HIV in Children 1

Facts & Figures

• Rare paed disease in 80’s. 1st child in 82
• 8th leading cause of paed death in USA
• In ’97- 2.3 mill deaths, 20% children
• 5-8 mill children infected at present
• Most cases are vertical transmission
• Maharashtra: seroprevalence pregnant women
0.25-4%, average 1%
Transmission rates Mother to Child
• USA - 14-33%
• Developing countries – 25-45% (av 30%)
o 30,000 HIV infected neonates/yr

o Additional burden

• Malnutrition & Infection

• Orphans of AIDS parents

• Intervention of MTCT mandatory

 2

Transmission

Sexual contact
• Parenteral exposure to blood
• Infected needles
• Vertical
o Antepartum – 30%

o Intrapartum – 70%

o Postpartum – Breast feeding

Natural history
• 3 distinct patterns of disease
o 15-25% Newborns have rapid course

 Onset of AIDS during 1st few mths of life

 Median survival 6-9mth if untreated

 +ve viral assay in 1st 48 h of life

 Infection in–utero

o 60-80% much slower progression

 Median survival of 6yrs

 -ve viral assay in 1st wk

 Transmission of virus intrapartum

o <5% long term survivors

 Minimal or no progression of disease

 Relatively normal CD4+ counts
 Low viral loads
 Median survival time >8 yrs
 Clinical manifestations 3

• Vary widely in infants, children & adolescents

• LN, Hepatosplenomegaly
• FTT, Chr or recurrent diarrhoea, pneumonia, oral
thrush, TB
• Difference from adults
o Transmission routes

o Diagnostic problems in NB & infants

o LIP & Chronic parotitis more common

o Severe & recurrent bacterial infections

o HIV encephalopathy more frequent

o CNS opportunistic infections uncommon

o Kaposi sarcoma & CNS lymphoma rare

 HIV classification 4

• Immune
o Absolute or percentage of CD4+ cells

 Moderate or severe immunosuppression

• Clinical categories
o Cat A – at least 2 mild symptoms

 LN, parotitis, HS megaly, dermatitis, pers or

recurrent sinusitis/OM
o Cat B – moderate

 LIP, oral thrush >2m, Rec/chr D, Fever>1m,

hepatitis, rec HS stomatitis, esophagitis, pn, diss

varicella cardiomegaly, nephropathy
o Cat C – severe 2 serious bact inf (Sepsis, meningitis,

pneumonia over 2 yr period)

 Esophageal, resp tr candidiasis, cryptococcosis,

cryptosporidiosis (>1m), encephalopathy,

malignancies, diss TB, PCP, cerebral
toxoplasmosis, severe wt loss
o Oppurtunistic inf occur with severe

immunosuppression
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Diagnosis

• Identification of HIV infection in women

• Diagnosis of infected neonates difficult
• Earlier:
o Devp of AIDS defining conditions <18 m
o HIV IgG Ab >18m
o Confirmation WB / Immunofluorescence assay
in chidren >18 mth
• Viral assays (HIV DNA / RNA / Culture)
o <48 h of birth (38%)

o Between 1-2 m (at 2 wks of age) (93-96%)

o Between 3 & 6 m

 assay +ve within 48 h of life &

subsequently – IUI
 assay -ve within 48 h of life, +ve after I wk

(no BF) – IPI

• HIV IgG serology –ve > 18m – No HIV
 6

Prevention

• Reducing viral load in mother

• Reducing exposure of fetus at delivery
• Reducing risk of infection if exposed
• Reducing PP exposure
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Regimes for Prevention…

Trial Regimen Transm Efficac

y

076 AN & lab: ZDV 14-34 wks 8% 68%

Infant : ZDV x 6wks NBF PL: 26%

Thai AN & lab: ZDV 36 wks 9% 51%

Infant : None NBF PL:19%

PETRA Gp1:AN:36wk, PP+Infant: Gp1: 9% 42%

2 drug 1wk Gp2: 11% 37%
ZDV+3 Gp2: Lab, PP+Infant: 1wk Gp3: 18% --
TC Gp3: Lab Gp4: 17% --
Gp4: PL

HIVNE Gp1: Lab: Nev, Inf: Nev (BF) Gp1: 13% 47%
T 012 Gp2 :Lab : ZDV, Inf: 1 wk Gp2: 25%
(BF)
 Breast feeding 8

• Transmission – 14% / 29% (inf PP)

o More in 1st few wks & months

• Factors affecting transmission:

o Maternal factors

 Viral load BM (> mothers of inf babies)

 ?colostrum more infective

 Vit A def mother

o Infant factors

 Prematurity
 Relative gastric alkalinity 1st few days of

life
 Immunogenetic profile of baby

 Exclusive BF/Substitutes/Mixed
• Western countries – NO BF
o BM banks

• India – GE & Resp inf

• ?Boiled BM
• Informed choice to mother
o Exclusive BF

o Exclusive Top feeds

o NO COMBINATION
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Immunization
Special issues
• Same schedule as HIV non-infected except a few
(live Vaccines)
• Polio: IPV No OPV
o India-OPV

• Measles & MMR – Benefits / risks

o Immune Cat 1 or 2 should be given,
contraindicated in severe suppression
o Response to HAART ? Vaccine given

o Exposed – IG within 72 h (0.25-0.5ml/kg)

• Influenza – yearly >6mo age

o Unimmunized <9yr – 2 doses 1 mo apart

• Pnemococcal vaccine
o Polyvalent >2yr age

o Protein conjugated heptavalent

• BCG – Contraindicated in USA

Given in developing countriesVaricella infection
morbidity in HIV
o Vaccine for asymptomatic / mildly symptomatic
– CDC class N1 or A1
 2 doses 3 mo apart

 Also for HIV –ve sibs & contact persons

 Exposed children ZIG within 96 h

 Management 10

• ART therapy and monitoring

o Viral load, CD4+ count & %age, clinical

o Sustainable suppression of viral replication

o Adherence to the regime is crucial

o Combination therapy

 NRTI + NNRTI

 Protease inhibitors

• PCP prophylaxis
• ?Prophlactic ATT
• Care & support for HIV infected children
o Vit A & others

o Psychosocial support

o Orphaned children

o Strengthening of Well Baby clinics

• Integration of HIV/AIDS in RCH/MCH

 Conclusion 11

• HIV steadily rising in children

• Urgent measures for prevention & reducing
transmission
• Informed choice to mother for breast feeding
• Immunization like non-infected except for live
vaccines