From Sheth fb
Paediatric HIV
- Adults
Heterosexual sex intercourse is the most common mode of transmission.
IV drug users: mislead by statistics? ..due to compulsory screening.
- How it involves children?
90% is due to Mother-child-transmission
– Rate of transmission from mother who is HIV positive
> 25% will get infected.
> 75% will not get infected.
Transfusions:
– Less common now. Blood product screenings.
Sexual Abuse:
– Uncommon!
– Why? > Most abuse case are fondling e.t.c.
– > Perpertrators are usually family members; unreported. Child/mother scared.
- HIV transmission
Although HIV can be found in blodd, urine, e.t.c. Only through genital secretions and blood.
“ I believe IV users are not infected through injection., but they get it sexually.” (Dr Zain, 2010)
- Risk
Sexual Transmitted Disease
– Especially that cause ulcers
– E.g. Herpes, Syphillis
–
Breastfeeding:
– Mucosal membrane of babies not mature.
Vaginal Delivery
– Mucosal membrane are not mature.
– Blood, vaginal, cervical secretions swallowed.
Invasive procedures:
– Amniocentesis, CVSampling.
High viral load in mother, low CD4 count.
- Diagnosis/ Lab investigations
Serology Test:
– If seen in child first time, more than 18mo. – do the test!
– High sensitivity & specificity
HIV enzyme immunoassay (ELISA)
– Must be positive X2.
Confirm by Western Blot/ immunofluorecense assay.
Virology :
– For the definitive diagnosis.
– More specific, sensitive.
– Can be done in advance disease, when specific Ab is inadequate.
– Remain positive even after aggressive treatment.
PCR , (can detect HIV RNA, HIV DNA, p24 antigen)
– DNA; in the CD4 cells, during latent period (provirus)
– RNA; in the blood (virus),
If negative; repeat by 6 weeks. (definitive confirmation; infected or not)
Viral Culture
– Nobody do culture anymore
Hepatitis B (off topic)
90% of carriers (mother ) will transmit to child.
That is why we give immunoglobulin to prevent chronic carriers in children.
Risk of transmission through needle prick injury? > 10%
- HIV ‘behavior’/ progression
HIV latent period does not follow the natural progression such in adults (e.g. after 6 month, low)
Newborn: immune not develop.
– Viral load very very high, and stays high.
– 1/3rd die within 1st year of life.
– Half die within 2nd year.
- Common AIDS indicator disease in children
– Pneumocyctis jirovecei pneumonia (30%)
– HIV wasting syndrome
– Bacterial infections (multiple + recurrent)
– HIV encephalopathy
– Candida (esophageal, respi tract)
– Lymphoid interstitial pneumonitis
– Mycobacteria TB (extrapulmonary)
– CMV
– Cryptosporoidis
– Toxo encephalitis
– Lymphoma.
- Prevention of transmission
Antenatal
– Antenatal care for mothers. HIV screening.
– Chemotherapy:
- As early possible (mother)
- Aim to suppress to undetectable level (sometimes may suppress viral load up to 50 copies/ml).
- Cannot cure, only suppress viral replication.
- Improves mother’s health.
- Prevent child infection.
Intrapartum
– Elective Caesar @ 38 weeks
- Prevent microtransmission
– Chemoprophylaxis
Post-Partum
– Do not breastfeed
– Pneumocystis pneumonia prophylaxis
- TREATMENT Chemotherapy
Always 3 drugs
Pregnant Mother
Nevirapine + efavirenz
Plus
Zidovudine + lamivudine
Child
Nevirapine (daily) until 4 weeks
Or
Zidavudine
- Prophylaxis (always one drug)
Antepartum: Zidovudine
Intrapartum: nevirapine + Zidovudine + lamuvidine
Breastfeeding: Nevirapine, until 1 week after stop breastfeeding.
Who are the children we treat?
All children diagnosed at <2 years. Regardless CD4, sign symptoms
2- 5 years: guided by CD4.
– <25%
– <750 cells/mL
5+ years
– <350 cells/ml
All children with clinical stage 3-4 WHO
Regardless CD4 count.
- Prognosis i.e. rate of transmission (mother-child)
Untreated mother – 25%
Chemoprophylaxis – drop to <10%
Chemo + Caesar – drop to < 5%
Chemo until undectectable level – drop to < 1%
Pro4Real 