gwendolyn scott recording - 39 years of progress in the diagnosis, treatment, and prevention of HIV infection in children

1981 first case reported of AIDS

• started much earlier than this, but cases were sporadic and unknown to be HIV/AIDS yet
• CDC reported rare case ammonia which usually in immunocompromised ppl in gay men
• end of 1981, 200 cases of some sarcoma reported
• generally rare / uncommon illnessed attacking gay young men

HISTORY OF HIV - 1920s

1920s

• researchers found that a form of simian immunodeficiency virus (SIV) jumped to humans in central africa
• believe HIV originated in kinshasa chimps -> humans
  • bc of slaughtering chimps/animals -> covered in blood = got it (exposed)
  • also rapid urbanization in africa at the time (ppl crowding = more spread)

1st known case 1959

• 1st known case HIV in human in person who died in the congo, later confirmed to have HIV from preserved blood sample
• june 28, NYC, a 49 y/o jamaican-american died of the rare pneumonia

HIV: the 60s

• 1964, jerome horwitz of barbara ann cancer institute synthesize AZT under a grant from NIH
  • AZT originally intended as a cancer drug
• 60s recap
  • made AZT
  • 1966 HIV first arrived in americas (1st person infected in haiti)
  • 1968 virus went to US
  • 1969 st louis teenager dies of unusualy illness (later HIV+)

35 years of AIDS progress

• 80s - early years - stigma, disease, high mortality, identified HIV as the cause
• 90s - emphasis on drug treatment, combination therapies, longer survival
  • no treatment until late 80s, AZT, and mid 90s started combination therapy
• 2000s-present - HIV is a chronic disease, significant increase in life span, prevention transmission thru drug therapy, long acting drugs, search for cure/vaccine, etc.

infection in children: 1981 JMH

• 1981: 2 children in same hospital, both <3 months, sick
  • oral trhush, dev delay, diarrhea, fever, anemia, elevated gamma globulin levels
  • both died before 6 mo
  • what disease? immune deficiency?
  • where from?
  • mother in good health
  • same type of infants kept being brought in
  • did not know what was going on
• 1982: report of infants getting aids from transfusions
  • 22 cases by end of year of opportunistic infections
• 1984: several cases published of children

HIV infection: chronology

The early years

• 1981 - initial cases seen at JMH
• 1983-4 - case reports of children with AIDS published
• 1983-4 - case definition developed for pediatric AIDS
• 1983 - first abandoned orphan in Miami
• 1983 - isolation of the virus (HIV)

miami had orphans bc of parental loss

• parents died of HIV and children left
• often, children also had HIV
• made very difficult to find homes for them
• there was no treatment, only supportive care
• stigma made it hard for ppl to find support, many left homes and lived in cars, etc. bc of stigma

1984 antibody test to try to test pts for HIV

pediatric HIV research: the beginning

could now test for HIV in children + research pediatric HIV

baby

• particular one
• died 1986
• was put up for adoption - orphaned
• contracted HIV before birth
• difficult to find homes for orphans bc ppl afraid they would get HIV
• mother died of AIDS, couldnt care for her

HIV infection 1st decade

• high rate of parinatal transmission (20-30% in USA, 39% in Africa)
• rapid disease progression in 20% infants
• death common in 1st 2 years og life
• multiple HIV associated complications (cardiomyopathy, encephalopathy, LIP, etc.)
• delay in diagnosis of infection - bc usually didnt have symptoms in first few months
• only supportive care available - no treatment
  • until early 90s
• lack of community support - rejection by families
• considered to be a progressive + fatal disease
• causative agent unknown at first
• early mortality

research areas

- as virus was identified

• once isolated virus
• household transmission of HIV
• perinatal transmission
• clinical trials drugs children/pregnant women
• study of long term survivors without progression of disease
  • some children survived for long time, studied them
• studied mother/fathers
  • often times did not seem sick, but babies were
  • mothers were infected - did not show symptoms but they were
• living in same house did not spread disease - casual contact

survival children HIV 1981-1987

• median age present symptoms 8 months
• survival about 38 months
• 25% children died by age 2
• PCP occurred at median age of 5 months, median survival for that was 1 month
• very sad overall

high mortality / morbidity in children w/ perinatal acquired infection w/ HIV

stigma of AIDS

• ryan white - hemophilia/HIV, denied school entry in indiana
  • allowed in, but family moved after bullet fired into his home
• 3 ray brothers w/ hemophilia/HIV
  • not allowed to attend school
  • family sued + won
  • home burned down 1 week later

surgeon general

• distributed info to every household to make ppl less afraid of ppl w/ HIV

1985-1990

• AZT used for HIV and was a miracle drug
• organized a pediatric subunit for clinical trials in 1986-87
• clinical trial funded in 1989 bc had no treatments
• suddenly children who would have died were allowed to live much better
• AIDS activists felt AZT was toxic, were against its use
• no other drug available, it was approved to be used

phase I clinical trials of AZT in children

well tolerated in children

perinatal transmission using AZT

• pregnant women took AZT
• not easy bc of worries + risks of AZT
• did small study w/ pregnant women
• developed into regimen for pregnant women
  • antepardum
  • antipardum
  • baby given after birth for 6 weeks, bc maternal blood can circulate in baby for that long

pregnancy + AZT

• transmission reduced from 25.5% placebo to 8.5% in AZT group mother to child
• affected for perinatal transmission
• rate of it began decreasing
• now 1-2% rate

prevention of perinatal transmission

• counsel + test pregnant women
• treatment for mother
• antiretroviral therapy for reduction of perinatal transmission of HIV given to mother/infant
• diagnostic testing for HIV and follow-up of infant

women at risk for perinatal transmission

• no prenatal care/late to care
• not offered HIV testing/counseling
• offered ARV but not take medication
• unexplained failures

1990-1994 pediatric HIV infection

• licensure of AZT + DDI
• trials of combination therapy
• could now manage + treat children with HIV
• pcp prophylaxis
• use of ZDV during pregnancy
• early diagnosis of HIV in infants - follow up until 4-6 months

once daily tablet

• companies combined multiple drugs so only take 1-2 pills a day
• revolutionized treatment, used to take handfulls of pills

long acting injectable drugs

long half life given every month or 2 being studied

so far see every 2 months has same efficacy as the 1 month one

now mother viral load undetectable

very little chance to transmit to baby

pediatric deaths after 1996 dropped dramatically

bc of combination therapy

ending HIV epidemic: plan for america

• 2019 - have tools to end HIV epidemic in the US
• initiative will leverage critical scientific advances in HIV prevention, diagnosis, treatment, and care through the programs, resources, and infrastructure of the CDC, NIH, HRSA, and HIS
• addresses 4 key pillars in implementation scientific research
  • testing for HIV
  • link to care and early treatment, improve retention and adherence
  • PrEP and PEP
  • rapidly detect and respond to emerging cluters of HIV infections

HIV cure

• hopes for cure
• early aggressive treatment protocols
  • active drugs
  • can prevent virus from hiding + assimilating
  • do this if baby born with HIV

prevention through PrEP

• if person dont have HIV but are at risk, can take pill to prevent risk fo becoming infected
• take daily, reduce risk of HIV by >90%