are dealing with a lot of issues. We have to support them. However, it's very hard to do so.
How are they being supported? This is all in Miami, right?
This is all in Miami. I take care of HIV-infected children, and we are seeing this throughout the board. We're seeing it in Montreal. We're seeing it in other areas in the United States, as well.
Well, because they are not only HIV positive, they don't have parents.
They don't have parents. Eighty percent of them were orphaned by at least one parent. There are probably a lot of socio-economic influences in this. But I do suspect that HIV does play a role, as well.
Are you continuing to study this population?
Yes. Yes, we are. The first step is the descriptive study. The second step is going to be a retrospective study of this same cohort, asking the questions. The ones that actually fared worse in 2005, or at the endpoint that we decided: Were they the ones that had more psychosocial problems? Were they the ones that had more hospitalizations? Did this affect them in the future?
Thank you very much for taking the time to speak to me.
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