HIV in African Children

Question 1

How many children under the age of 15 have HIV?

Answer 1

3.3 million (3.0 – 3.7 million)

Question 2

What proportion of people with HIV are children?

Answer 2

1 in 10 are children

Question 3

What proportion of deaths in children are as a result of HIV?

Answer 3

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

Trend however is towards increasing proportion of deaths in TEENAGERS with perinatally acquired HIV.

Question 4

What are causes of HIV in children?

Answer 4

90% due to mother-to-child transmission.

But child sexual abuse or exchanging sex for food/shelter are significant risk factors for vulnerable children.

Question 5

What is this?

Answer 5

A very common feature of HIV in African children - chronic bilateral parotid swelling, and molluscum..

Question 6

What is this?

Answer 6

Dramatic lymphadenopathy - sign of immune activation following HIV infection - likely to be accompanied by hepatosplenomegaly and lymphoid interstitial pneumonitis (LIP).

Question 7

What is this?

Answer 7

Skin rashes are common - this is a typical extensive folliculitic rash, but some of the lesions may be insect bites. Scabies can be extensive and atypical - in advanced HIV infection it may not be itchy, since this require a host response to the mite faeces.

Question 8

What is this?

Answer 8

Oral candidiasis - may be associated with oesophageal candidiasis, resulting in pain on swallowing, poor feeding, weight loss.

Question 9

What is this?

Answer 9

Severe dental caries and frequent upper respiratory tract infections are common.

Question 10

What is this?

Answer 10

Lymphoid interstitial pneumonitis - also illustrating how impossible it is to distinguish this condition from TB radiologically.

Question 11

What is this?

Answer 11

Clubbing - not seen with uncomplicated TB or LIP. Suggests bronchiectasis with chronic lower respiratory tract infection may have occurred in the wake of LIP.

Question 12

What is this?

Answer 12

TB Spine - Pott’s Disease

Question 13

What is this?

Answer 13

Primary varicella zoster infection (chicken pox) complicated by pneumonitis.

Question 14

What is this?

Answer 14

More common manifestation of VZV infection = multidermatomal zoster (shingles).

Question 15

What is this?

Answer 15

Molluscum contagiosum

Question 16

What is this?

Answer 16

Neuro-imaging of HIV Encephalopathy:

• Basal ganglia calcification
• White matter changes
• Atrophy
• Vasculopathy/Strokes

Question 17

What is this?

Answer 17

Pneumocystis jiroveci pneumonia in a 3 month old infant

Question 18

What is this?

Answer 18

Left Eye

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

Question 19

What is this?

Answer 19

Oral Kaposi’s sarcoma

Question 20

What proportion will be infected if mother has HIV?

A. 10% or less

B. About one third of the infants

C. About two thirds of the infants

D. More than 75%

Answer 20

B. About one third of the infants - generally

C. About two thirds of the infants - if mother has high viral load

Question 21

How can HIV be transmitted perinatally?

Answer 21

Through breast feeding

In utero

Intra partum

Question 22

What is a major risk factor for vertical transmission?

Answer 22

Maternal plasma viral load

Question 23

Why can a mother have one child with HIV, a couple without HIV and then have another child with HIV years later?

Answer 23

Natural timecourse of illness - high viral load, natural suppression, overwhelmed immune system.

Question 24

What acts as a barrier betwen mother and child for HIV?

Answer 24

Placenta

Question 25

Which twin is more likely to get HIV?

Answer 25

First born twin is more likely to get HIV because they are in birth canal for longer.

Also prolonged delivery.

Question 26

What is the association between risk of transmission and duration of rupture of membranes?

Answer 26

Risk of MTCT increases by 2% for every hour post-rupture of membranes.

Question 27

What is the association between C-section and transmission risk?

Answer 27

C-section halves transmission risk

Question 28

What is the association between formula feeding and HIV risk?

Answer 28

No further transmission in formula fed advice. However, low adherence to formula fed.

Risk from drinking 1 litre of breast milk = Risk from one episode of unprotected sex.

Question 29

How can interventions reduce the risk of transmission?

Answer 29

None: 25 - 40%

Avoid B/F: 12 - 25%

AZT mono Rx: 6 - 8%

ELCS + AZT mono: < 2%

Combo Rx (VL < 50): << 1%

Question 30

What is the comprehensive approach to prevent HIV infection in infants?

Answer 30

Care and support for HIV-infected women, their infants and their families.

• Prevention of HIV in parents to be.
• Prevention of unintended pregnancies among HIV-infected women.
• Prevention of transmission from an HIV-infected woman to her infant.

Question 31

Which antiretroviral drug classes are focused on preventing HIV entry?

Answer 31

Fusion Inhibitors: Enfuvirtide (T-20)

CCR5 coreceptor antagonists: Maraviroc (MVC)

Question 32

Which antiretroviral drug classes are pre-transcriptional?

Answer 32

NRTI:

• Zidovudine (ZDV)
• Lamivudine (3TC)
• Didanosine (ddI)
• Stavudine (d4T)
• Abacavir (ABC)
• Emtricitabine (FTC)

NtRTI:

• Tenofovir (TDF)

NNRTI:

• Nevirapine (NVP)
• Efavirenz (EFV)
• Etravirine
• Rilpivirine

Question 33

Which antiretroviral drug classes are post-transcriptional?

Answer 33

Integrase inhibitors:

• Raltegravir
• Elvitegravir
• Dolutegravir

PI:

• Lopinavir (LPV)
• Ritonavir (RTV)
• Fosamprenavir
• Darunavir (DRV)
• Atazanavir (ATZ)
• Saquinavir (SQV)
• Indinavir (IDV)
• Tipranavir (TPV)

Question 34

What are some challenges associated with preventing HIV in children?

Answer 34

• 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 and transport