HIV infection

Question 1

HIV infection

• Globally, HIV infection affects over 2 million children, mostly in sub-Saharan Africa
• major route of HIV infection in children is mother-to-child transmission (MTCT)
• major route of HIV infection in children is mother-to-child transmission (MTCT)
• may also be transmitted to children by infected blood products, contaminated needles or through child sexual abuse, but this is uncommon

Answer 1

Diagnosis:

• children over 18 months old, HIV infection is diagnosed by detecting antibodies to the virus
• Children less than 18 months of age who are born to infected mothers will have transplacental maternal IgG HIV antibodies, and at this age, a positive test confirms HIV exposure but not HIV infection
• The most sensitive test for HIV diagnosis before 18 months of age is HIV DNA PCR. All infants born to HIV-infected mothers should be tested for HIV infection, whether or not they are symptomatic

Question 2

HIV infection

Clinical features

Answer 2

• A proportion of HIV-infected infants progress rapidly to symptomatic disease and onset of AIDS in the first year of life; however, other infected children remain asymptomatic for months or years before progressing to clinical disease
• Children with mild immunosuppression may have lymphadenopathy or parotitis; if moderate, they may have recurrent bacterial infections, candidiasis, chronic diarrhoea and lymphocytic interstitial pneumonitis
• Severe AIDS diagnoses include opportunistic infections, e.g. Pneumocystis jiroveci (carinii) pneumonia (PCP), severe failure to thrive, encephalopathy (Fig. 14.24), and malignancy, although this is rare in children

Question 3

HIV infection

Treatment

Answer 3

A decision to start antiretroviral therapy (ART) is based on a combination of clinical status, HIV viral load and CD4 count, except in infants who should all start ART shortly after diagnosis, because they have a higher risk of disease progression. As in adults, combinations of three (or four) drugs are used. Prophylaxis against Pneumocystis jiroveci (carinii) pneumonia (PCP), with co-trimoxazole, is prescribed for infants who are HIV-infected, and for older children with low CD4 counts

• Immunisation, which is important because of the higher risk of infections, and should follow the routine vaccination schedule, with the exception of BCG which should not be given as it is a live vaccine that can cause disseminated disease. Additional vaccination against influenza, hepatitis A, B and varicella zoster should be considered.
• Regular follow-up, with particular attention paid to weight, neurodevelopment and clinical signs and symptoms of disease