HIV INFECTION IN CHILDREN

HIV infection is now a common problem in children.

Means of transmission

  1. The majority of children acquire the infection from the mother either during pregnancy or delivery or
    through breastfeeding (mother to child transmission)
  2. A few are infected sexually through rape
  3. Fewer through blood transfusion.

The rate of progression of HIV children once infection has occurred is in two forms:

  • One form progresses rapidly and the patients die within 2 years from birth (these are termed rapid progressors)
  • The other form progress slowly over a few to several years before becoming symptomatic (these are termed slow progressors).

PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT)

Without intervention, 20–45% of mothers infected with HIV transmit the infection to their babies.
However, appropriate intervention can reduce HIV transmission from mother to child to 5% or even less
Prevention of HIV/AIDS centres around:

  • Diagnosis of infection in the parents: Routine testing of all parents is recommended.
  • Good quality obstetric care:
  • Ensuring adequate maternal nutrition in pregnancy.
  • Staging the degree of immunosupression for pregnant women so that those with a CD4 count of <350 or in clinical stage 3 or 4 are started HAART; this is important for their own health and that of the foetus.
  • Avoiding prolonged rupture of membranes (>4 hours).
  • Ensuring a clean, a traumatic delivery.
  • Giving mother ARV during pregnancy and/or labour, and postnatally to the baby. The drugs currently in use are zidovudine and nevirapine. It is important to use the currently recommended ARVs.
  • Counselling on feeding options for the baby. Counselling is best done antenatally to allow parents to choose the best option according to their socioeconomic situation and other social factors.

FEEDING OPTIONS FOR HIV INFECTED

WOMEN EXCLUSIVE BREASTFEEDING FOR 6 MONTHS

In this method of feeding;

  • Seropositive mothers breastfeed their babies exclusively for 6 months.
  • Then the baby is tested for HIV infection using PCR if possible.
  • If the baby is not infected, advise the mother to wean the baby over several days.
  • The baby can then get other types of milk with complementary feeding.
  • If the baby is infected, she can continue breastfeeding together with complementary foods.
  • If a mother stops breastfeeding and cannot afford any other milk for her baby after 6 months it will be necessary to teach her how to heat treat her breast milk.
    Otherwise the baby will develop malnutrition

    REPLACEMENT FEEDING

  • This refers to mothers who are not breastfeeding but using another type of milk exclusively for 6 months and introducing other feeds at 6 months while continuing the milk.
  • The present WHO recommendation is that when replacement feeding is acceptable, feasible, affordable, sustainable, and safe (AFASS), then mothers should avoid breastfeeding.
  • If this is not possible mothers should be counselled on how to safely breastfeed.
  • Recent studies from Africa, however, indicate that replacement feeding is associated with increased morbidity and mortality even when formula milk is provided by the government. In light of findings from these studies, it appears that it is in the best interest of child and their survival to breastfeed rather than use formula milk.
  • All mothers should be counselled to avoid mixed feeding, i.e., combining breast milk with other milks, liquids, or food unless they heat treat the breast milk.

CARE OF HIV EXPOSED INFANTS

Care of an infant exposed to HIV consists of the following:

  • Initiating cotrimoxazole prophylaxis at 6 weeks.
  • Continuing feeding counselling at all visits.
  • Ensuring immunization according to KEPI schedule.
  • Giving vitamin A according to national guidelines.
  • Monitoring growth: The growth curve should be evaluated: if the baby is not gaining weight appropriately despite nutrition counselling, the baby may have been HIV infected and should be referred to a facility that can carry out the tests to confirm infection (PCR or CD4 counts).
  • Testing for HIV infection:
    • A negative PCR test for HIV for non breastfeeding baby done at 6 weeks of age and when repeated at 3 months suggests that the baby is most probably not infected. For a breastfeeding baby, breastfeeding has to be stopped and the test done 6 weeks to 3 months later. If the test is negative, the baby is not infected. However, the baby needs to be followed up till 12 to 18 months of age.
    • An HIV antibody test is done between 12 and 18 months and if it is found negative, the child is followed up in the normal MCH clinic. If the test is positive, however, the child should be referred to nearest HIV comprehensive care centre.

CARE OF HIV INFECTED CHILDREN

Unfortunately most mothers do not know their HIV status in pregnancy and consequently the diagnosis of HIV in children tends to be made late.
Early signs of HIV infection are also often missed by the primary health care provider.
Many of the severe illnesses that occur as complications of HIV/AIDS disease are also the common causes of illness in non infected children.
Thus, health workers do not realize that they might be occurring as complications of HIV/AIDS.

Diagnosis

  • Diagnosis of HIV infection is made by an antibody test, in the form of a Rapid test or an Elisa test for all children aged above 18 months.
  • Diagnosis can also be made by virological (antigen) test using the PCR; this is a confirmation test for
    infection in children below 18 months.

Ideally, all children attending MCH should be tested for HIV to facilitate early intervention and appropriate management.
All children requiring admission should be tested to minimize missing of infected children and to facilitate optimum care. HIV infection can be suspected in the
presence of the following:

  • Chronic otitis media.
  • Persistent parotid enlargement.
  • Slow growth or weight loss that fails to respond to adequate nutrition.
  • Non specific skin rashes.

In more advanced disease, the following features are usually noted:

  • Recurrent serious infections, e.g., pneumonia.
  • Persistent or recurrent fevers.
  • Severe and recurrent oral thrush.
  • Recurrent and persistent diarrhoea.
  • Herpes zoster.
  • Neurological dysfunction, either delayed or regressed milestones.
  • Failure to thrive.

It is advisable to encourage all adults with HIV and on treatment to bring their children for testing even if they think the children are not infected.

It is necessary to refer the patient if:

  • HIV infection cannot be confirmed.
  • Child diagnosed to have HIV, so that they can be taken care of in a comprehensive care centre, where CD4 counts can also be done.

Management

Mother and child and any other infected family members should access care preferably in the same setting. If the clinic only caters for children then adult members must be referred to an appropriate clinic

Nutrition for Affected Children Ensure adequate diet for age of the child. Their energy needs are higher than those
of non HIV infected children. Many infected children have poor appetite, thus the parent or caregiver should vary and
experiment on foods offered. Nutritional supplementation may be necessary, especially micronutrients.

HIV STAGING

Two approaches are taken to determining the phase or stage of HIV infection,WHO’s clinical criteria, given below, and an immunological approach. The immunological approach, based on age specific CD4 counts, is summarized in the Table

WHO Clinical Staging

Stage 1:

  • Asymptomatic
  • Persistent generalized lymphadenopathy

Stage 2:

  • Skin eruptions that include recurrent/extensive lesions that may be infections
    due fungi or Molluscum contagiosum virus, or may be immunological like
    seborrheic dermatitis (eczema) and any non specific dermatitis.
  • Herpes zoster
  • Recurrent or chronic upper respiratory and/or ear infections
  • Parotid enlargement
  • Recurrent oral infections
  • Hepatosplenomegaly

Stage 3:

  • Moderate malnutrition (-2SD or Z score) not responding to therapy
  • Unexplained persistent diarrhoea
  • Oral candidiasis (outside neonatal period)
  • Unexplained persistent or recurrent fevers
  • Severe recurrent pneumonias (>2 episodes in 12 months)
  • HIV related chronic lung disease
    • Symptomatic lymphoid interstitial pneumonitis
    • Pulmonary or lymph node TB
    • Systemic varicella infection
    • Unexplained anaemia, neutropaenia, thrombocytopaenia

Stage 4:

  • For a child <18 months of age: 2 or more of the following: oral candidiasis,
    severe pneumonia, failure to thrive or sepsis
  • For a child of any age:
    • Severe wasting, stunting, or malnutrition not responding to therapy
    • Pneumocystis jiroveci pneumonia (PCP)
    • Extra pulmonary TB
    • Candidiasis of oesophagus, trachea, or lungs
    • HIV associated cardiomyopathy, or nephropathy, or encephalopathy
    • Kaposi’s sarcoma or other lymphomas
    • Unusual bacterial, fungal, or viral infection

Immunological stages: Based on age specific CD4 counts

Stage <12 months(%) 12–35 (%)months 36–59 months (%) 5 years & above (Cells/Cm)
Not significant >35 >30 >25 >500
Mild 30–35 25–30 20–25 350–499
Advanced 25–34 20–24 15–19 200–349
Severe <25 <20 <15 <200 or <15%