Indian J Pediatr (November 2012) 79(11):14891490 DOI 10.

1007/s12098-012-0885-7

SYMPOSIUM ON PEDIATRIC HIV/AIDS

Editorial: The Clinical Features of HIV and Methods to Prevent its Transmission
Guest Editor: Rashid H. Merchant

Received: 28 August 2012 / Accepted: 30 August 2012 / Published online: 4 October 2012 # Dr. K C Chaudhuri Foundation 2012

Presently, approximately 2.5 million children in the world live with HIV, and about 1,000 children succumb to AIDS daily. The countdown to zero global initiative is ongoing, and its goal is to eliminate new HIV infection in children by 2015 and increase the survival rates of their mothers. The 2012 WHO PMTCT (Prevention of Mother to Child Transmission) program recommends a single universal regime both to treat pregnant women for HIV and to prevent transmission to their infants. This special issue of the IJP focuses on actions which may be taken to ensure that no child is born with HIV. The articles have been written by academicians specialized in this field and peer reviewed. Hopefully, information provided in these manuscripts will help in the achievement of our goals and will enhance the care offered to the HIV infected child. HIV transmission may occur before, during, or after delivery; however, even in the absence of intervention not all children born to seropositive women will get infected. The single most important risk factor determining vertical transmission is the maternal plasma viral load. Maternal plasma HIV load of >100,000 copies has a transmission rate as high as 40 %, while transmission is seldom reported with viral load <1,000 copies. The earliest documented study (ACTG-076) to prevent vertical transmission used oral Azidothymidine (AZT) in a dose of 500 mg/d orally from the end of the first trimester, followed by intravenously during labor until delivery, combined with administration orally to the infant for the first 6 wk of life. Since then, many more effective interventional strategies using multiple drugs have been tried, and it is
R. H. Merchant (*) Department of Pediatrics, Dr. Balabhai Nanavati Hospital, S. V. Road, Vile Parle (West), Mumbai 400056, India e-mail: deandoc2000@hotmail.com

proven that if initiated early enough during pregnancy, can reduce mother to child transmission(MTCT) to <1 %. In the article Prevention of parent to child transmission: What is new? the authors Lala and Merchant contrast the problem of PMTCT in developed and developing countries. As 39 % of HIV positive individuals in India are women, reduction of vertical transmission would benefit an enormous population of newborns. This article stresses the importance of universal screening of pregnant women and the provision of anti retroviral (ARV) therapy to all who are HIV infected, regardless of viral load or CD4 count. The problem of drug resistance emerging as a result of incomplete suppression of HIV is addressed, especially with reference to single dose nevirapine therapy. Regarding intrapartum prevention, although elective LSCS is a well known effective method to reduce transmission, the authors also suggest that spontaneous normal vaginal delivery can be a safe alternative as long as sufficient ARV is given. The benefits and risks of both breast-feeding and replacement feeding are evaluated to conclude that in resource limited settings, replacement feeding is a poor option. The main message in the article by Anju Seth on Care of the HIV Exposed Child- to Breast Feed or Not? is that combining breastfeeding with ARV prophylaxis gives an infant, in resource limited settings, the best chance of HIV free survival. While the risk of transmission through breastfeeding ranges from 14 % to 29 %, if ARV is taken throughout pregnancy and the breastfeeding period, the risk falls to 2 %. The author provides statistics and risk factors regarding the transmission of HIV through breastfeeding and also enumerates the various benefits of human milk. An HIV infected mother has two options: a) replacement feeding only if certain criteria are met and b) exclusive breastfeeding with ARV prophylaxis until 1 wk after stopping breast milk. Heat treatment of expressed milk may be useful as it inactivates the virus without affecting its nutritional content.

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Indian J Pediatr (November 2012) 79(11):14891490

Within the article Common Clinical Problems in Children Living with HIV/AIDS: Systemic Approach, Merchant and Lala have methodically divided different manifestations into the organ systems affected. Children have a poorly developed immunity which permits greater dissemination of the virus throughout the body and major differences in their clinical features when compared to adults. In the respiratory system three important diseases are described: Lymphoid Interstitial Pneumonitis, Pneumocystis jiroveci Pneumonia and Tuberculosis. Besides causing numerous opportunistic infections, the virus itself is responsible for HIV related encephalopathy, HIV enteropathy, and HIV associated nephropathy. Recognition of these signs and symptoms early in the disease process not only

helps in timely diagnosis but also in gauging progression and response to treatment. It is now estimated that only 28 % of children in need of HIV treatment are receiving it, and that 30 % of HIV infected infants die within their first year if untreated. A better way, perhaps, to attack this problem is through prevention of transmission itself. The elimination of pediatric HIV infection is no longer a dream and is within reach, as virtual prevention of MTCT is now possible. I commend the IJP for choosing such a valuable topic for their symposium with the intention of spreading awareness to all of its readers. We now have the unprecedented opportunity of making new pediatric infection history; however this is going to be no easy task in our country.