Cleveland Plain Dealer: Cleveland researcher at forefront of pediatric HIV/AIDS work; area lags behi

Cleveland Plain Dealer | October 5, 2010

The Cleveland Plain Dealer published this article addressing pediatric AIDS research and a current study addressing children infected with HIV and correlating heart problems. The Foundation's Vice President of Research, Dr. Laura Guay, M.D., was interviewed about the importance of increasing pediatric studies in HIV and AIDS research.

The National Institutes of Health manages a website that provides a comprehensive list of clinical trials conducted in the United States and around the world. On it are about 4,500 studies devoted to HIV or AIDS.

Less than 6 percent of those studies are pediatric in nature.

As with much medical research, studies devoted to the youngest HIV and AIDS patients lag far behind those focused on the disease in adults.

In 2008, the most recent year for which data is available, more than 9,300 children under age 13 with HIV were living in the United States, according to the Centers for Disease Control and Prevention.

That wasn't even 1 percent of the country's total number of diagnosed AIDS cases.

More than 90 percent of those children contracted the disease from their HIV-positive mother, either before birth or from the mother's breast milk.

Pediatric research in general has always taken a back seat to that of adults. Away from American soil, where the number of children and adolescents with HIV or AIDS has reached epidemic proportions, the discrepancy is even more pronounced.

"Funding for pediatric HIV research has to be fought for," said Dr. Annette Sohn, a pediatrician and vice president for global initiatives and director of TREAT Asia at amfAR, The Foundation for AIDS Research.

"Children with HIV are consistently a second priority to adults -- whether that is in funding for research or development of antiretroviral [medications]," she recently wrote in an email. "Although I have only conducted HIV research in children in Asia, I am certainly aware that funding [in the United States] is not easy."

A researcher at the Pediatric AIDS Clinic at University Hospitals Rainbow Babies & Children's Hospital is conducting what researchers believe is the only study on HIV-infected children and heart problems, for which they are at a higher risk, despite their youth.

Dr. Grace McComsey, Rainbow's chief of Pediatric Infectious Diseases, Rheumatology, and Global Health and professor at Case Western University School of Medicine, is leading the four-year study that is trying to determine the causes of those heart problems.

Advances in the field of pediatric HIV are a double-edged sword for children in the United States who live with the disease, McComsey said.

"There are not a lot of new cases, which is good," she said. "But a few kids are suffering from our success. They are caught in between."

Tracking patients in Ohio

Researchers are tracking 80 children (the youngest is 2, the oldest is 21, the mean age is 9) with HIV. The children, all patients of McComsey at Rainbow, live across Ohio.

At the start of the study they were given blood tests to assess their cholesterol levels, diabetes or pre-diabetes, and to look for markers of inflammation -- a condition that is higher in HIV patients.

"In adults, atherosclerosis [or blockage in heart arteries] is checked with a CT scan," McComsey said. But that test involves too much radiation for it to be routinely used on children safely."

Instead, noninvasive ultrasound is used to measure carotid IMT (intima media thickness) and to tell if there is any buildup of plaque.

"Whatever happens in the neck artery is a reflection of what happens in the heart vessel," she said.

Carotid arteries supply blood to the brain. Cholesterol can develop in the artery lining (the intima and media layers), causing it to thicken and, in turn, to block the flow of blood completely.

The initial study findings show that children with HIV have significantly higher IMT [readings], cholesterol levels and prediabetes than HIV-negative healthy kids.

"All of these cardiovascular risk factors put them at higher risk even though they don't show signs of heart disease, such as chest pain."

The initial data was published in the April issue of the journal Atherosclerosis. Subsequent data will look at following years.

The study, however, also showed that after one year -- in which researchers observed the children but otherwise didn't intervene -- the children's lipid levels improved significantly in HIV positive patients, but not HIV negative patients, McComsey said.

The children's CD4 count, a measure of immune system health, also improved over that one-year period, associated with improvement of IMT.

McComsey credits the positive changes to patients and their parents adopting an improved diet and increasing their activity levels. She stressed that the changes were nothing that researchers prompted, but that parents helped make after becoming more aware of potential cardiovascular risks.

"When you give a consent form to the parents, even without us trying to influence the results of the study, they changed the way [their children] were eating and exercising," she said.

Keeping research separate

Such research is critical at a time where there is a growing feeling that pediatric HIV research be lumped with adult research.

Dr. Laura Guay, vice president for research at the Elizabeth Glaser Pediatric AIDS Foundation, is concerned about what that would bode for children with the disease.

"In the early years [of the epidemic] they were put together and children didn't benefit," said Guay, who worked with McComsey in the 1990's during McComsey's fellowship in pediatrics at Rainbow and CWRU.

"NIH created these pediatric-specific research networks that made huge breakthroughs," she said. "Now the sentiment is that there isn't much to do in the pediatric agenda."

Guay frequently travels to Africa, where the foundation has a strong presence. She recently returned from Zambia, where she has been working with UNICEF on a pilot program to improve the delivery of prepackaged health kits for HIV-positive women to help prevent the transmission of the disease to their unborn children. The kits are currently being used in four African countries.

Pediatric HIV and AIDS continues to be overlooked in the United States, Guay said.

"We hope that in all our activities and groups we work with, that it isn't an either/or," she said about how resources and awareness are allocated around the globe.

The pervasive idea that the disease has been successfully managed in children in the U.S. lulls people into thinking that there is no more work to be done, she said.

"We've made incredible progress, but it's not over," Guay said. "We have to keep working on prevention and supporting all HIV-infected children and adolescents. We can't let that fall by the wayside."

Even internationally, Guay says, "So much focus on vaccine development has been on adults." But providing resources for research into a vaccine for infants only makes sense, especially since it could be easily added to the schedule of other childhood vaccines.

"One day it would be great if you could get your DPT, polio and HIV vaccine and you wouldn't have to worry about it," she said.