Poster
Exhibitions:
1. Title:
Characterization of
productive
HIV-1 infection in breast milk of African women from KwaZulu-Natal,
South
Africa.
Authors:
S. Cassol (1),
E.
Cassol,
A. Coutsoudis,
T. Page, H.M. Coovadia
Affiliations: 1HIV Molecular Virology and
Bioinformatics
Unit, Africa Centre, Doris Duke Research Institute, University of
KwaZulu-Natal,
Durban, South Africa; 2Department of Paediatrics, Nelson R. Mandela
School
of Medicine, University of KwaZulu-Natal, Durban, South Africa; 3Centre
for
HIV/AIDS Networking, Nelson R. Mandela School of Medicine, University
of
KwaZulu-Natal, Durban, South Africa
Background: Previous studies have reported that
infants
born to HIV-1 positive mothers ingest up to 25,000 infected cells daily
and
that viable, living cells are required for virus transmission through
breast
feeding. At present, little is known about the identity of
productively-infected
cells in breast milk, or the factors controlling HIV-1 expression. This
knowledge
is fundamental to the design of intervention strategies that are safe,
affordable
and appropriate for the developing world.
Methods: Milk leukocytes of 41 HIV-1-infected
treatment-naive
mothers from KwaZulu-Natal, South Africa were analyzed using a combined
immunophenotyping/in
situ hybridization assay. The proportion of cells expressing HIV-1
gag-pol
mRNA was evaluated using a panel of phenotypic markers for
monocyte-macrophages,
and for CD4, CD8 and CD45 lymphocytes. Results were correlated with
blood
CD4+ counts and duration of breast feeding.
Results: 67% of samples had detectable HIV-1 mRNA.
Viral
mRNA was detected in CD4+CD45RO+ T-cells, CD14+CD16+ monocytes, and
macrophages
bearing CD40+ and CD206+ mannose receptors. The proportion of samples
with
>10% productively infected CD4+ CD45RO+, CD206+, CD14+CD16+ and
CD40+
cells was 56%, 32%, 29% and 7.1%, respectively. Mothers with CD4+
counts
<500 cells/µl were more likely to be HIV-1 mRNA positive. The
percentage
of samples with >10% productively infected CD4+CD45RO+ lymphocytes
was
91.7% among women with CD4+ counts <500 cells/µl compared to
42.9%
for women with counts >500 cells/µl. Women with low CD4+
counts
(<500 cells) also had increased HIV-1 mRNA expression in CD14+CD16+
(50.0%
vs 14.3%) and CD206+ 41.7% vs. 14.3%) cells.
Conclusions: In addition to being principal carriers
of
productive HIV-1 infection in breast milk, CD4+CD45RO+ and CD14+CD16+
cells
are major reservoirs of ongoing viral replication during HAART. There
is
an urgent need for innovative new drugs that target long-lived
CD4+CD45RO
memory T-cells and cells of the monocyte-macrophage lineage.
Day: Thursday, code: [ThPeB7072]
2. Title:
Antiretroviral
treatment
of African patients infected with HIV-1 subtype C: Suppression of viral
replication
in CD4+CD45RO+ and CD14+ CD16+ reservoirs is predictive of
immunological
recovery and clinical outcome.
Authors:
E. Cassol (1),
T. Page, A.
Mosam,
E. Dwyer, G. Friedland,
S. Cassol, H.M. Coovadia
Affiliations: 1HIV Molecular Virology and
Bioinformatics
Unit, Africa Centre, Doris Duke Research Institute, University of
KwaZulu-Natal,
Durban, South Africa; 2Department of Dermatology, Nelson R. Mandela
School
of Medicine, University of KwaZulu-Natal, Durban, South Africa; 3Yale
University
School of Medicine, New Haven, United States; 4Centre for HIV/AIDS
Networking,
Nelson R. Mandela School of Medicine, University of KwaZulu-Natal,
Durban,
South Africa
Background: During antiretroviral therapy, HIV-1
replication
persists in CD14+CD16+ monocytes and CD4+CD45RO+ memory T-cells.
Understanding
the factors that enhance or suppress HIV-1 replication in these
cellular
reservoirs is fundamental to the design of more effective treatment
strategies.
Methods: Twelve HIV-1 infected South African patients with Kaposi's
Sarcoma,
treated with 3TC, d4T and NVP, were subjected to intense therapeutic
monitoring.
HIV-1 gag mRNA levels in circulating CD4+CD45R0+ and CD14+CD16+ cells
were
measured at days 0, 4, 7, 14, 28, 60 and 90 using a dual
immunophenotyping/in
situ hybridization assay. Results were correlated with changes in viral
load,
CD4 and CD8 counts.
Results: All patients exhibited a 3-log decline in
plasma
viral load during the first 7 days of treatment, with 83.3% of patients
reaching
undetectable HIV-1 RNA levels (<40 copies/mL) by day 90. This was
accompanied
by a significant, parallel increase in the number of HIV-1 mRNA
expressing
CD4+CD45RO+ and CD14+CD16+ cells. In 6/12 patients, peak mRNA
expression
was followed by a substantial decrease in intracellular HIV-1 mRNA,
beginning
at day 28. In this group, decreased viral replication was associated
with
CD4+ restoration, an increase in CD8+ T-cells and prolonged suppression
of
plasma viremia. One patient exhibited a marked reduction in HIV-1 mRNA
expression
in CD14+CD16+ monocytes, but not in CD4+CD45RO+ T-cells. This patient
showed
a particularly pronounced increase in CD8+ T-cells. Five patients had
persistent
high level mRNA expression in both reservoirs, despite undetectable
plasma
virus. In this group, failure to control HIV-1 replication was
associated
with low baseline CD4+ counts, a decrease in CD8+ T-cells and/or
clinical
progression and death (n = 2).
Conclusions: These findings suggest that a combination
of
antiretroviral therapy and CD8+-based immune therapy may provide the
best
hope for controlling/eliminating HIV-1 replication in long-lived
reservoirs.
Day: Tuesday, code: [TuPeA4353]
3. Title:
HHV-8 viral load as
an
indicator of patient response to therapy.
Authors:
T.N. Page (1),
E. Cassol,
A. Mosam,
G.H. Friedland, H.M. Coovadia,
S. Cassol
Affiliations: 1HIV Molecular Virology and
Bioinformatics
Unit, Africa Centre, Doris Duke Research Institute, University of
KwaZulu-Natal,
Durban, South Africa; 2Department of Dermatology, Nelson R Mandela
School
of Medicine, University of KwaZulu-Natal, Durban, South Africa; 3Yale
University
School of Medicine, Newhaven, United States; 4Centre for HIV/AIDS
Networking,
Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
Durban,
South Africa
Background: Viral load (VL) assays are important
indicators
of disease progression and response to antiviral therapy. Accurate and
reliable
VL assays for HHV-8 are under development, but it is unclear as to
which
tissue and cellular compartment will be most informative. This study
compares
the clinical utility of HHV-8 VL assays performed on KS biopsies,
plasma
and circulating blood PBMCs of African patients co-infected with HIV-1
subtype
C.
Methods: Late stage HIV-1/KS patients (n = 15) were sampled pre- and
post-treatment
with 3TC, d4T and NVP, a drug regimen that is being widely implemented
in
southern Africa due to its low cost, availability, ease of
administration
(once-daily dosing) and high level of compliance. Nine patients
received
delayed chemotherapy, beginning on day 28. HHV-8 was measured in plasma
and
PBMCs at months 0, 3 and 6, and in KS lesions at months 0 and 6 using
real-time
PCR of ORF26.
Results: HHV-8 VLs in plasma, PBMCs and KS tissue were
substantially
higher than those reported for patients co-infected with HIV-1 subtype
B.
Mean pre-treatment values were 32,800 copies per 103 PBMCs, 174 copies
per
ml plasma and 62,500 copies per mg tissue. Seven (47%) patients had
undetectable
HHV-8 DNA in PBMCs at baseline, 1 patient (7%) had undetectable HHV-8
in
plasma and 3 (20%) had undetectable tissue virus. Viral load
decreases/increases
were greatest in PBMCs. Among patients with detectable virus 57%, 29%
and
25% had statistically significant decreases in PBMC VL, plasma VL and
tissue
VL respectively at months 3 and 6.
Conclusions: These preliminary findings suggest that
simultaneous
monitoring of HHV-8 VL in PBMCs and plasma will be most sensitive and
informative
indicators of response to therapy in patients with late-stage
AIDS-related
KS. The PBMC compartment is believed to be the primary reservoir of
lytic
infection and viral dissemination.
Day: Thursday, code: [ThPeA6948]
4. Title:
HIV
Proteomics Resource: combining HIV-1 protein data with bioinformatics
tools.
Authors:
R.S. Doherty (1), T. De Oliveira,
C. Seebregts,
S. Danaviah, M. Gordon, S. Cassol
Affiliations: 1HIV Molecular Virology and
Bioinformatics
Unit Africa Centre, Doris Duke Medical Research Institute, University
of
KwaZulu-Natal, Durban, South Africa; 2Research Information Systems
Division,
South African Medical Research Council, CapeTown, South Africa
Background: Online resources are available for protein information
or
HIV sequence data, but both aspects must be combined in order to answer
important
unresolved questions about HIV-1 pathogenesis, transmission, evolution
and
response to therapy. This is especially true of HIV, due to the
extensive
post-transcriptional modification of HIV gene products. Our objective
was
to develop an online proteomics resource that provides easy access to
information
and unique tools for analyzing HIV protein structure, gene expression,
post-transcriptional/post-translational
modification, functional activity, and protein-macromolecule
interactions.
Methods: HIV gene product information was gathered
from
literature and online sources. Bioinformatics analyses were performed
using
HIV-1 HXB2 as a model system. Structural models were created by using
homology
modelling techniques.
Results: The HIV Proteomics Resource has 5 components:
HIV
proteome, HIV-1 cleavage sites, HIV protein data-mining tool,HIV
structure
BLAST and proteomics tools directory. The HIV proteome section contains
extensive
data on each of the 19 HIV proteins, including functional
characteristics,
sample analyses of HIV-1 HXB2, structural models and links to other
online
resources. The cleavage sites section describes the position and
sequence
of Gag, Pol and Nef cleavage sites in relation to unique
characteristics
of subtype C viruses. The protein data-mining tool allows for sequence
analyses
of 27 HIV-1 M-group isolates (subtype A through K), showing the
influence
of variation between subtypes. The HIV structure BLAST tool takes any
amino
acid sequence and lists similar HIV proteins with experimentally
determined
structures. The proteomics tools directory is a categorized list of
websites
and software relevant to HIV protein sequence/structure analysis.
Conclusions: The HIV Proteomics Resource will
facilitate
the research of scientists and students interested in HIV proteins. It
is
a centralized database of HIV proteins and protein-specific
bioinformatics
tools, easily accessed through the BioAfrica website at:
http://www.bioafrica.net/proteomics
Day: Tuesday, code: [TuPeA4337]
5. Title:
Surveillance of
antiretroviral
drug resistance in a single HIV clinic in KwaZulu-Natal (KZN) South
Africa
Authors:
M. Gordon (1), N. Graham, K. Van
Laethem,
J. Giddy, J. Hampton,
K. Bishop, S. Cassol
Affiliations: 1HIV-1 Molecular Virology and Bioinformatics
Unit,
Africa Centre, Doris Duke Research Institute, University of
KwaZulu-Natal,
Durban, South Africa; 2Rega Institute, Katholieke Universiteit, Leuven,
Belgium;
3Sinikithemba Clinic, McCord's Hospital, Durban, South Africa
Background: Screening for drug resistance is an
important
component of antiretroviral programs. At the patient level, screening
ensures
that each patient receives optimal therapy, avoids the use of
ineffective
drugs, improves long-term outcome and reduces health care costs. At the
population
level, screening of treated patients ensures that drug programs are
being
properly administered and that they remain effective, while screening
of
drug-naive populations provides information on the transmission of
resistant
viruses.
Method: In preparation for the planned roll-out of
antiretroviral
therapy in South Africa, we tested the first 100 sequential patients
receiving
treatment from the Sinikithemba Clinic in Durban. Samples showing
virologic
failure were genotyped using the Viroseq system (ABI). Sequences were
assembled,
translated, phylogenetically subtyped and analyzed for resistance
mutations.
Results: Overall, 18 (18%) patients (including 3
children)
had genotypic evidence of resistance, 16 infected with subtype C and
one
each with subtype A and A/G infection. Of these, 7 were on first-line
therapy
(2 on dual therapy [children]; 5 on HAART). Eleven patients had either
switched
to a more affordable first-line drug combination, or were on
second-line
therapy following treatment failure. The most common resistance
mutations
in order of decreasing frequency were: RT M184V (39%); K103N, V106M and
Y188L/C
(28%); G190A (22%); K70R, A98G, V179D, K101E/Q, L210W/S, L215F/Y,
T69N/A
and K219Q/E (11%); T69I, K70E, V75I, K103S, V106A, Y181C, P225H, F227L
and
G333E (6%). Overall, 83% of patients had multi-NNRTI resistance,
reflecting
the predominant use of NNRTI-based drug regimens. Although our
experience
is limited, HIV-1 C-infected patients failing NNRTIs are still
responsive
to NRTI and protease inhibitors.
Conclusions: These findings suggest that the pattern and level of
resistance
in African patients will be similar to that observed for the treatment
of
subtype B infection.
Day: Wednesday, code: [WePeB5711]
6. Title:
Resistance patterns in
mother-infant
pairs following single dose nevirapine (NVP) for the prevention of
mother-to-child
transmission (MTCT) of HIV-1.
Authors:
N. Graham (1),
M. Gordon,
R. Bland, N. Rollins, M. Claassen, H.M. Coovadia, M. Bennish,
S.
Cassol
Affiliations: 1HIV-1 Molecular Virology and
Bioinformatics
Unit, Africa Centre, Doris Duke Research Institute, University of
KwaZulu-Natal,
Durban, South Africa; 2Africa Centre for Health and Population Studies,
Mtubatuba,
South Africa; 3Tygerberg Hospital, Cape Town, South Africa; 4Centre for
HIV/AIDS
Networking, Nelson R. Mandela School of Medicine, University of
KwaZulu-Natal,
Durban, South Africa
Background: Administration of NVP to HIV-1-infected
women
at the onset of delivery, and to the infant during the first 72 hours
after
birth, is a simple and affordable approach for the prevention of MTCT
in
developing countries. However, there are ongoing concerns about the
development
of drug resistance and its potential impact on subsequent treatment.
Studies
in Uganda have suggested that risk of resistance may depend on viral
subtype.
These data have mainly been reported from populations infected with
clades
A and D.
Methods: We examined NVP resistance patterns in eleven
mother-infant
pairs (including a set of twins) infected with HIV-1 subtype C, who had
participated
in a pMTCT program (012 regimen). HIV-1 RNA was extracted from 6 week
post-partum
dried blood spots using the NASBA system, amplified by RT/PCR and
sequenced
with the Viroseq HIV-1 Resistance Genotyping kit. Subtyping was
performed
by phylogenetic tree analysis.
Results: No resistance mutations were detected in 7
(63.6%)
of 11 mother-child pairs. A single K103N mutation was detected in one
mother,
but not in her infant. In the remaining pairs (n = 3), resistance was
detected
in the infant only. Y181C, the most common mutation, was present in all
4
children. In addition to Y181C, one infant had a K103N mutation, and a
second
infant carried an HIV-1 C-associated M106M mutation. No correlation was
found
between the emergence of resistance in the infant and the mother's
viral
load or CD4+ count.
Conclusions: NVP resistance occurred more frequently
in
infants than in mothers, suggesting that the mutations were acquired
through
de novo viral replication in the infant. These findings, together with
data
from other studies, reinforce the view that although NVP is effective,
affordable
and simple to administer, the search for safer regimens to prevent MTCT
should
be intensified.
Day: Thursday, code: [ThPeB7045]
7. Title:
An automated HIV-1
subtyping
tool.
Authors:
T. de Oliveira (1), M. Salminen,
S.
Cassol, R. Camacho, K. Deforche, D. Pavareskevis, C. Seebregts, J.
Snoeck,
A.M. VanDamme
Affiliations: 1HIV Molecular Virology and
Bioinformatics
Unit, Africa Centre, Doris Duke Research Institute, University of
KwaZulu-Natal,
Durban, South Africa; 2Department of Infectious Disease Epidemiology,
HIV-Laboratory,
National Public Health Institute, Helsinki, Finland; 3Virology
Laboratory,
Hospital Egas Moniz, Lisbon, Portugal; 4Rega Institute for Medical
Research,
Katholieke Universiteit Leuven, Leuven, Belgium; 5Research Information
Systems
Division, South African Medical Research Council, Cape Town, South
Africa
Background: Rapid and easy genetic subtyping of HIV-1
isolates
is critical to understanding genetic evolution, drug resistance, and
the
design of subtype-specific vaccines and antiretroviral drugs. To
facilitate
genetic analysis, we developed a bioinformatics tool that uses
phylogenetic
and bootscanning analyses to determine the subtype of novel nucleotide
sequences,
and reveal the presence of recombination.
Methods: The subtyping process consists of four steps.
The
initial step involves construction of a phylogenetic tree containing
the
query sequence and group M pure subtypes A-D, F-H, J and K, as
references.
The next step, involves construction of a second tree using the query,
HIV-1
pure subtypes, and CRFs sequences. In the third step, the query
sequence
is analysed for recombination using bootscanning using a sliding window
of
400 bps moving in steps fo 50 bps. Finally, in the fourth step, the
alignment
is examined to determine whether it contains sufficient phylogenetic
signal
for subtype determination using Treepuzzle
Results: The output is a report detailing: 1) the
constructed
phylogenetic trees of the different alignments (ie. including, or not
CRFs
sequences), 2) the bootstrap support for the previous trees, 3) a
graphic
image of the bootscanning analysis, and 4) values for the phylogenetic
signal
(and noise). Using this approach, we successfully validated the output
of
the tool by analysing 1,000 HIV-1 published sequences with know HIV-1
subtype.
For both "pure" subtypes and known CRFs, our subtyping results matched
the
published data for >95% of sequences.
Conclusions: These findings indicate that the
automated
HIV-1 subtyping tool is both reliable and accurate. The availability of
this
tool will facilitate HIV-1 subtyping, especially at a large scale
databases,
and in settings where phylogenetic expertise is limited. The tool is
useful,
convenient, easy to use and freely available from the BioAfrica website
(http://www.bioafrica.net).
The program can be downloaded and installed on local computers, or
accessed
directly via the web interface.
Day: Tuesday, code: [TuPeA4377]
8. Title:
HIV-1C subtype in
Southern
Brazil seems to be two times more infectious than HIV-1B.
Authors: M. Salemi (1),
T. de Oliveira, M.A.
Soares,
O.G. Pybus, A.T. Dumans, A. Tanuri, A.M. Vandamme,
S. Cassol,
W.M.
Fitch
Affiliations: 1University of California Irvine, Irvine,
United
States; 2Nelson Mandela School of Medicine, Durban, South Africa;
3Universidade
Federal do Rio de Janeiro, Rio de Janeiro, Brazil; 4University of
Oxford,
Oxford, United Kingdom; 5Universidade do Rio de Janeiro, Rio de
Janeiro,
Brazil; 6Rega Institute for Medical Research, Leuven, Belgium
Background: HIV, the cause of AIDS in humans, is
characterized
by great genetic heterogeneity. In particular, HIV-1 group M subtypes
are
responsible for most of the infections worldwide. It is hypothesized
that
characteristics such as a higher or lower transmissibility and/or
fitness
could explain the success or failure of different subtypes in different
regions,
but no definitive conclusion has been reached so far.
Methods: We investigated the demographic history of
HIV-1B
and HIV-1C subtypes in South Africa and Brazil using both a parametric
and
a nonparametric approach based on coalescent theory, and calculated R0,
the
basic reproductive number (infectivity), for both subtypes.
Results: Both subtypes appear to be spreading
exponentially.
In Brazil, HIV-1C growth rate is about twice as fast as Brazilian
HIV-1B
or South African HIV-1C. By calculating R0 we also show that each
primary
HIV-1C infection in Brazil generates on average 8 secondary infections,
versus
about 4 secondary infections generated by HIV-1B in South Africa and
Brazil.
Conclusions: The present study provides evidence, for
the
first time, of a different epidemic potential between two HIV-1
subtypes,
and it may have important consequences for devising future vaccination
and
therapeutic strategies.
Day: Tuesday, code: [TuPeA4370]
9. Title:
Both HIV-infected and
uninfected
infants of HIV infected mothers have poorer outcomes from Severe
Pneumonia
their Non-HIV Exposed Peers.
Authors: L.M. McNally (1), P.M. Jeena, S.A. Thula,
K.
Gajee, A.W. Sturm, A. Smith,
K. Bishop,
S. Cassol, D.
Goldblatt,
A.M. Tomkins, H.M. Coovadia
Affiliations: 1Institute of Child Health, London,
United
Kingdom; 2Nelson R Mandela School of Medicine, Durban, South Africa;
3Africa
Centre Laboratory, Durban, South Africa
Background: Acute Respiratory Infections are the most
common
cause of both admission and death in HIV infected African children. The
WHO
treatment regimens for severe pneumonia were devised before the HIV
pandemic.
There has been some limited evidence that the uninfected children of
HIV
infected mothers are also at increased risk of respiratory infections.
Methods: Children aged 1 to 59 months admitted to King
Edward
Hospital, Durban with WHO defined (very) severe pneumonia were
enrolled.
Children were treated with high dose benzylpenicillin (200 000
iu/kg/day)
and gentamicin (7.5 mg/kg/day). All infants received high dose
co-trimoxazole.
Children who failed to respond after 48 hours had a second blood
culture
(BC) and either a lung aspirate (LA) or non-bronchoscopic
bronchoalveolar
lavage (BAL). All children had anonymous linked HIV ELISA followed by
HIV
viral load if seropositive.
Results: 362 children were recruited. 70% were under one year. 238
children
were HIV infected, 77 negative and 39 exposed (ELISA positive, viral
load
negative). 40% of children failed to respond by 48 hours to the
treatment
regimen and 16% children died. Both infected and exposed children were
significantly
more likely than their uninfected peers to fail treatment at 48 hours
(OR:2.77,
1.84: p<0.001 respectively), require admission to intensive care (OR
5.57,
4.17 p= 0.01) or die (OR 1.33, 7.14 p < 0.001).
Conclusions: HIV Infected children respond
significantly
less well to WHO Paediatric Severe Pneumonia Therapy than HIV
uninfected
children. However, HIV exposed children are also at an increased risk
of
failing treatment, being admitted to intensive care or dying than
uninfected
children. 78% of the children in this South African cohort were either
infected
or exposed and therefore the WHO guidelines for Acute Severe Pneumonia
in
HIV endemic areas need to be revised.
Day: Tuesday, code: [TuPeB4457]
10.Title:
The Meaning of
Multisectoral
Collaborations to Improve HIV and AIDS Care in Resource-Scarce
Settings:
The South African Enhancing Care Initiative (ECI) Experience.
Authors: R. Pawinski (1), U. Lalloo, K. Mtinjana, L.
Barnabas,
K. Defillipi, T. Moll,
S. Cassol, P. Kocheleff, P.S. Makatini,
B.
Mears, D. Moodley, J. Ramdeen, A. Kay, S. Gruskin, R. Marlink
Affiliations: Harvard School of Public Health,
Boston,
United States
Issues: To develop more effective HIV/AIDS
interventions
globally, multisectoral initiatives offer a unique and highly promising
mechanism.
There is no one single formula that makes this approach effective;
however,
the success of a multisectoral collaboration depends on partners'
ability
to combine their resources in innovative ways in response to their
local
situation.
Description: Work of ECI South Africa characterizes
care
in the context of political challenges. Some team members had
previously
established partnerships and shared similar goals but the potential for
mutual
benefit and the possibility of scaling up antiretrovirals as best
practice
brought members together. This partnership included academia,
government,
NGO/CBO, private sector.
Lessons learned: By coming together as a multisectoral
team,
ECI South Africa benefited from the opportunity offered to
university-based
partners to move their research into practice, for all partners to
achieve
their goals on a larger scale, and for the ability offered to service
providers
to jointly approach funders interested in multisectoral implementation
grants.
Recommendations: Successes in working together come
from
the development of shared goals between team members. Challenges
related
to funding, administrative structure, and team leadership can be
overcome
by readiness to adapt to dynamic changes within the team regarding team
strategies
and changes in vision. This in turn fosters team building and trust
among
members. It is important to be open to power balance changes, and the
potential
need to bring others partners into the team as work develops.
Day: Wednesday, code: [WePeE6769]
11. Title:
Non-Bronchosopic BAL to
diagnose
HIV related acute severe paediatric pneumonia in a resource constrained
setting
Authors: L.M. McNally1, P.M. Jeena, S.A. Thula, M.
Adhikari,
A.W. Sturm, K. Gajee, L. Pillay, A. Smith,
S. Cassol,
K.
Bishop,
H.M. Coovadia, D. Goldblatt, A.M. Tomkins
Affiliations: 1Institute of Child Health, London,
United
Kingdom; 2Nelson R Mandela School of Medicine, Durban, South Africa;
3Inkhosi
Albert Luthuli Hospital, Durban, Durban, South Africa; 4Africa Centre
Laboratory,
Durban, South Africa
Background: Respiratory Infections are the commonest
cause
of morbidity and mortality in HIV infected African children.
Determining
the aetiological agent and thus optimising treatment is difficult. We
report
on our experience using Non-Bronchoscopic Alveolar Lavage (NBBAL) in a
study
to determine the aetiology of HIV related paediatric pneumonia at King
Edward
Hospital, Durban, South Africa.
Methods: Children admitted with WHO defined severe
pneumonia
were recruited and a standard treatment regimen of high dose
benzylpencillin
and gentamicin used. All infants also received high dose
co-trimoxazole.
Routine admission investigations included blood culture, induced sputum
and
nasopharyngeal aspirate. Children who failed to respond and had no
dense
peripleural consolidation proceeded to NBBAL under sedation. Children
were
intubated, positioned and a nasogastric tube inserted down the
endo-tracheal
tube. 1 mL/kg (max 10 mL) saline was instilled. PEEP was applied and
the
saline retrieved using a mucus extractor. Children remained on ICU for
a
minimum of four hours post procedure for continuous monitoring of vital
signs.
All children had a post procedure chest X-Ray.
Results: 97 children had a NBBAL. (76 HIV infected, 9
HIV
exposed. 9 HIV negative, 3 unknown). 33 were ventilated on ICU at time
of
procedure. Of the remaining 64, only 2 required admission to ICU
post-NBBAL
but neither required ventilation. 5% of cases had a complication,
including
mild-moderate pulmonary haemorrhage (4) and worsening oxygenation (2).
No
child had a pneumothorax. A probable aetiological agent was identified
on
NBBAL in 94% of children and was a mixture of bacteria (42), PCP (29),
viruses
(56) and TB (8). Two or more organisms were identified in 61 children.
NBBAL
identified a different or additional pathogen from admission in 77
children.
Conclusions: NBBAL provides a high level of microbial
diagnosis
with low level of risk. It can be recommended as an important tool in
the
diagnosis of HIV associated acute paediatric pneumonia.
Day: Tuesday, code: [TuPeB4455]
