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Page 2 of 6 Original Research

Human immunodeficiency virus-related neurological that children had advanced HIV disease, assessed by
manifestations are common in both adults and children. 2,3,4,5,6 WHO staging. 23,24 The eligibility criteria for initiation of ART
They include opportunistic central nervous system (CNS) and the type of first-line regimen for infants and children
infections, behavioural problems and psychiatric disorders, with HIV infection following HIV guidelines changed in
4
as well as neurodevelopmental delay and epilepsy. 2004, 2010, 2013 and 2015. The clinicians in our setting used
25

Epilepsy is a potentially disabling disease whose treatment the appropriate guidelines for the specific year the children
is challenging in sub-Saharan Africa, 7,8,9,10,11,12,13 particularly were firstly seen in the clinics. Since 2014, every child younger
among children with HIV infection, who are often orphaned than 5 years with confirmed HIV infection was eligible for
and have to face poverty. 14 treatment, regardless of his/her clinical (WHO staging) and
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laboratory status (CD4 counts) ; since 2017, all people in
The prevalence of seizures in children with confirmed HIV South Africa with confirmed HIV infection have immediate
infection has been reported to range from 2% to 14%, 9,15,16,17,18 access to ART.
and the prevalence of epilepsy is estimated between 0.29%
and 11.3%. 19,20,21 This wide variation is believed to be a result In our setting, the routine approach to children presenting
of differences of risk factors in different regions. 22
with seizures consists of a detailed clinical history and
Epilepsy in HIV-infected persons may occur as a result of physical examination, including blood pressure, as well as
several different processes: direct viral damage to the brain assessment of blood glucose and, if indicated, antiepileptic
by uncontrolled viral replication; following a CNS infection drug plasma levels. Emergency computed tomography (CT)
by opportunistic pathogens; as a result of malignancies; is performed if the child has new-onset focal seizures,
following the use of some medications; as a result of metabolic encephalopathy or prolonged neurological fallout. In
and electrolyte derangements; or as a secondary acquired children with suspected meningitis, encephalitis or other
pathology because of HIV encephalopathy. 4 inflammations, appropriate serum markers are investigated,
and a lumbar puncture is performed unless contraindicated.
19
Of interest, Bearden et al. argued that earlier initiation of Human immunodeficiency virus testing is offered to all
antiretroviral therapy (ART) might prevent the manifestation children. In children known to be HIV infected, CD4 count
of epilepsy in children with HIV infection. This study was and HIV viral loads (VLs) are assessed.
conducted in Botswana, and there is no other study on record
so far to confirm or challenge these results in a different Cases were identified by screening all available subfiles for
population.
‘epilepsy’ and by interrogating the fixed data fields of an
electronic database, the Paediatric ART Data Management
We describe the prevalence of epilepsy, including associated
neurological disabilities, immunological and clinical status Tool (PADMT), for exposure to antiepileptic drugs.
and history of CNS infection in children with HIV infection Unstructured ‘comments’ fields were hand-searched for
on ART in a mixed rural/urban area in the Eastern Cape. The relevant terms like epilepsy, seizures, fits and szs, paroxysmal
aim is to show that late diagnosis of HIV infection and events, faints or syncope or electroencephalogram (EEG).
delayed initiation of ART in children are linked to higher Eligible subject folders were then retrieved to validate the
rates of epilepsy. digital data.

Material and methods Children with a single seizure or single seizure episode
Setting during acute illness because of metabolic disturbances,
hypertension, neurocysticercosis or infection, or those with
We conducted a retrospective study (2004–2014) at the diagnosis of febrile seizures were excluded from further
two major referral sites for HIV-infected children aged analysis.
0–16 years in the Eastern Cape, South Africa. One centre is
a paediatric and adolescent HIV referral clinic in a tertiary Those children with a diagnosis of epilepsy, as defined
hospital in East London, and the other is the HIV clinic for by Fisher et al., were further assessed for aetiology by
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children and adolescents in the township of Mdantsane, reviewing clinical information, laboratory results, brain
which serves as a major referral centre as well as the local imaging and EEG studies, if available. In epileptic children
health clinic.
diagnosed with HIV encephalopathy with no other clinical,
laboratory or imaging findings, the neurotoxic effect of HIV
The Eastern Cape belongs to one of the most underprivileged
parts of South Africa, and its health service is among the was considered as the cause of epilepsy.
most under-resourced. Together, the two hospitals serve
around 3.5 m people, including more than 890 000 children Human immunodeficiency virus encephalopathy is defined
younger than 15 years (Census 2011 Municipal report). as damage or malfunction of the brain because of HIV
infection. Human immunodeficiency virus encephalopathy
In South Africa, ART became available in state health facilities in children must include at least one of the following findings
from 2004. At this time, the criteria for ART required present for at least 2 months in the absence of a concurrent

http://www.sajhivmed.org.za 407 Open Access