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HIV stands for the Human Immunodeficiency Virus. The virus is infectious and can be spread from one person to another and is found in most body fluids, e.g. blood, semen, vaginal secretions and breast milk.
HIV is the Human Immunodeficiency Virus.
Two types of HIV are recognized: HIV 1 and HIV 2. Most infections in Southern Africa are caused by HIV 1 which has many subtypes (clades). The important subtype in Africa is subtype C while subtype B is the most common subtype in the developed world.
HIV infects the CD4 lymphocytes of the immune system. The CD4 lymphocytes are a special group of white cell which play an important role in protecting the body from infections. HIV introduces its own genes into the nucleus of the CD4 lymphocytes giving instructions to produce millions of new HIV. These HIV are then released into the blood stream where they infect and kill other CD4 lymphocytes. When HIV causes illness it is called symptomatic HIV infection or HIV disease.
HIV belongs to a group of viruses known as retroviruses. Retroviruses usually cause long periods of silent infection before symptoms and signs of disease appear.
AIDS is the Acquired Immune Deficiency Syndrome. This is an advanced stage of HIV infection presenting with serious clinical illness. It presents in both adults and children in many different ways. The main feature of AIDS is severe damage to the immune system leading to many viral, bacterial and fungal infections, many of which do not usually occur in people with a healthy immune system. These are called HIV associated infections or opportunistic infections. They take the ‘opportunity’ of infecting people with poor immune function (immune deficiency). At present AIDS can be controlled but cannot be cured. If not treated with antiretroviral drugs, AIDS is a fatal condition.
AIDS is a serious illness caused by the Human Immunodeficiency Virus (HIV).
Yes. Adults are usually infected with HIV for years while remaining clinically well (asymptomatic HIV infection). Only after this long latent period do the clinical signs of HIV infection develop (symptomatic HIV infection). In children the latent period may be as short as a few months. HIV infection is only called AIDS when the patient becomes seriously ill due to HIV related infections. Therefore, AIDS is the most advanced and serious form of HIV infection.
AIDS is the most advanced and serious stage of HIV infection.
HIV is frequently transmitted by people who appear to be clinically well and do not know that they are infected with HIV.
Most cases of HIV infection occur in Africa where the spread of the HIV epidemic is greatest in Southern Africa. Over 40 million people world-wide have HIV infection. South Africa has one of the fastest growing HIV epidemics with 1000 to 2000 people infected every day. Between 12 and 15% of all South Africans are currently infected with HIV. Approximately 30% of pregnant women in South Africa are HIV-positive (i.e. infected with HIV) and over 100 000 infants are infected annually.
Symptomatic HIV infection is causing a widespread epidemic in Africa.
HIV infection is having a devastating effect on the health of children and many of the gains made in child survival during recent years are now being reversed. In many hospitals in Southern Africa, most paediatric beds are now filled with children suffering from HIV infection.
HIV may be transmitted from one person to another by:
There is no evidence that HIV can be spread by mosquitoes, lice or bed bugs. HIV infection is not spread by kissing, holding hands or sharing cups or eating utensils. In Africa HIV is most commonly spread between adults by heterosexual intercourse.
In adults HIV is usually spread by sexual intercourse.
In children HIV is usually spread from a mother to her fetus or young infant. This is called mother-to-child transmission or MTCT. An HIV-infected mother may pass the virus to her child by the following routes:
If a mother is infected with HIV and is not being given antiretroviral prophylaxis:
Therefore, without antiretroviral prophylaxis, the risk of HIV transmission with vaginal delivery and no breastfeeding is 20% (i.e. 5% plus 15%). With mixed breastfeeding the risk increases to 35% (i.e. 5% plus 15% plus 15%). It is important to know that at least 65% or more of infants born to HIV-infected mothers are not infected with HIV.
Most infants born to HIV-infected mothers are not infected with HIV.
HIV is present in breast milk and HIV can be transmitted in the mother’s milk to the breastfeeding infant. The risk is greatest if the mother both breastfeeds and gives other foods, such as water, fruit juice, formula feeds and solids (i.e. mixed breastfeeding). With mixed breastfeeding the risk of passing HIV to the infant is:
The risk of HIV transmission with breastfeeding is further increased if:
With exclusive breastfeeding, for the first 6 months, the risk of HIV transmission appears to be small. Further research is still needed to document the risk of HIV transmission with exclusive breastfeeding.
The best feeding choice must be made by the mother herself after counselling to enable her to understand the risks and advantages of both forms of feeding. Formula feeding is usually only advised if all the following conditions can be met:
If any of these conditions cannot be met, which is common when mothers are living in or returning to rural areas, then exclusive breastfeeding for 4 to 6 months followed by rapid weaning off the breast is probably safest. In these infants, the risk of death due to gastroenteritis and malnutrition if formula fed is often higher than the risk of HIV infection via breastfeeding.
In older children (and adults) the ELISA or rapid screening tests are used to confirm the diagnosis of HIV infection. These tests detect antibodies against HIV in the blood and usually become positive between 2 to 6 weeks after the infection (i.e. after the window period for the screening tests). As maternal HIV antibodies cross the placenta to the infant, and can remain in the infant’s blood for up to 18 months after delivery, the screening tests can only diagnose HIV infection in an infant if the test remains positive after 18 months of age. A positive screening test in the infant before 18 months may simply indicate that there are still maternal antibodies to HIV in an infant who is not infected (i.e. HIV-exposed but not infected).
A positive ELISA or rapid test in a child younger than 18 months does not necessarily mean the child has HIV infection.
A PCR test (polymerase chain reaction) detects HIV DNA (part of the genetic code of HIV). If the PCR blood test is positive the infant is infected with HIV. As the PCR test may take up to 6 weeks after the time of infection to become positive (the window period for the PCR test), an HIV-infected infant may have a negative test during this time (a false negative test).
If the mother is HIV-positive and does not breastfeed, the PCR test should be done on the infant 6 weeks after delivery (at the time of the first immunisation). If the mother breastfeeds, the test should only be done 6 weeks after the last breastfeed. It is a great advantage to establish whether an HIV-exposed child is infected with HIV or not.
A positive PCR test indicates that the child has HIV infection.
There are many advantages of diagnosing HIV infection early in infants. If the infant has not been breastfed, PCR testing can screen the infant for HIV infection at 6 weeks after delivery. Most infants will be negative and their parents can be reassured. These infants do not need the routine care offered to HIV-exposed infants from 6 weeks and can be followed at a well baby clinic. Infants with a positive PCR test should be closely followed up as they need additional care and monitoring. Breastfed infants should only be rescreened later after they have received no breast milk for 6 weeks. As HIV can cause severe illness and even death in the first few months of life, it is important to make the diagnosis as early as possible so that treatment can be started.
HIV-exposed infants should be screened for HIV infection at 6 weeks of age.
HIV infection can present in many different ways in children and, as a result, may present with a wide range of signs and symptoms. This makes the clinical diagnosis of HIV infection difficult at times. Clinical signs usually slowly develop over a number of months but can present earlier in some infants. The clinical presentation of HIV infection depends on which stage has been reached.
HIV infection in children is divided into 4 stages:
Some previously-well infants can present with stage 4 disease without first progressing through the other stages.
A definite diagnosis of symptomatic HIV infection (i.e. HIV infection causing disease) can be made if both of the following are present:
Additional blood tests showing a weakened or damaged immune system help to confirm the diagnosis of symptomatic HIV infection but are not essential. Therefore, when laboratory tests of immune function are not available, a diagnosis of illness due to HIV infection can still be made on clinical signs and symptoms together with blood tests confirming HIV infection.
These children are generally well (asymptomatic) but may have persistent generalised lymphadenopathy.
Stage 2 HIV infection presents with any of the following:
Stage 3 HIV infection is recognised by:
Stage 4 HIV infection is recognised by:
The main feature of stage 4 HIV infection is severe opportunistic infection such as Pneumocystis pneumonia. Unlike adults, children with HIV infection rarely present with malignancies.
A detailed description of the 4 stages of HIV infection are given at the end of this chapter.
HIV infects and damages the CD4 lymphocytes. These are important cells that control the whole immune system. HIV results in a fall in the number of CD4 cells in the blood (immunosuppression) which weakens or damages the function of the immune system (immunodeficiency).
The concentration or percentage of CD4 lymphocytes is used to measure the degree of immune damage. In children the number of CD4 cells is higher than in adults and normally reduces with age. Therefore, in young children (under 5 years) the number of CD4 cells is best expressed as a percentage:
The lower the CD4 percentage the greater is the damage to the immune system and, therefore, the higher the risk of serious HIV-related infections.
A CD4 percentage below 25% in young children indicates immunosuppression.
The absolute CD4 count is used in children aged 5 years and more. Healthy HIV-negative children of 5 years or above have a CD4 count above 500 cells/μL. A CD4 count below 200 cells/μL indicates severe immune suppression.
This depends on both:
All pregnant women should be screened for HIV infection when they book for antenatal care. HIV-positive women must have their CD4 count measured and be offered HIV prophylaxis before delivery. Usually AZT 300 mg orally twice daily is given from 28 weeks gestation followed by a 300 mg oral dose 3-hourly during labour. In addition, oral Nevirapine 200 mg should be given to the mother at the onset of labour. After delivery the infant should be given both:
HAART (Highly Active Antiretroviral Treatment) with 3 antiretroviral drugs should be given to HIV-infected pregnant women with a CD4 count below 200 cells/μL. This will reduce the risk of HIV transmission to the fetus if it is started before 28 weeks.
All HIV-exposed infants should be managed as follows unless appropriate PCR testing excludes HIV infection:
There are great advantages in identifying HIV-infected infants as soon as possible with PCR testing. Infants who are not infected with HIV can be followed at a well baby clinic.
It is safe to give all routine immunisations to infants in the first months of life, provided they do not have signs of symptomatic HIV infection. Infants with HIV infection should not be given BCG.
Good nutrition plays an important role in helping to maintain the normal functioning of the immune system. Malnutrition (undernutrition) weakens the immune system, especially in HIV-infected children. Good weight gain on the Road-to-Health Card is the best indicator that the child is well nourished. A careful nutritional history must be taken in children who fail to thrive or lose weight. If necessary, supplementary feeds should be given. It is also important to regularly de-worm children.
Vitamin A is important in maintaining a healthy immune system. To prevent vitamin A deficiency, children at risk of HIV infection should be given a multivitamin supplement 0.6 ml daily. This can be stopped if the child is found to be not infected with HIV. If multivitamin supplements are not available, give 50 000 iu of vitamin A orally once if under 6 months (best at 6 weeks). Then give 100 000 iu once at 6 months and 200 000 at 12 months and every 6 months thereafter to HIV-infected children.
Adequate nutrition is an important part of managing children with HIV infection.
All infants born to HIV-positive women should be given prophylactic co-trimoxazole from 6 weeks until one year or until HIV infection in the child has been excluded by PCR testing. Prophylaxis should be continued beyond one year in any child with clinical signs of HIV infection. Prophylactic co-trimoxazole syrup is usually given daily for 5 days a week (Monday to Friday). The dose depends on the child’s weight:
|< 5 kg||2.5 ml paediatric suspension|
|5–9 kg||5 ml paediatric suspension|
|10–14 kg||7.5 ml paediatric suspension|
|15–22 kg||10 ml (or 1 regular strength tablet)|
|> 22 kg||15 ml (or 1.5 regular strength tablets)|
Prophylactic co-trimoxazole decreases the risk of pneumonia caused by Pneumocystis. It also reduces the risk of other bacterial infections and diarrhoea due to some opportunistic infections.
Side effects to co-trimoxazole are uncommon in children. However, co-trimoxazole must be stopped immediately and the child referred if a maculopapular rash (red and easily palpable) develops as this may be the first sign of severe allergy to the drug.
Prophylactic co-trimoxazole reduces the risk of pneumocystis pneumonia.
Early, correct treatment of HIV infection can enable children to enjoy a good quality of life for many years.
Although HIV infection is believed to eventually have a fatal outcome, much can still be done to improve the quality and length of these children’s lives.
Because young children, especially those born pre-term, have an immature immune system, the course of the disease is more rapid than in adults.
The earlier the onset of symptomatic HIV infection, the poorer the expected outcome. Infants who are infected before delivery probably present early while infants infected via breast milk probably present late.
The clinical categories and immunological status (CD4 percentage) can be used to give an idea of the expected outcome. Children with asymptomatic HIV infection and an intact immune system (normal CD4 percentage) do best while the children with stage 3 or 4 HIV infection and a damaged immune system have the worst outlook.
Children with AIDS who do not receive antiretroviral therapy die much sooner than those who receive full treatment.
The progress in HIV-infected children can be roughly divided into 3 groups:
Children with an early onset of symptomatic HIV infection have the worst outcome.
Pneumocystis pneumonia and lymphoid interstitial pneumonitis are seen very rarely in HIV-negative children.
Pneumocystis pneumonia is a severe opportunistic infection caused a fungus called Pneumocystis jiroveci. This fungus does not cause pneumonia in healthy children. Therefore, a diagnosis of Pneumocystis pneumonia usually indicates that the child has AIDS. Pneumocystis pneumonia commonly presents in the first year of life with high fever, a cough and marked respiratory distress.
The risk of Pneumocystis pneumonia can be greatly reduced with co-trimoxazole prophylaxis from 6 weeks in all HIV-exposed infants (i.e. infants born to HIV-positive women).
Infants with suspected Pneumocystis pneumonia must be urgently referred to hospital for treatment with intravenous co-trimoxazole.
Yes. Tuberculosis is one of the commonest serious bacterial infections seen in children with HIV infection.
Tuberculosis is common in children with HIV infection.
Pulmonary TB due to Mycobacterium tuberculosis is the commonest form of TB in both HIV-infected and non-infected children. However, tuberculosis of other organs (extra-pulmonary TB) is far more common in children who are infected with HIV.
A combination of HIV and TB infection leads to rapid immunosuppression with progression of both diseases. As a result, TB is more severe in children with HIV infection.
TB in HIV-infected children usually responds well to treatment. However, multiple drug resistant TB is becoming a problem with HIV-infected children. It is the result of inadequate or incomplete treatment.
See chapter 8 for details on tuberculosis.
Except for children with mild, acute diarrhoea, all these children should be referred to hospital for further investigation and management. Oral candidiasis can usually be treated with local mycostatin or miconazole at a primary care clinic.
Many common skin conditions occur in children who are HIV-infected. However, they are more severe, and often take longer to respond to treatment, than in children who are not immunosuppressed. Common skin conditions in children with HIV infection are:
Any of these severe skin conditions, especially shingles, suggests that the child is infected with HIV. Molluscum contagiosum and warts are often extensive and do not recover spontaneously. Severe tinea capitis and impetigo often need systemic therapy and do not respond to local treatment.
Skin conditions and their management are discussed in chapter 12.
The neurodevelopment of children with HIV infection is often retarded. They may even lose developmental milestones that have earlier been achieved. Slow development may be due to chronic illness, hospitalisation, lack of stimulation at home or depression. However, HIV may infect the brain causing an encephalopathy. Children with HIV infection are also at increased risk of bacterial and tuberculous meningitis.
Very important. Children with HIV infection should receive an adequate balanced diet and a multivitamin supplement. Many children feel much better and become hungry once antiretroviral therapy is started. Therefore they may need financial support or free food supplements.
It is very important that opportunistic infections (HIV-associated infections which occur because the immune system has been weakened) are treated early and aggressively. If possible, tuberculosis should be well controlled before antiretroviral therapy is started. The use of prophylaxis with co-trimoxazole in children with immune suppression is important. INH prevention (prophylaxis) must be given to young children who have household contact with adults suffering from pulmonary tuberculosis.
With antiretroviral therapy, the aim should be to return the child to normal health, growth and development and maintain this for as long as possible. Antiretroviral therapy has changed AIDS from a rapidly fatal to a chronic, manageable illness.
Antiretroviral therapy prolongs and improves the quality of life.
There remains a lot of debate as to when treatment should be started and guidelines are changing rapidly as more information becomes available. In South Africa, treatment is started when either:
The clinical staging and CD4 percentage are used as indications for antiretroviral therapy.
The mother or carer must also be ready to accept the diagnosis and make a commitment to treatment (‘treatment-ready’).
It is most important that antiretroviral therapy is given correctly every day.
The first line choice of antiretroviral treatment with highly-active antiretroviral therapy (HAART) in South Africa is a combination of:
If there are serious side effects to one or more drugs, or if the patient fails to respond, a second line of treatment with a different combination of drugs will be necessary. These decisions will be made at an infectious disease clinic.
Highly-active antiretroviral therapy (HAART) is given with a combination of 3 drugs.
All antiretroviral drugs have side effects. Most are mild, especially in children. However some can be severe and even fatal in rare cases. Nausea, vomiting, headache, fatigue and mild rashes are common. Rash, raised liver enzymes, peripheral neuropathy and anaemia must be looked for. Most serious side effects occur within one month of starting treatment.
Poor drug compliance (not taking the medication on time every day) may lead to drug resistance and treatment failure.
All children on antiretroviral therapy must be monitored:
Unfortunately, there is not. However, an enormous amount of research is being done to develop an HIV vaccine. This holds the most promise of stopping the spread of the HIV epidemic.
HIV affects the whole family. Counselling is needed when the diagnosis is made and for some time afterwards until the family comes to both accept and disclose the diagnosis. HIV counselling is usually provided by lay counselors. The support of the community is also very important.
Families with AIDS are often very poor with little or no income. The bread winners are often ill or have died. A child may be head of the family. Many children with AIDS, and children from families with AIDS, become orphans. Social services and community organizations need to be involved in the management of children with AIDS. Financial grants may also be needed.
Almost all children with AIDS have parents who are HIV-infected. It is important that the whole family receives good care. In poor communities, the death of a mother often results in the death of her children, even if they are not HIV-infected.
The family of a child with AIDS usually needs emotional, medical and financial support.
Palliative care is the care given to patients who cannot be cured of their illness. It addresses the physical, emotional and psychological needs of the child and family. Because HIV infection is incurable, palliative care starts when HIV infection is first diagnosed and continues for the duration of the illness. Emotional and spiritual support is also important. The aim of palliative care in children is to achieve the best quality of life for the child and family.
Terminal care is the care given to children in the last stages of AIDS. Pain management is an essential part of terminal care. Terminal care is best provided at home (home-based care) by a multi-disciplinary team of nurses, doctors, social workers and members of the community. It should be compassionate and patient-centred (what is best for the patient). The Hospice movement has greatly improved the quality of terminal care both at home and in institutions.
Palliative care includes terminal care. During the final stages of the disease the aim shifts to keeping the patient comfortable with love and dignity, relieving distress, limiting or reducing the duration of any hospital admissions, and providing the family with additional support.
Palliative care starts when HIV infection is first diagnosed and continues for the duration of the illness.
A young woman is counselled and screened during pregnancy and found to be HIV-positive. She delivers at home and takes her infant to the clinic 3 days later. She breastfeeds for 24 months and introduces formula and solids from one month after delivery. The clinic refuses to give the routine immunisations because the child is positive for HIV on an ELISA screening test.
There is a 5% risk of HIV transmission during pregnancy plus a 15% risk during labour and vaginal delivery, giving a combined risk of 20%.
By giving both the mother and newborn infant prophylactic antiretroviral drugs.
About 15% as mixed breastfeeds (breast milk plus other foods) were given for 2 years. Therefore the total risk of mother-to-child transmission of HIV is 35% (5% + 15% + 15%).
Either exclusive breastfeeding (breast milk only with no other fluids or solids) or exclusive formula-feeding (formula but no breastfeeds).
No. HIV-exposed infants should receive their routine immunisations.
Not necessarily. Antibodies from an HIV-positive mother cross the placenta, giving the infant a positive screening test up to 18 months. A positive PCR test would indicate that this child was HIV-infected. However, a negative PCR test cannot exclude HIV infection until 6 weeks after the mother has stopped breastfeeding.
A 4-year-old child presents at a local clinic with loose stools for 6 weeks and a sore mouth. The Road-to-Health Card shows failure to thrive for the past 3 months. On examination the child is generally unwell and thin, has oral thrush, a rash and generalized lymphadenopathy. After counselling the mother, an HIV screening test (rapid test) is done. This is positive. The CD4 percentage is 20%.
Because failure to thrive with chronic diarrhoea and a sore mouth are common presenting signs of HIV infection.
Yes. Wasting, oral thrush (candidiasis), a rash and generalized lymphadenopathy are typical of symptomatic HIV infection.
Stage 3 as the child is generally unwell with chronic diarrhoea and oral candidiasis.
Yes, as the child is older than 18 months.
It shows that the child’s immune system has been weakened (normal above 25%).
The child should be referred to an HIV clinic where he can be evaluated for antiretroviral therapy. His oral thrush must be treated. Co-trimoxazole prophylaxis should be started. He needs an adequate balanced diet and the parents must to be counselled. They may also need emotional and financial support.
A 1-year-old child presents with severe pneumonia. The mother is know to be HIV-positive. On examination the child also has extensive scabies and chronic otitis media. The infant has not started to crawl yet.
Yes. With extensive scabies, you should always think of HIV infection. The pneumonia and chronic ear infection also suggests that this child has a suppressed immune system. Knowing that the mother is HIV-positive makes the diagnosis very likely.
Probably bacterial pneumonia, pulmonary tuberculosis or Pneumocystis pneumonia. This child needs urgent referral for investigation and treatment. A chest X-ray may show the typical appearance of pneumocystis pneumonia.
Prophylactic co-trimoxazole from 6 weeks is very effective in preventing Pneumocystis pneumonia in HIV-infected infants. It will also reduce the risk of other bacterial infections such as otitis media There is no history that this child received prophylaxis.
Yes. Retarded development is common in children with symptomatic HIV infection. It may be one of the first clinical signs of HIV encephalopathy, indicating stage 4 disease.
He has stage 4 HIV infections (i.e. AIDS) with severe immunosuppression. Without correct treatment, including antiretroviral therapy, he will probably die within months.
A 5-year-old girl, who was infected with HIV following a sexual assault, has been followed for 2 years at an HIV clinic. She has remained well until now when she presents with tuberculosis . On examination it is noted that she has bilateral parotid enlargement and an itchy papular rash Her CD4 percentage is less than 15%. She is started on TB treatment, followed 2 months later by antiretroviral therapy. Soon after beginning the antiretroviral therapy she feels nauseous and has headaches.
This is a very common early sign of HIV infection, as is an itchy papular rash.
Yes. HIV infection should be suspected in all children and adults with TB.
No. If possible the TB should be controlled first before the antiretroviral therapy is started.
Antiretroviral therapy (HAART) should always be started with 3 drugs (multi-drug therapy). This lessens the risk of drug resistance and treatment failure.
In South Africa the first-line treatment regime is d4T and 3TC (both nucleoside reverse transcriptase inhibitors) together with Kaletra (a protease inhibitor) in young children and nevirapene or efavirenz (a non-nucleoside reverse transcriptase inhibitor) in older children.
Yes. These are usually mild, especially in children. Nausea, vomiting, headache, fatigue and mild rashes are common and improve with time. Severe side effects can occur, but they are rare.