HIV in African Children

Question 1

How many children (<15) have HIV?

Answer 1

3.3 million
Mostly in sub saharan Africa
10% of all HIV pts

Question 2

What is the under 5 mortality including AIDS?

Answer 2

A lot higher
HIV accounts for 35% of deaths in children < 5 yrs in S. Africa

Question 3

How do kids get HIV?

Answer 3

90% mother to child
Some is child sexual abuse

Question 4

What are the clinical features of HIV?

Answer 4

Infections e.g. Oral thrush. caries, gingivitis
Progressive Encephalopathy
Enlarged LNs
Severe pneumonia
Clubbing
Herpes Zoster/ VZV
Hepatosplenomegaly
Bruising
Diarrhoea
Molluscum Contagiosum
Skin rashes e.g. scabies, folliculitic rash
Lymphoid interstitial pneumonitis (co inf w/ EBV)

Question 5

What is this?

Answer 5

Basal ganglia calcification

White matter changes

Atrophy

Vasculopathy / Strokes

Question 6

What does failure to thrive look like?

Answer 6

Question 7

What can CMV do in HIV kids?

Answer 7

Sight-threatening retinitis due to co-infection with cytomegalovirus (CMV)

Question 8

Do kids survive HIV?

Answer 8

Not really if not treated

Question 9

What proportion will be infected?

①10% or less

②About one third of the infants

③About two thirds of the infants

④More than 75%

Answer 9

About one third of the infants

Question 10

How does HIV get transmitted vertically?

Answer 10

Breast feeding

Utero

Intrapartum

Maternal viral load increases chance

Question 11

How does viral load change over time?

Answer 11

Question 12

A healthy placenta is an effective barrier to transmission of HIV from mother to baby

Answer 12

A healthy placenta is an effective barrier to transmission of HIV from mother to baby

Question 13

What makes a placenta unhealthy?

Answer 13

Malaria

Toxoplasmosis

Chorioamnionitis

Contractions

Question 14

Why is the first twin more likely to have HIV?

Answer 14

First baby sweeps the top layer of the birth canal and is more likely to be infected

Question 15

Does Breastfeeding increase chances of death?

Answer 15

Some increased risk

Risk of HIV transmission must be balanced against risk of increased mortality from formula feeding

Question 16

How do we reduce HIV?

Answer 16

Contraception advice

Education

Good care

If IMR is > 40 / 1,000 live births, recommend exclusive breast feeding + ARVs for mother or baby [WHO 2010]

Question 17

What are the WHO guidelines for treatment of breastfeeding women with HIV?

Answer 17

All 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 atleast 12 months

Question 18

What drugs exist?

Answer 18

NNRTIs

NRTIs

PIs

InI

Question 19

How do you treat HIV?

Answer 19

Combination therapy

2 NNRTIs/ 1PI

Question 20

What are the ADDITIONAL INFLUENCES OF HIV?

Answer 20

• ­­ stigma / secrecy
• physical effects of HIV
• growth, puberty, CNS impairments
• ARVs and their toxicities
• sexually transmissible
• risk of rejection

Question 21

What are challenges in HIV in Africa?

Answer 21

–Severe malnutrition

–Multiple co-infections (especially TB)

–Risk of immune reconstitution inflammatory syndromes (IRIS)

–Family disruption:

• Multiple carers
• Children as caretakers

–Stigmatisation in school

–Depression / Disclosure

–Poverty

• Lack of school fees
• Transport

Question 22

How do you promote adherence?

Answer 22

Increasing use of peer facilitators who talk about their personal successful experiences.

Question 23

Does C section halves transmission risk?

Answer 23

Yes

Question 24

How can cultural change help?

Answer 24

Engagement of the elders involved in the circumcision rituals has successfully generated peer-group pressure to achieve an undetectable viral load prior to participation

Question 25

How can you give adherence support?

Answer 25

Family based care

Multi-disciplinary teams

Education (HIV / drugs)

Improved formulations

Question 26

The crucial issue is whether we can deliver ARVs on the scale needed to ensure children can survive to become productive adults. The current aspiration of the HIV policy makers is to produce an AIDS-free generation from 2015 onwards.

Answer 26

The crucial issue is whether we can deliver ARVs on the scale needed to ensure children can survive to become productive adults. The current aspiration of the HIV policy makers is to produce an AIDS-free generation from 2015 onwards.