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Anita Shet, Smitha Holla, Vijaya Raman, Chitra Dinakar, Sapna V, Mysore Ashok St. John’s Medical College Hospital Bangalore, India. Cognitive, neurological and adaptive behaviour functioning among children with perinatally-acquired HIV infection. 23-27 July 2012, Washington DC. Background.
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Anita Shet, Smitha Holla, Vijaya Raman, Chitra Dinakar, Sapna V, Mysore AshokSt. John’s Medical College HospitalBangalore, India Cognitive, neurological and adaptive behaviour functioning among children with perinatally-acquired HIV infection 23-27 July 2012, Washington DC
Background • Increased access to ART for children will result in improved survival. • HIV is now a chronic disease. • Neurocognitive and behavioral functioning of HIV-infected children: an important area to address.
Background • In infancy: delay in motor and mental development. • Drotar D et al. Peds 1997; Chase C et al. Pediatrics 2000. • Later childhood: poorer neurocognitive functioning in comparison to HIV-uninfected children. • Jeremy RJ, et al. Pediatrics 2005; 380-7 • Impact of ART: improvement in some test scores. • Martin SC, et al. Dev Neuropsychol 2006 • Other risk factors: malnutrition, poverty, parental illness and death.
Specific Aims • To examine the effects of HIV infection on cognitive, neurological, and behavioral functioning on children by comparing these areas in HIV-infected and HIV-uninfected children. • To determine whether clinical, immunological, and treatment status can predict adaptive behavior and neurocognitive functioning in HIV-infected children.
Specific Testing Tools Neurological Testing • Motor, sensory, cranial, cerebellar examinations. • Soft neurological signs using Physical and Neurological Examination for Soft Signs (PANESS) tool. Cognitive Testing • 3.5 to 6 yrs: Wechsler Preschool & Primary Scales of Intelligence (WPPSI) • 7-16 yrs: Wechsler Intelligence Scale for Children, 3rd Ed (WISC-III) (Verbal and Performance IQ) Adaptive Behaviour • Ability to adjust to different situations for day-to-day functioning. • The Vineland Adaptive Behaviour Scales (VABS) assesses personal and social functioning.
Soft Neurological signs • HIV-infected children had higher scores • Difference most marked at ages 7-10 yrs. • Boys with HIV had more abnormal soft neurological signs.
Cognition: IQ Scores • HIV-infected children had lower IQ scores compared to HIV-uninfected children, irrespective of age, sex, orphan status, anemia status
Adaptive behaviour (VAB) • Adaptive behaviour scores were similar for both HIV-infected and uninfected children – at all ages, and both in males and females. • Among the orphans HIV-infected children had higher/better scores than orphans without HIV.
IQ Scores: ART status p=0.006 p=0.06 p=0.02 Not on ART (39) On ART (43) Score Total IQ Performance IQ Verbal IQ ART may have a role in improving overall cognitive functioning
IQ Scores in children not on ART • Among children who were not on ART, mean total IQ scores demonstrated a tendency to decrease with increasing age
IQ Scores and VABS: Immunological status CD4 ≥ 15% 78 Low CD4 (<15%) 96 IQ Score VABS score 69 89 Total IQ Score VABS
Multivariate regression analysis Cognition Independent factors that affected IQ scores: • HIV status (OR 9.1) • Weight-for-age Z score (OR 2.5) • Hemoglobin (OR 2.1) Adaptive behaviour and soft neurological signs • HIV status had no independent effect
Conclusions • HIV-infected children had higher risk of having abnormal soft neurological signs. • and lower IQ scores compared to HIV-uninfected children, irrespective of age, gender, orphan status, anemia status. • indicating subtle neurocognitive impairment that may be related to perinatal HIV infection. • Malnutrition and anemia had a definite role in poor cognitive outcomes. • Use of ART has a positive effect, and subtle worsening may be seen among those children not on ART.
Recommendations • Routine neurocognitive assessments in children • Early initiation of ART • Early intervention and stimulation, with focus on educational and emotional development
Acknowledgements • St. John’s Research Society for funding support • National AIDS Control Organization • Sneha Care Home and Prithvi House staff • Staff at the ID and general pediatric clinics • Children and caregivers who participated