MI: HIV in African Children

Question 1

What are some causes of HIV infection in children?

Answer 1

• Mother-to-child transmission (90%)
• Child sexual abuse

Question 2

List some clinical features of HIV infection in children.

Answer 2

Many of the same as adult patient with AIDS

Question 3

How can HIV be transmitted perinatally?

Answer 3

• In utero
• Intrapartum
• Breastfeeding

Question 4

What proportion of babies of HIV positive mothers will be infected? What is a major risk factor for vertical tranmission?

Answer 4

• 1/3 will be infected
• Maternal viral load is the biggest risk factor

Question 5

Describe the pattern of viraemia in an HIV-affected adult.

Answer 5

• Burst in viraemia soon after being infected (primary infection)
• This will then be brought under control by the cellular and humoral immune responses (latent stage)
• Later on, there will be immune escape where the virus overcomes immune defences leading to an increase in viral load and drop in CD4 count (AIDS)

NOTE: if the mother acquires HIV during or immediately before pregnancy, they are at high risk of transmission to the baby

Question 6

What is an effective barrier to HIV transmission from mother to baby during pregnancy?

Answer 6

Healthy placenta

NOTE: there are conditions that can damage the placenta (e.g. malaria, toxoplasmosis)

Question 7

During which period in pregnancy is transmission most likely?

Answer 7

End of pregnancy (the placenta becomes less effective as a barrier) - especially following rupture of membranes

Question 8

State a perinatal risk factor for HIV transmission.

Answer 8

Prolonged rupture of membranes

Question 9

What intervention can reduce HIV transmission at the end of pregnancy?

Answer 9

Elective C-section

Question 10

What are the recommendations for breastfeeding and HIV transmission?

Answer 10

• Breastfeeding should be avoided if a safe alternative (i.e. formula) is available
• In some developing countries, the risk of diarrhoea from avoiding breastfeeding may outweight the risk of HIV transmission from breastfeeding

Question 11

Outline the WHO comprehensive approach to prevent HIV infection in infants.

Answer 11

• Prevention of HIV in parents to be
• Prevention of unintended pregnancies in HIV-positive women
• Prevention of transmission from an HIV-infected mother to the baby

Question 12

List some classes (with examples) of antiretroviral drugs.

Answer 12

• NRTI (e.g. zidovudine)
• NNRTI (e.g. efavirenz)
• Integrase inhibitors (e.g. raltegravir)
• Protease inhibitors (e.g. lopinavir)

Question 13

List the research priorities for HIV in developed and developing countries.

Answer 13

High income countries:

• Highly individualised care
• Simplifying treatment
• Investigating new drugs

Developing countries with high HIV burden:

• Improving access to treatment
• Improving diagnosis
• Improving formulations

Question 14

List some challenges for HIV treatment in Africa.

Answer 14

• Malnutrition
• Co-infection (especially TB)
• Risk of immune reconstitution inflammatory syndrome (IRIS)
• Family disruption
• Stigma
• Depression

Question 15

List some ways in which adherence to ART has been promoted in Africa.

Answer 15

• Peer-facilitators
• Improved formulations and education
• Simplifying treatment

Question 16

What is the are the BHIVA recommendations for pregnant women regarding:

• ART
• Delivery
• Neonatal treatment
• Breastfeeding

Answer 16

• cART should be taken throughout the pregnancy and then lifelong
• Vaginal delivery only if viral load is <50 copies/ml
• Neonatal given PEP with zidovudine monotherapy (started within 4 hours) for 2 weeks
• BHIVA recommends formula-feeding in all cases
• However if mother chooses to breastfeed, has undetectable VL and is compliant with ART, then she should be supported

Suppressive maternal cART significantly reduces, but does not eliminate, the risk of vertical transmission of
HIV through breastfeeding. The undetectable=untransmittable (U=U) statement applies only to sexual transmission, and we currently lack data to apply this to breastfeeding