Overall, the incidence of HIV infection in Greece (37.9 incident cases per million inhabitants) is markedly lower than that reported in other Western European countries (76.1 incident cases per million inhabitants) [15
]. The prevalence of HIV infection among pregnant women residing in Greek urban areas (13 per 10,000 women) is approximately half (1.32%) of that reported in other European capitals [8
]. Specifically, among 1517 pregnant women (1250 of Greek origin and 267 of other ethnicities) surveyed during 1999-2000, 2 were HIV positive. Moreover, the cumulative prevalence of mother-to-child HIV transmissions (MTCT) in Greece was 0.5% and is significantly lower than that reported throughout the WHO European Region [6
]. To date, 24 children born with HIV MTCT currently reside in Greece and are registered at the National Referral Centre for Pediatric HIV infection. Of these, 20 children (83.3%) were assessed for the purposes of the present study. According to surveillance data compiled by the Hellenic Centre of Infectious Diseases Control, MTCT is the most frequent (63.76%) transmission route in children aged less than 13 years. Hence, factors associated with low prevalence rates of HIV infection among pregnant women in the specific region, including free access to HIV screening tests during the first trimester of pregnancy and free access to antiretroviral drugs during pregnancy, may have contributed to the low observed levels of pediatric HIV infection in Greece [27
The prevalence of HIV-related neuroimaging abnormalities among vertically infected children with HIV evaluated for the purposes of our study was 25.0%. The observed prevalence of neuroimaging abnormalities is markedly greater than those reported in the scientific literature, ranging between 1.6% and 10% [3
]. Prior to the introduction of HAART, the prevalence of neuroimaging abnormalities among HIV infected children ranged between 35% and 50% [4
]. The introduction of HAART has contributed to the diminishment of such findings [3
]. The elevated prevalence of HIV-related neuroimaging abnormalities among the study population may be attributed to the fact that CNS involvement may be the initial presentation of HIV infection among as many as 18% of pediatric HIV patients [7
With regard to the presence of perinatal risk factors for impaired cognitive development, the study findings indicated that HIV infected children both with and without neuroimaging abnormalities were as likely as controls to have experienced either premature birth and/or low birth-weight. In contrast, both case groups were more likely to have experienced hypoxia at birth as compared to controls. Although the potential detrimental effects of hypoxia at birth upon consequent childhood development among otherwise healthy neonates have been extensively documented, there exists limited evidence regarding similar effects among neonates with HIV infection [30
The study findings indicated that only 40.0% of patients without neuroimaging abnormalities had a general IQ score within normal range. Moreover, none of the patients without neuroimaging abnormalities had a General IQ score indicative of severe mental retardation. No statistically significant difference was observed between the Verbal and the Practical IQ scores of HIV patients without neuroimaging abnormalities as compared to their healthy peers. Hence, vertically infected children without neuroimaging abnormalities receiving HAART were observed to have a global intelligence analogous to non-infected children. The study findings are in agreement with those established in the literature [30
]. Elevated rates of moderate and severe cognitive impairment among children with HIV have been reported [8
] but are attributed to the lack or limited administration of HAART among the children examined [4
Due to the structural, and consequent functional, alterations inherent in the central nervous system, the effects of HIV-related CNS involvement upon children's cognitive development have been documented [4
]. In the present study, among children with HIV and concomitant neuroimaging abnormalities, none had a General, Practical, and/or Verbal IQ score within the normal range. Moreover, two fifths of the patients in this group had a General IQ score indicative of severe mental retardation. Thus, despite the administration of HAART, children with HIV who presented with neuroimaging abnormalities were observed to have severe deficits in cognitive function as compared to non-infected children.
With respect to the emotional and social skills of HIV infected children, neither those children with nor without neuroimaging abnormalities had SDQ scores indicative of abnormal overall psychosocial maladjustment. This is in agreement with similar findings in the literature [33
]. Moreover, patients without neuroimaging abnormalities were significantly more likely to have abnormal Emotional and Hyperactivity scores as compared to their healthy peers. Even so, among patients without neuroimaging abnormalities, neither their emotional nor their social skills were affected. These findings, though, may be partly attributed to the fact that patients had not been disclosed of their specific health condition prior to the time of assessment.
In contrast, children with HIV who presented with neuroimaging abnormalities had an elevated frequency of Abnormal Peer Problems, as compared to their healthy counterparts. However, while the social skills of patients with neuroimaging abnormalities were compromised, their emotional adjustment was similar to that of their healthy peers. The impaired verbal skills of children with HIV who presented with neuroimaging abnormalities may lead to compromised communication skills and consequent impaired peer relations [34
]. As a result, such impaired functions may be attributed multilaterally to both impaired cognitive and verbal skills.
This study provides evidence suggesting that vertically infected children with HIV receiving HAART are observed to have an increased risk for poor cognitive outcome solely if they present with HIV-related neuroimaging abnormalities. As compared to their healthy peers, pediatric patients without neuroimaging abnormalities are more likely to experience maladjustment with respect to their emotional and activity spheres, while children with HIV who present with neuroimaging abnormalities are more likely to have compromised social skills. The observed normal scores regarding emotional adjustment and social parameters could be attributed either to the fact that systematic psychological and social support is provided by the national health services, or to the fact that all cognitive, emotional, and social skills assessments took place prior to the disclosure of HIV infection among the population examined.
Children who are unable to master adaptive strategies for emotional self-regulation at early ages demonstrate numerous problematic outcomes, including impaired social competence and delayed externalization of problems during late adulthood [35
]. The present study findings indicating that pediatric HIV patients have an increased likelihood of abnormal emotional and hyperactivity scores may be indicative of a potentially elevated risk for impaired social skills in adulthood, particularly following the additional emotional distress inherently imposed following the disclosure of patients' disease status. As a result, it is recommended that the assessment of both the emotional and social skills of pediatric HIV patients should be undertaken prior to disclosure in order to efficaciously address the further development of either emotional and/or social maladjustment [38
The strengths of the study include its contribution to the related scientific literature regarding the concomitant assessment of cognitive, emotional, and social function among children with HIV according to the occurrence of HIV-related neuroimaging abnormalities, following HAART. Moreover, while the study population reflects in excess of 83% of all pediatric HIV patients reported in Greece, its limited size may inhibit the generalization of the study findings to larger cohorts, particularly of older age. Due to the cross-sectional study design, the limitations of the study include the inability to establish an etiological relationship between HIV-related neuroimaging abnormalities and impaired cognitive and psychosocial development among pediatric HIV patients receiving HAART. A longitudinal study is necessary in order to assess whether the emotional and psychosocial characteristics of pediatric HIV patients in adulthood may vary, independently of HIV-related neuroimaging abnormalities, following the disclosure of their condition, initiation of sexual relationships, and consequent lifestyle changes.