2s: African Child HIV Flashcards
HIV epidemiology
Majority Sub-Saharan Africa (2.9 out of 3.3m)
1 in 10 are children → massive contribute to under-5 mortality
- 35% deaths in children <5 in SSH
- increase proportion in teenagers with undiagnosed perinatally-acquired HIV
- over 90% from mother-to-child transmission (sexual abuse also a major RF)
Clinical features of HIV in children
Chronic bilateral parotid swelling with molluscum (early)
Lymphadenopathy +/- Hepatosplenomegaly and Lymphoid Interstitial Pneumonitis (LIP)
- lymphoproliferation due to immune activation → bronchiectasis and chronic suppurative lung pathology → clubbing
- LIP impossible to distinguish from TB on CXR
dental caries, gingivitis, URTIs
scabies (may not be itchy, required immune reaction)
shingles (>1 dermatome raises suspicion of immunodeficiency)
PML/progresive multifocla leukoencephalopathy (from HIV-infecting oligodendrocytes → less neuronal nutritions nd so progressive neuronal cell death)
CMV retinitis (‘white cotton wool exudates’ in eyes)
Kaposi sarcoma (HHV8)
PCP pneumonia
Perinatal transmission of HIV
Maternal viral load = MAJOR RF for transmission
transmission through:
- breastfeeding
- in utero
- intra-partum
If mother acquires HIV during or just before pregnancy → they are at high risk of transmitting it to the baby
infection → initial viraemia birth → under control by cellular and humeral immune response → immune escape where virus overcomes immune defences → rise in viral load
The role of the plants in HIV transmission
A healthy placenta is an effective barrier to transmission of HIV from mother to baby
- There are some conditions that cause an unhealthy placenta (e.g. malaria, toxoplasmosis)
- Most transmission tends to occur towards the end of pregnancy (placenta not as good)
- Twins = 1st-born is more likely to get HIV → they pass through the birth canal and sweep it of vaginal secretions
What increases and decreases risk of transmission perinatally
- Prolonged rupture of membranes (PROM) is also associated with increased risk of transmission
- Elective C-section in affected mothers will halve the risk of transmission
transmission in breastfed vs formula-fed
breastfed = increased transmission
formula = more diarrhoea
WHO recommend that if infant mortality rate >40/1k live births:
- Exclusive breastfeeding
- ARVs for mother and baby
What is the WHO Comprehensive Approach to Prevent HIV infection in Infants
- Prevention of HIV in parents to be (e.g. contraception, education)
- Prevention of unintended pregnancies among HIV-infected women
- Prevention of transmission from an HIV-infected woman to her infant
- Guidelines for the use of ARVs in treating and preventing HIV infection
ARV guidelines
pregnant and BF women should initiate triple ARVs
- Fixed dose combination Tenofovir+3TC+efavirenz
- BF infants should receive daily NVP for 6 weeks
Maintain ARVs for duration of MTCT risk
Maintain ARVs lifelong with those meeting Rx eligibility (CD4< 500) (strong recommendation)
Maintain ARVs lifelong in all for programmatic reasons (conditional recommendation)
Uninfected infants should exclusively BF for 6 months and continue to BF until at least 12 months
The different types of anti-retroviral therapies
Research priority (high income vs low income)
Challenges to HIV tx in Africa
- malnutrition
- co-infection (especially TB)
- risk of immune reconstitution inflammatory syndromes (IRIS) = renaming immune system can be BAD
- family disruption = multiple carers, children as caretakers
- stigma in school
- depression
- poverty = lack of school feed, transport
How do promote HIV tx and arv adherence
- Increasing use of peer-facilitators who talk about their personal experiences
- Improved formulations and education
- Simplifying treatment
