October 5, 2010

A conversation with Dr. Grace McComsey, Rainbow Babies pediatric HIV/AIDS researcher

Published: Tuesday, October 05, 2010, 4:00 AM Updated: Tuesday, October 05, 2010, 6:32 AM

Angela Townsend, The Plain Dealer

A Q&A with Dr. Grace McComsey, chief Pediatric Infectious Diseases, Rheumatology, and Global Health at University Hospitals Rainbow Babies & Children's Hospital.

What is the life expectancy of a child born with HIV/AIDS?

The answer is not known. It's still short of the normal population because of co-morbidities like heart disease, liver disease, kidney disease. Any patient who is compliant with treatments is expected to live [a relatively normal life expectancy.] But the two big co-morbidities are heart disease and cancers.

Is HIV preventable in unborn babies?

Yes. Pediatric HIV is 100 percent preventable. That's why screening is so important. If a mother takes her medications and complies with treatment, yes.

What is the status of HIV studies involving children?

Any research of kids and HIV always lags behind adults.

For cardiovascular disease, my group tried to get ahead of the curve. Initially, we had a hard time getting funding [because of] all of this skepticism of the cardiovascular disease risk in kids. But we've already generated several papers and we've really changed the mentality of doctors treating patients.

Is there really a cardiovascular risk in children?

The youngest person [at Rainbow] who had a heart attack was a 24-year-old with HIV. It's true that a 10- or 15-year-old is not having a heart attack, but a 24-year-old with no risk factor had a huge heart attack. This was 4-5 years ago. At that time, we were not as aware as we are now.

Who are the pediatric HIV patients in your study? [Note: McComsey is leading a four-year study that is trying to determine the causes of heart problems in HIV-positive children].

All but one was born with HIV. They all started medication early on. They average [nine years of taking medication] by the time the study started.

Their viral loads are very low. They are doing well from an HIV point of view.

Their CD4 count (the number of CD4 cells a blood sample; the higher the number, the better one's immune system is able to fight off the disease) is very good. This is a good population, a compliant population. No opportunistic infections.

A lot of (the patients) were obese. People have worried so much about wasting that now they don't watch what they eat. They're at the other extreme now.

[Note: Wasting is a condition marked in AIDS patients by the loss of at least 10 percent of one's body weight, and/or severe diarrhea, weakness and fever.]

What have been some of the medical gains in diagnosing and treating newborns and babies?

The diagnosis used to be that you can't really rule out HIV until the child is 18 months of age. You could carry the antibody and [not have it show up] until 18 months. Now we can diagnose by 3 months. I can tell 100 percent if they have it or not when they are born with a blood test when they're born, another blood test at 1 month and a third test at 3 months.

[Note: HIV testing at birth is not done automatically. Parental consent must be provided before the test can be administered.]

Is there a typical regimen of drugs for kids?

There are three different medications, sometimes four, to start. They have to take them twice a day, in contrast with adults who could take one pill, once a day.

At Rainbow, the youngest kid in the study was treated at 9 days old, as soon as he was diagnosed with HIV. You don't want the immune system to take a hit. We can give them oral medications through a tube.

How does treating children differ from treating adults?

Taking care of HIV-infected kids is harder. There are very few drugs in suspension (liquid) form. Domestically, they're not available. All of the money for pediatric HIV [care] is going overseas. We still have a domestic issue.

How do the drugs and the HIV itself impact other areas of health in children?

The long term complications of HIV treatment in kids and adults include lipodystrophy (an abnormal change in body composition with either fat loss or fat build up) due to old medications such as AZT. It also causes mitochondrial toxicity (damage that decreases the number of mitochondria, which provide the body's cells with energy) which is shown to increase depression and decrease quality of life.

Kids stop taking their meds because of lipodystrophy. These meds are keeping them alive but there are complications. In adults we're using newer drugs but in kids we are obligated to use the older drugs.

Tenofovir has really replaced AZT but it does not come in suspension form for kids.

How did you get into this field?

I trained at Case in infectious diseases at a time when we had a lot of sick HIV patients. During my training we lost five HIV kids. Sometimes some cases really hit you. One was a 10-year-old, so cute! I just saw him wasting and wasting, and then dying. He was a hemophiliac and got it through a blood transfusion. It just broke my heart.

HIV is really my passion. I wanted to make a difference. That's why I got into that field.

-- Angela Townsend


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