As maternal CD4+ cell counts were only recorded routinely in participating centres since 1995, there was a limited subset [24 of 161 (15%)] of mothers with available measurements at delivery and multivariable analysis was thus not possible. In univariable analysis a log increase in maternal CD4+ count was compatible with a 75% reduction in risk of progression for the child (P = 0.171).
Gender- and race-specific effects of clinical and immunological markers
In analyses of models including terms representing interactions of gender and race with each of the clinical and immunological measurements, effects on disease progression of early immunological markers and clinical indicators were not modified by gender or race (P > 0.3, all tests for gender, P > 0.5, all tests for race). In the subset of 22 children who had not progressed to serious disease or death by age 2 years and had available CD4+ measurements at that age, a CD4+ count below 500 × 106 cells/l at age 2 years was associated with a greater risk of clinical progression for boys than for girls although the difference was not statistically significant. [hazard ratio (HR) = 3.65 and 2.62, respectively, P = 0.521]. A CD4+ percentage of less than 15% was associated with greater progression risk in black children than white, but again, not statistically significantly so (HR = 8.88 and 1.31, respectively, P = 0.213).
Simultaneous predictive value of early clinical and immunological variables
In multivariable analysis allowing for ART (Table 2), children with a first CD4+ percentage below 20% had nearly a three-fold increased risk of progression to serious disease or death compared with those with a value above 20% (P = 0.041). A log (ten-fold) increase in first AL count independently reduced risk of progression by 77% (P = 0.014) and lymphadenopathy at two or more visits within the first 6 months of life increased risk by 88% (P = 0.045). A CD4+ percentage above or below 20% was substantially more predictive of disease progression than AL count or lymphadenopathy (deviance differences = 81.4, 5.2 and 3.2, respectively). For example, keeping other variables constant [no early persistent lymphadenopathy and an AL count of 6000 cells (3.78 in log units), say] and accounting for treatment, compared with a child with an early CD4+ percentage above 20% (with a risk of progression by age 5 years of 25%), one with a CD4+ percentage value below 20% were 2.79 times more likely to progress (with a risk of progression by age 5 years of 70% (2.79 × 25%). Hepatomegaly (HR = 1.885; P = 0.035; Model χ2 = 17.32; P = 0.0039) and lymphadenopathy had similar and interchangeable, but not independent predictive effects. Allowing for trimethoprine sulfamethoxazol Pneumoncystis carinii pneumonia (PCP) prophylaxis and for the use of intravenous immunoglobulin before disease progression did not significantly alter estimates.
Threshold for CD4+ percentage
Using all clinical status and CD4+ percentage data beyond 6 months of age, classification tree analysis was used to investigate the optimal value for splitting the CD4+ percentage measurements into two groups in terms of predicting subsequent disease progression. At any age, the threshold value of 10% for CD4+ percentage (HR = 4.83; 95% CI, 2.63–8.86; P < 0.0001) was found to best predict progression to serious disease or death.
Of the 65 children who progressed to serious disease or died, 28 (43%) did so within the first year of life. The majority (19 of 28, 68%) had opportunistic infections, mostly PCP (12 of 19, 63%); four had encephalopathy; two serious bacterial infections and the remaining three died at home probably of an undiagnosed opportunistic infection. The predictive value of a log increase in first CD4+ cell count was significant and reduced rapid progression risk by 89% (HR = 0.11; 95% CI, 0.02–0.71; P = 0.021); a first CD4+ percentage below 20% was associated with a four-fold increase in risk (HR = 4.16; 95% CI, 1.66–10.39; P = 0.002). The reduction in risk of rapid progression with a log increase in first AL measurement was 81% (HR = 0.19; 95% CI, 0.04–0.87; P = 0.003). Prematurity was not associated with rapid disease progression (P = 0.813). In a multivariable model also including ART, first CD4+ percentage below 20% and log AL count were independently predictive of rapid disease progression or death ( HR = 6.62; 95% CI, 2.35–18.66; P < 0.001 and HR = 0.11; 95% CI, 0.39–98, P = 0.012, respectively). Neither gender nor race modified effects of any early laboratory or clinical markers. Adjusting for TMP-SMX and intravenous immunoglobulin prophylaxis did not alter risk estimates.
Progression to serious disease after 1 year of age
The remaining 37(57%) children progressed to serious disease after age 1 year: 10 (27%) with encephalopathy, nine (24%) with serious recurrent bacterial infections, 13 (35%) with opportunistic infections (only three of which were PCP); four with another C-defining illness and one died of unspecified HIV-related causes. In univariable analysis, early persistent hepatomegaly (HR = 2.22; 95% CI, 1.11–4.46; P = 0.024) and early persistent lymphadenopathy (HR = 2.16; 95% CI, 1.01–4.61; P = 0.048) were associated with progression beyond the first year. Severe prematurity was marginally associated with late disease progression (HR = 2.24; 95% CI, 0.91–5.54; P = 0.080). In multivariable analysis, adjusting for ART, persistent hepatomegaly (HR = 2.15; 95% CI, 1.03–4.47; P = 0.040) was the single significant independent indicator of disease progression after age 1 year. Separately, persistent lymphadeopathy was associated with a doubled, but not statistically significant risk (HR = 2.01; 95% CI, 0.90–4.46; P = 0.087). Adjustment for TMP-SMX and IVIG did not impact on estimates.
In this cohort of children born and followed up in Europe, early life measures of CD4+ percentage below 20% and a ten-fold increase in AL counts were independently associated with clinical progression throughout childhood, and with rapid disease progression or death within the first year of life. Early persistence of lympadenopathy and hepatomegaly additionally predicted subsequent overall progression to serious disease and progression beyond 1 year of life, but not rapid progression. CD4+ percentage was more informative than any other laboratory or clinical indicator. However, for a given value of clinical or immunological marker early in life or around age 2 years, disease progression did not differ by gender or race. Less than half of this cohort received combination therapy before disease progression, but differentiating between double and other combination therapies in the treatment adjustment had no bearing on the results (data not shown). With adjustment for ART, results inform knowledge about underlying mechanisms of vertically-acquired disease progression and thus remain relevant in the HAART era.
These findings enhance previous work addressing the prognostic value of early markers of disease progression and death in the early years in life. However, earlier studies used measurements relatively close to progression [13,14], or cross-sectional data from clinical trials [15–17]. Studies with longitudinal data from birth have been limited to shorter follow-up [3,18,19], have focused on limited laboratory determinations [2,20–23] or have involved too few children to draw reliable conclusions . Whether predictive values of given markers vary by gender or race has not been previously explored. We have been able to consider an extensive period of follow-up, providing a largely natural account of both short- and long-term paediatric disease progression and predictors.
Although clinical evidence of infection in the first 6 months of life, such as lymphadenopathy and hepatomegaly, are not associated with subsequent rapid progression before age 1 year, they are predictive of long-term prognosis. Hepatomegaly was the only factor associated with disease progression beyond age 1 year when assessed separately. These findings appear to contradict those of Rich et al  who found early presence of lymphadenopathy, hepatomegaly or splenomegaly with CD4+ percentage predicted rapid progression. However, their approach differed methodologically: first, rapid progression was defined as occurring during the first 6 months of life only; second, clinical progression preceding laboratory determinations in some children was nonetheless included and third, their statistical methods involved only logistic models with presence or absence of progression as a binary response. That early immunological factors were predictive of progression before 1 year of age but not beyond in our cohort is consistent with earlier observations of levels reflecting current status more than long-term survival and wellbeing .
We recently described significant differences in immunological patterns over 12 years by gender and race . However, these differences were small in the first year, which agrees with our findings here that effects of early life markers on overall disease progression are not dependent on gender or race. Despite the magnitude of differences in immunological patterns becoming larger as children get older , we did not find gender differences in progression for a given CD4+ count or race differences in progression for a given CD4+ percentage at age 2 years. This may have been due to small numbers.
A CD4+ percentage cut-off of 10% best identified the risk of disease progression beyond 6 months of age, which is lower than the 15% threshold in the CDC categories below which children are classified as severely immunosuppressed . The CDC clinical and immunological classification systems have been shown to be in poor agreement [1,25]. The high degree of overlap in lymphocyte measurements in uninfected and infected children  could explain the necessity for more extreme limits in predicting serious progression.
Because of limited numbers of infected children and of mothers with relevant data, we were unable to investigate effects of other factors possibly associated with disease progression in vertically infected children such as maternal ART use [5,20,26], timing of transmission , p24 antigen , maternal viral load [2,27], and vitamin A . Our findings of higher maternal CD4+ lymphocytes associated with lower risk of disease progression, although not significant, are compatible with findings of others [2,28].
We were also unable to assess the child's HIV RNA viral load as a marker for disease progression directly here, but the association between clinical indicators such as lymphadenopathy and hepatomegaly and viral activity indicates that early viral load measurements, when available, would be useful prognostic indicators, as has been shown by others [3,17,19]. It has been suggested that virus load is the optimal predictor of paediatric HIV progression , however, the relative stability of immunological markers, especially CD4+ percentage, compared to the highly variable HIV RNA viral load levels , may make them as clinically relevant in predicting serious disease progression. We were unable to confirm an association of either overall or rapid disease progression with prematurity  which could be due to small numbers of infants born very prematurely.
The findings here and elsewhere [29–31] imply that in the absence of specific CD4+ cell assays, AL measurements alone would provide sufficient insight to inform management of individual children after the first few months of life, which could be particularly relevant in less developed countries where laboratory resources may be limited.
Generally in this cohort, early progression was due to opportunistic infections whereas progression later in life was more dominated by encephalopathy and bacterially-related illnesses. Our findings indicate that CD4+ percentages and AL counts could inform prevention management of PCP and similar morbidities, whereas occurrence of early persistent hepatomegaly could alert the need for measures to prevent bacterial infections and encephalopathy. This is in line with findings from an American birth cohort study which suggested encephalopathy was more likely following development of early symptoms of HIV .
This extension of knowledge about the associations of early-life clinical and immunological factors with rapid and long-term progression to serious disease or death informs the understanding of the dynamics of vertically-acquired HIV infection.
We gratefully acknowledge the support from Mrs L. Toxtle and Dr Simona Fiore (London). We thank Professor L. Chieco-Bianchi, Professor F. Zacchello, Dr A. Mazza, Dr E. Ruga, Dr A. Laverda, Dr A.M. Del Mistro, and Mrs S. Oletto (Padua); Dr C. Feiterna, and Dr Ralf Weigel (Berlin); Dr S. Burns, Dr N. Hallam, Dr P.L. Yap, and Dr J. Whitelaw (Edinburgh); Dra B. Sancho, and Dr G. Fontan-Casanego (Madrid); Dr A. Gonzalez Molina, Dr M. Gobernado, Dr J.L. Lopez, and Dr J. Cordoba (Valencia); A. van der Plas (Amsterdam); Dr B. Christensson, Dr P. Bolme, Dr U. Ewald (Sweden); Dr G. Di Siena, Professor M.F. Pantarotto, G. Mantero, and Dr P. Dignetti, Dr M. Camera, Dr R. Rosso, Dr B. Ciravegna (Genoa); and Dr A. Hottard, Dr M. Poncin, Dr S. Sprecher, Dr B. Lejeune, Dr G. Zississ, and Professor N. Clumeck (Brussels), Dr M. Guxens, Dr P. Martinez (Barcelona); Dr S. Pisa, Dr B. Martinez de Tejada, Dr L. Zamora, (Barcelona); Dr M. Casellas Caro (Barcelona); Dr Y. Canet (Barcelona); Dr G. Zucotti (Milan); Dr M. Carla Re, Dr V. Venturi (Bologna); Dr C. Christini, Dr F. Castelli, Dr A. Rodella, Dr E. Prati, Professor. MÒ Duse (Brescia); Dr G. Scaravelli, Dr M. Stegagno (Rome); Dr I. Quinti, Professor A. Pachí (Rome); Dr G. Noia (Rome); Dr M. De Santis (Rome); Professor P.A. Tovo, Dr C. Gabiano, Dr N. Ziarati (Turin); Dr A.E. Semprini (Milan), Dr F. Ravagni Probizer (Pavia); Dr G. Ferraris, Dr A. Bucceri (Milan); Dr L. Rancilio (Milan); Dr J. Jimenez (Madrid); Dr A. Horban (Warsaw); Dr E. Pagliaro, Dr M.T. Melisi (Naples), The Regional Health Office and RePuNaRC (Naples).
Sponsorship: The European Collaborative Study is a concerted action of the European Commission (Biomed II PL 97 2005 and QLK2-CT-2000-00002). The Medical Research Council (UK) provides support to the co-ordinating centre. Collaborating centres were supported at various times by grants from the Ministero della Sanita - Istituto Superiore di Sanita, Progetto AIDS (Padua, Genoa); the Medical Research Council (UK), the AIDS Virus Education Research Trust, the Scottish Office Home and Health Department (Edinburgh); Praeventiefonds No. 28-1704 (Amsterdam); Bundesminister fur Gesundheit (Berlin); Fonds Houtman, Office de la Naissance et de L'Enfance, Communaute Francaise de Belgique (Brussels); and the Reserch Foundations of Karolinska Institutet (Stockholm).
1. European-Collaborative-Study, Gray L, Newell ML, Thorne C, Peckham C, Levy J. Fluctuations in symptoms in human immunodeficiency virus-infected children: the first 10 years of life.Pediatrics
2. Women and Infants Transmission Study Group, Rich K, Fowler MG, Mofenson LM, Abboud R, Pitt J, et al
. Maternal and infant factors predicting disease progression in human immunodeficiency virus type 1-infected infants.Pediatrics
3. Women and Infants Transmission Study Group, Kalish LA, McIntosh K, Read JS, Diaz C, Landesman SH, et al
. Evaluation of human immunodeficiency virus (HIV) type 1 load, CD4 T cell level, and clinical class as time-fixed and time-varying markers of disease progression in HIV-1-infected children.J Infect Dis
4. European Collaborative Study. Children born to women with HIV-1 infection: natural history and risk of transmission.Lancet
5. de-Souza RS, Gomez-Marin O, Scott GB, Guasti S, O'Sullivan MJ, Oliveira RH, et al
. Effect of prenatal zidovudine on disease progression in perinatally HIV-1-infected infants.J Acquir Immune Defic Syndr
6. European Collaborative Study. Are there gender and race differences in cellular immunity patterns over age in infected and uninfected children born to HIV-infected women?.J Acquir Immune Defic Syndr
7. European Collaborative Study. Level and pattern of HIV-1-RNA viral load over age: differences between girls and boys?AIDS
8. Morris CR, Araba-Owoyele L, Spector SA, Maldonado YA. Disease patterns and survival after acquired immunodeficiency syndrome diagnosis in human immunodeficiency virus-infected children.Pediatr Infect Dis J
9. European Collaborative Study. HIV-infected pregnant women and vertical transmission in Europe since 1986.AIDS
10. Centers For Disease Control. 1994 Revised classification system for human immunodeficiency virus infection in children less than 13 years of age.MMWR
11. Andersen P, Gill R. Cox's regression model for counting processes, a large sample study.Ann Stat
12. Breiman L., Friedman J.H., Olshen R.A., Stone CJ. Classification and Regression Trees
. Monterey: Wadsworth and Brooks/Cole, 1984.
13. HIV Paediatric Prognostic Markers Collaborative Study Group. Short-term risk of disease progression in HIV-1 infected children receiving no antiretroviral therapy or zidovudine monotherapy: a meta-analysis.Lancet
14. CASCADE Collaboration. Short-term risk of AIDS according to the current CD4 count and viral load in antiretroviral naive individuals and those treated in the monotherapy era.AIDS
15. Palumbo PE, Raskino C, Fiscus S, Pahwa S, Fowler MG, Spector SA, et al
. Predictive value of quantitative plasma HIV RNA and CD4+ lymphocyte count in HIV-infected infants and children.JAMA
16. Dickover RE, Dillon M, Gillette SG, Deveikis A, Keller M, Plaeger-Marshall S, et al
. Rapid increases in load of human immunodeficiency virus correlate with early disease progression and loss of CD4 cells in vertically infected infants.J Infect Dis
17. Mofenson LM, Harris DR, Rich K, Meyer WA, Read JS, Moye JJ, et al
. Serum HIV-1 p24 antibody, HIV-1 RNA copy number and CD4 lymphocyte percentage are independently associated with risk of mortality in HIV-1-infected children. National Institute of Child Health and Human Development Intravenous Immunoglobulin Clinical Trial Study Group.AIDS
18. Tetali S, Bakshi S, Than S, Pahwa S, Abrams E, Romano J, et al
. Plasma virus load evaluation in relation to disease progression in HIV-infected children.AIDS Res Hum Retroviruses
19. Abrams EJ, Weedon J, Steketee RW, Lambert G, Bamji M, Brown T, et al
. Association of human immunodeficiency virus (HIV) load early in life with disease progression among HIV-infected infants. New York City Perinatal HIV Transmission Collaborative Study Group.J Infect Dis
20. Kuhn L, Abrams EJ, Weedon J, Lambert G, Schoenbaum EE, Nesheim SR, et al
. Disease progression and early viral dynamics in human immunodeficiency virus-infected children exposed to zidovudine during prenatal and perinatal periods.J Infect Dis
21. Women and Infants Transmission Study Group, Shearer WT, Quinn TC, LaRussa P, Lew JF, Mofenson L. et al
. Viral load and disease progression in infants infected with human immunodeficiency virus type 1.N Engl J Med
22. Salvatori F, Masiero S, Giaquinto C, Wade CM, Brown AJ, Chieco-Bianchi L, et al
. Evolution of human immunodeficiency virus type 1 in perinatally infected infants with rapid and slow progression to disease.J Virol
23. Dickover RE, Dillon M, Leung KM, Krogstad P, Plaeger S, Kwok S, et al
. Early prognostic indicators in primary perinatal human immunodeficiency virus type 1 infection: importance of viral RNA and the timing of transmission on long-term outcome.J Infect Dis
24. Hall AJ, Yee LJ, Thomas SL. Life course epidemiology and infectious diseases.Int J Epidemiol
25. The French Pediatric HIV Infection Study Group and European Collaborative Study, Blanche S, Newell ML, Mayaux MJ, Dunn DT, Teglas JP, et al
. Morbidity and mortality in European children vertically infected by HIV-1.J Acquir Immune Defic Syndr Hum Retrovirol
26. The Italian register for HIV Infection in Children. Rapid disease progression in HIV-1 perinatally infected children born to mothers receiving zidovudine monotherapy during pregnancy.AIDS
27. New York City Perinatal HIV Transmission Collaborative Study Group, Lambert G, Thea DM, Pliner V, Steketee RW, Abrams EJ, et al
. Effect of maternal CD4+ cell count, acquired immunodeficiency syndrome, and viral load on disease progression in infants with perinatally acquired human immunodeficiency virus type 1 infection.J Pediatr
28. Diaz C, Hanson C, Cooper ER, Read JS, Watson J, Mendez HA, et al
. Disease progression in a cohort of infants with vertically acquired HIV infection observed from birth: the Women and Infants Transmission Study (WITS).J Acquir Immune Defic Syndr Hum Retrovirol
29. Kumarasamy N, Mahajan AP, Flanigan TP, Hemalatha R, Mayer KH, Carpenter CC, et al
. Total lymphocyte count (TLC) is a useful tool for the timing of opportunistic infection prophylaxis in India and other resource-constrained countries.J Acquir Immune Defic Syndr
30. Mofenson L, Harris DR, Bethel J, Moye J, Read J, Meyer W, et al
. Second tier surrogate markers for use in resource-limited settings: association of total lymphocyte count and immune-complex dissociated p24 antigen with mortality in HIV-infected children.Tenth Conference on Retroviruses and Opportunistic Infections
, Boston, February 2003.
31. Badri M, Wood R. Usefulness of total lymphocyte count in monitoring highly active antiretroviral therapy in resource-limited settings.AIDS
32. Women and Infants Transmission Study Group, Cooper ER, Hanson C, Diaz C, Mendez H, Abboud R, et al
. Encephalopathy and progression of human immunodeficiency virus disease in a cohort of children with perinatally acquired human immunodeficiency virus infection.
Women and Infants Transmission Study Group. J Pediatr
Dr C. Giaquinto, Dr O. Rampon, Dr F. Ebo, Professor R. D'Elia and Professor A. De Rossi (Universita degli Studi di Padova, Italy); Prof I. Grosch-Wörner (Charite Virchow-Klinikum, Berlin, Germany); Dr J. Mok (Royal Hospital for Sick Children, Edinburgh); Dr I. Bates, Dr I. de José, Dr F. Hawkins, Dr M.C. Garcia-Rodriguez, Dr C. Ladrón de Guevara, Dr J.Ma. Peña, Dr J. Gonzalez Garcia and Dr J.R. Arribas Lopez (Hospital Infantil La Paz, Madrid); Professor F. Asensi-Botet, Dr M.C. Otero, Dr D. Pérez-Tamarit, Dr A. Orti, Dr M.J. San Miguel and Dr R. de la Torre (Hospital La Fe, Valencia, Spain); Dr H.J. Scherpbier, M.E. Kreyenbroek and Dr K. Boer, Ms A. Hes (Academisch Medisch Centrum, Amsterdam, The Netherlands); Dr A.B. Bohlin, Dr E. Belfrage, Dr L. Navér, Dr S. Lindgren (Huddinge and Karolinska University Hospitals, Sweden); Professor J. Levy, Dr P. Barlow, Dr M. Hainaut, Dr A. Peltier, Dr S. Wibaut, Dr G. Debruyne (Hospital St Pierre, Brussels, Belgium); Dr A. Ferrazin and Professor D. Bassetti, (Department of Infectious Diseases, University of Genoa, Italy); Dr A. De Maria (Department of Internal Medicine, University of Genoa, Italy) Dr C. Gotta (Department of Obstetrics and Gynecology–Neonatology Unit, University of Genoa, Italy); Dr A. Mûr, Dr A. Payà, Dr M. Viñolas, Dr M.A. López-Vilchez, Dr M. Rovira, Dr R. Carreras, Dr E. Esteban Tores, Dr S. Herrero Perez (Hospital del Mar, Universidad Autonoma, Barcelona, Spain); Dr N. H. Valerius (Hvidovre Hospital, Denmark)); Dr T. Niemieç and Dr M. Marczynska (Centrum Diagnostyki I Terapii AIDS, Warsaw, Poland).
Keywords:© 2004 Lippincott Williams & Wilkins, Inc.
paediatric; determinants; disease progression; gender; race; vertically-acquired infection; Europe