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1

Introduction to childhood HIV infection

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Contents

Objectives

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Introduction to HIV

1-1 What is HIV?

HIV stands for the human immunodeficiency virus. Viruses are extremely small, very simple organisms which can only exist and multiply by invading and taking control of a plant or animal cell (the host cell). Viruses are responsible for many different diseases. Unlike bacteria, they are not killed by antibiotics.

HIV is the human immunodeficiency virus.

Note
HIV was first identified in Paris in 1983. HIV is a new human virus which first appeared clinically in the 1950s. Recent genetic studies suggest it was probably transmitted to humans from chimpanzees in central Africa towards the end of the 19th century.

1-2 What type of virus is HIV?

Viruses may be divided into many different groups. HIV belongs to a group of viruses known as retroviruses. These viruses are unique in nature as they have a special enzyme called reverse transcriptase. This enzyme enables HIV to introduce its own genes into the nucleus of the host cell. The host cell is then instructed to produce millions of new copies of the virus each day. These are released into the bloodstream and can then infect other cells. Retroviruses usually cause long periods of silent infection before signs of disease appear.

HIV is a retrovirus.

Note
Retroviruses contain an RNA genetic code. The viral enzyme reverse transcriptase allows HIV to make double-strand DNA copies of its single-strand RNA. The viral DNA copy is then inserted into the DNA of the nucleus in the host cell. Only retroviruses have this ability to make a DNA copy of their RNA code.

1-3 What disease is caused by HIV?

HIV causes a chronic illness which is usually referred to as symptomatic HIV infection or HIV disease. When HIV infection has reached an advanced, serious stage it is called AIDS (acquired immune deficiency syndrome). Unfortunately, the public often uses the term AIDS incorrectly to describe the illness in anyone who is infected with HIV. Without treatment with antiretroviral drugs, AIDS is a fatal disease. HIV is the only cause of AIDS.

HIV causes a serious chronic illness.

A person who has HIV infection is said to be HIV-positive, while someone without HIV infection is HIV-negative.

1-4 What is the clinical presentation of HIV infection?

Symptomatic HIV infection may present in many different ways. The symptoms and signs of HIV infection are usually due to secondary infections caused by a wide range of organisms. While some of these organisms are the same as those that infect HIV-negative children, other infections are due to uncommon organisms not normally seen in children who are HIV-negative.

HIV infection may present with a wide range of symptoms and signs.

1-5 How does HIV cause disease?

HIV infects, damages and finally destroys a special type of lymphocyte (white cell) called a CD4 cell. As the CD4 cells play a very important role in the functioning of the immune system, this destruction of CD4 cells damages the immune system, leading to immune deficiency.

The normal immune system protects the body against infection. By killing CD4 cells, HIV infection weakens the immune system which is then no longer able to prevent infection by many viruses, bacteria, fungi and parasites. As a result the person becomes ill.

HIV infection damages the immune system by killing CD4 cells.

Note
HIV also damages other immune cells with CD4 receptors, such as macrophages and dendritic cells in the skin. About 10 billion copies of HIV are produced daily in infected adults.

1-6 Are there different types of HIV?

Two types of HIV are recognised: HIV1 and HIV2. Most HIV infection in southern Africa is caused by HIV1 which has many subtypes (clades). The important subtype in Africa is subtype C. Subtype B is the most common subtype in the developed world.

The spread of HIV

1-7 Is HIV infectious?

Yes. HIV infection can be spread from one person to another.

1-8 How is HIV transmitted from one person to another?

The virus may be transmitted from one person to another by:

  1. Unprotected sexual contact (horizontal transmission). Body fluids such as vaginal and cervical secretions, semen and blood may contain large numbers of HIV. HIV is not present in urine or stool, while very little is present in saliva.
  2. Crossing from a mother to her fetus or newborn infant (vertical transmission).
  3. Intravenous drug abusers who use or share syringes and needles which are soiled with HIV-infected blood.
  4. Health workers reusing disposable needles, blades or syringes, and using surgical instruments which are contaminated with HIV and have not been sterilised.
  5. Using HIV-contaminated needles or blades in traditional rituals (e.g. circumcision).
  6. Accidental needle-stick injuries.
  7. A blood transfusion with HIV-infected blood or other HIV-infected blood products such as factor VIII in haemophiliacs. This is very rare in South Africa, where all blood products are screened for HIV.
  8. Wet-nursing (feeding another woman’s infant) with HIV-contaminated breast milk.
  9. The common practice in some African societies of chewing food before giving it to an infant may also spread HIV.

There is no evidence that HIV can be spread by mosquitoes, lice or bed bugs. Neither can it be spread via food or water. In Africa HIV in adolescents and adults is most commonly spread by heterosexual intercourse.

HIV in adolescents and adults is usually spread by sexual intercourse.

1-9 How are children usually infected with HIV?

By the spread of HIV from a mother to her fetus or from a mother to her newly born or young infant. 95% of HIV-infected children are infected by their mother. Children may also be infected by sexual contact.

Children are usually infected with HIV by their mother.

1-10 What forms of sexual contact may transmit HIV?

  1. HIV is almost always transmitted in adolescents and adults by penetrative sexual intercourse (heterosexual or homosexual). However, all forms of oral sexual contact (mouth to vagina or mouth to penis) can also result in infection, although the risk is much lower. Deep kissing may possibly transmit HIV, especially if mouth ulcers are present. HIV cannot penetrate intact skin but may infect open sores, cuts and abrasions, or mucous membranes. The transmission of HIV is more common in uncircumcised men as the mucous membrane under the foreskin is easily infected.
  2. The thin, friable rectal mucosa is easily damaged during anal intercourse. This increases the risk of infection. The highest risk of sexual transmission for both men and women is during anal intercourse. The risk of HIV transmission from sexual intercourse is very high (up to 50%) in the first few months after one of the partners has become infected. The risk of infection is also raised if other sexually transmitted diseases are present.
  3. Sexually abused children may be infected with HIV by penetrative sexual intercourse.

1-11 Can you become infected with HIV during normal social contact?

Family and friends of an HIV-infected person do not become infected except by sexual contact. HIV is not transmitted by close social contact such as touching, holding hands, hugging and social kissing. HIV is also not spread by coughing, sneezing, swimming pools, toilet seats, sharing cooking, drinking and eating utensils or by changing a nappy. However, any bleeding, such as nose bleeds, may spread HIV.

Note
There are a few very rare but well-documented cases of horizontal HIV transmission between family members.

1-12 Can you have HIV infection and not be ill?

Yes. Adults are usually infected with HIV for years before becoming ill. Most children who are infected with HIV are clinically well (asymptomatic) for the first few months. However, the illness progresses rapidly in many children and by the age of 12 months almost 80% of HIV-infected children will have symptomatic disease. In Africa, by two years of age more than 50% of HIV-infected children will die unless the correct treatment is available.

Note
Most children are ‘fast progressors’ as the asymptomatic HIV infection rapidly leads to clinical illness.

Many adults and some children with HIV infection are clinically well.

1-13 Can an HIV-infected person who is well transmit the virus?

Yes. HIV is frequently transmitted by people who appear to be clinically well but are infected with HIV. This is the great danger of HIV infection as most infected people do not know that they have been infected. They are also unaware that they may transmit HIV to another person.

HIV in society

1-14 How common is HIV infection in the general public?

Over 36 million people worldwide have HIV infection. It is estimated that 7 million South Africans are infected with HIV. In 2014, more than 30% of all pregnant women in South Africa were HIV-positive. The province of KwaZulu-Natal had the highest prevalence. In some health districts, over 45% of pregnant women are HIV-positive.

Almost a third of pregnant women in South Africa are infected with HIV.

1-15 How can the sexual spread of HIV in the general public be reduced?

By practising the behavioural change of ‘ABC’:

A reduction in multiple sexual partners seems to have resulted in the declining HIV prevalence in some countries such as Uganda and Zimbabwe. However, all three behavioural changes are important but difficult to implement.

Recent additions to preventing HIV transmission include:

Antiretroviral treatment reduces the likelihood of HIV transmission by 96%.

1-16 How common is HIV infection in children?

At the end of 2015, 2 million children under the age of 15 years were infected with HIV worldwide. At least 83% of these children live in sub-Saharan Africa. At the end of 2015 there were about 240 000 children in South Africa with HIV infection.

1-17 How often does HIV infection cause death?

It is estimated that the under 5 mortality due to HIV in South Africa has dropped from 46% in 2008 to 8% in 2015. Many of these deaths could be prevented with the correct management. However, without antiretroviral treatment most people with HIV infection will eventually die of AIDS. With antiretroviral treatment HIV infection is ‘a life sentence, not a death sentence’.

1-18 Is HIV infection a more serious disease in children?

Yes. Because they are still young and have immature immune systems. As a result, the progress of HIV infection to illness and death is faster in children than in adults.

1-19 Is the HIV epidemic in South Africa still expanding?

Hopefully the rapid increase in new cases will slow down. Between 1990 and 2003 the rate of HIV infection in women attending state antenatal care clinics in South Africa has steadily climbed from less than 2% to reach about 30%. Since then this rate has persisted at approximately 30%. South Africa has one of the fastest-growing HIV epidemics in the world, with one to two thousand people infected every day.

South Africa has one of the fastest-growing HIV epidemics in the world.

1-20 What is the impact of HIV infection on society?

The epidemic of HIV infection is having a devastating impact on society in South Africa and other countries in sub-Saharan Africa. Since the start of the AIDS epidemic in South Africa, the average life expectancy had fallen from 60 to 45 years but has now increased again to 62.5 years in 2015.

In Africa the majority of people with HIV infection are female and most are from poor communities. This has a massive effect on the whole family and increases the risk of childhood undernutrition and death, even in HIV-negative children. The number of children who have lost one or both parents to HIV in Africa already exceeds 12 million. At the end of 2015 it was estimated that there were 3.7 million AIDS orphans in South Africa. As a result of the ever-increasing number of deaths, ill people and homeless children, HIV infection is having an enormous social and financial impact on all communities and placing a strain on the health services.

HIV infection is seriously affecting the lives of people in all communities in southern Africa.

HIV transmission from mother to child

1-21 When can HIV be transmitted from a mother to her infant?

Mother-to-child transmission of HIV (vertical transmission) may occur:

  1. During pregnancy
  2. During labour and delivery
  3. During breastfeeding

Most children with HIV are infected by mother-to-child transmission (more than 95%).

Most children with HIV are infected by mother-to-child transmission.

1-22 What is the risk of HIV transmission during pregnancy?

If antiretroviral prophylaxis or treatment is not used, the risk of HIV crossing the placenta from a mother to her fetus during pregnancy is about 5%. Although transmission may take place at any time during pregnancy, the risk is probably greatest in the last trimester (28 to 40 weeks of gestation).

A number of factors will increase the risk of HIV transmission during pregnancy:

  1. If the mother becomes infected with HIV during pregnancy
  2. If the mother has advanced HIV infection (stage 3 or 4)
  3. If the mother has a CD4 count below 350 cells/μl
  4. If the mother has a detectable viral load above 400 copies/ml

These women have a large amount of virus (high viral load) in their blood and are, therefore, more infectious.

Other factors which increase the risk of HIV crossing the placenta are:

  1. Chorioamnionitis (infection of the placental membranes)
  2. Malaria
  3. Amniocentesis (sampling amniotic fluid) or external cephalic version (manually turning a fetus in the breech position)
  4. Maternal undernutrition, including vitamin A deficiency

1-23 What is the risk of HIV transmission during labour and delivery?

If antiretroviral prophylaxis or treatment is not used, the risk of HIV crossing the placenta from a mother to her fetus during labour and vaginal delivery is about 15%. As with pregnancy transmission, mothers with a high viral load have a greater risk of infecting their infant.

Other factors which increase the risk of infecting the infant during labour and vaginal delivery are:

  1. Preterm labour
  2. Prolonged labour and prolonged rupture of the membranes (more than four hours)
  3. Episiotomy
  4. Instrument delivery (forceps or vacuum)
  5. The use of a scalp clip or fetal scalp pH monitoring
  6. Suctioning the infant’s mouth and nose after delivery
  7. Birth order. HIV infection is commoner in first-born than second-born twins
  8. If the mother has a detectable viral load above 400 copies/ml

The longer the infant is exposed to vaginal and cervical secretions during labour e.g. when there is a prolonged rupture of the membranes, the greater the risk of HIV infection.

1-24 Can elective Caesarean section reduce the risk of HIV transmission during labour and delivery?

Yes, provided it is performed before the onset of labour when the risk of HIV transmission during labour and delivery can be almost totally removed. However, the risk of post-operative bacterial infection is high in these mothers while Caesarean sections require additional staff, facilities and funds. Therefore, antiretroviral prophylaxis is the preferred method of reducing HIV transmission during labour and delivery.

1-25 What is the risk of HIV transmission during breastfeeding?

This depends on the method and duration of breastfeeding:

  1. With mixed breastfeeding for 24 months (when the infant is breastfed and also receives additional fluids or food such as water and porridge) the risk of HIV transmission is about 15% if antiretroviral prophylaxis is not used. The approximate risk of transmission is 5% during the first six months, another 5% during the second six months and an additional 5% during the second year.
  2. With exclusive breastfeeding (only breast milk with no additional fluid or food) the risk is much less.
  3. The risk is very small if the mother is on antiretroviral treatment or the infant is on antiretroviral prophylaxis.
  4. There is no risk of transmission during infant feeding if only formula is used (exclusive formula feeding).

Other factors which increase the risk of HIV transmission in the breast milk are oral candidiasis (moniliasis or thrush) in the infant and breast problems (cracked nipples, mastitis or abscess) in the mother. Mothers with a high viral load (either early or advanced HIV infection) are also at greater risk of transmitting HIV via their breast milk.

Note
About 300 000 infants are infected via breast milk worldwide annually.

1-26 What is the overall risk of HIV transmission from a mother to her infant?

Without the use of antiretroviral drugs, the total risk after a vaginal delivery and two years of mixed breastfeeding is approximately 35% (i.e. 5% in pregnancy plus 15% at delivery plus 15% with mixed breastfeeding).

The overall risk of mother-to-child transmission is 35% if steps are not taken to reduce the risk.

1-27 How can the risk of mother-to-child transmission be reduced during pregnancy and delivery?

  1. Avoid unplanned pregnancies. Many women would choose not to fall pregnant if they knew they were HIV-positive.
  2. Good antenatal care, including the early diagnosis and treatment of other sexually transmitted diseases.
  3. Screen all pregnant women for HIV infection when they first book for antenatal care. If negative at booking, repeat the screen at 32 to 34 weeks of gestation. HIV testing monthly during pregnancy, at the onset of labour or at delivery, at the 6 week immunisation visit and 3 monthly throughout breastfeeding.
  4. Some HIV-positive women may decide to have their pregnancies terminated.
  5. Avoid infection with HIV during pregnancy (‘ABC’).
  6. Reduce the amount of virus in the mother’s blood and body secretions with antiretroviral treatment.
  7. Avoid episiotomy, scalp clips and instrument deliveries if possible.
  8. Do not rupture the membranes unless there is a good obstetric indication.
  9. Do not routinely suction infants at birth (suctioning meconium-stained infants or infants who need resuscitation remains important).

Every effort must be made to keep the community, especially women of childbearing age, HIV-negative. Reduction in the number of unwanted pregnancies would significantly decrease the number of HIV-infected children.

Preventing unwanted pregnancies would reduce the number of HIV-infected children.

1-28 How can antiretroviral drugs be used to reduce the risk of mother-to-child transmission?

The prevention of mother-to-child transmission (PMTCT) is usually achieved by the use of lifelong antiretroviral treatment in all HIV infected pregnant or breastfeeding women regardless of their CD4 count, in addition to giving prophylactic antiretroviral drugs in their newborn HIV exposed infants. The aim of PMTCT is to reduce the amount of HIV in the mother’s blood and vaginal secretions and to protect the fetus and infant when exposed to HIV. PMTCT is given to both protect the infant and to treat the mother.

Note
The use of antiretroviral prophylaxis was first described in the USA in 1994. All HIV infected pregnant and breastfeeding women should be fast-tracked onto antiretroviral treatment for life with three drugs. Usually TDF (tenofovir), 3TC (lamivudine) and EFV (efavirenz) are used and provided together as a fixed dose combination (FDC) tablet.

1-29 How successful is the prevention of mother-to-child transmission?

In women who deliver vaginally and do not breastfeed the risk of transmission can be reduced to about 2% with PMTCT intervention. In both developed and developing countries mother-to-child transmission of HIV has been dramatically reduced due to successful PMTCT programmes.

Antiretroviral drugs have dramatically reduced mother-to-child transmission of HIV.

1-30 How is a prevention of mother-to-child transmission programme managed?

  1. This is provided as part of the routine maternity care.
  2. All pregnant women must book for antenatal care as soon as the pregnancy is confirmed.
  3. All pregnant women must be offered HIV screening. Mothers are given information in groups before screening so that they can make an informed decision. In South Africa mothers are given the opportunity to ‘opt out’ of screening (as with syphilis screening). Women have the right not to be tested.
  4. HIV-positive women must be individually counselled and offered immediate (same day) antiretroviral treatment (ART).
  5. Newborn infants born to HIV infected women should be given prophylactic antiretroviral drugs.
  6. HIV-positive women must be counselled about feeding options.
  7. All pregnant women must be encouraged to practise safer sex. HIV-negative women must be told about how to remain negative.
  8. Certain healthcare practices may be altered (e.g. no unnecessary rupture of the membranes).
  9. Elective Caesarean section because the mother is HIV-positive is rarely indicated now that antiretroviral prophylaxis is available.

HIV in a family is often first detected because of HIV screening during pregnancy. This provides an opportunity to manage the whole family.

1-31 What regimen of antiretroviral prophylaxis is used?

  1. The mother should be given lifelong TDF + 3TC + EFV from the time that HIV infection is diagnosed. Antiretroviral treatment should be given during pregnancy, labour, breastfeeding and continued after breastfeeding has been discontinued.
  2. The infant should be given nevirapine (NVP) at birth and then daily for six weeks, unless there are circumstances that warrant 12 weeks of NVP or dual prophylaxis of NVP plus zidovudine (AZT).

Antiretroviral treatment to the mother and nevirapine prophylaxis to the infant are used to prevent mother-to-child transmission of HIV.

1-32 How should antiretroviral treatment be given to the mother to reduce the risk of vertical transmission of HIV?

  1. Throughout pregnancy, labour, breastfeeding HIV infected women should be given TDF + 3TC + EFV. Thereafter, mothers should remain on lifelong antiretroviral treatment.
  2. TDF, 3TC and EFV are combined in a single tablet, which is administered once daily

1-33 How should nevirapine be given to the infant at birth to reduce the risk of vertical transmission of HIV?

The first dose of nevirapine is given to the infant within 6 hours after delivery. Thereafter, a daily NVP dose is administered. The dose of NVP to the infant depends on the infant’s weight and age after birth:

1-34 How should zidovudine be given to the infant to reduce the risk of vertical transmission of HIV?

Both NVP and AZT (dual prophylaxis) is given to some categories of high risk HIV exposed infants. The first dose of oral AZT should be given to the infant within 6 hours after delivery. Thereafter, AZT should be administered twice daily. The dose of oral AZT to the infant is 10 mg twice daily if 2.0 to 2.5 kg and 15 mg twice daily if above 2.5 kg, between 0 and 6 weeks of age.

1-35 Which HIV exposed infants should receive nevirapine prophylaxis for 6 weeks?

All infants born to HIV infected mothers who have been on antiretroviral treatment for more than 4 weeks before delivery.

Most HIV exposed infants are given 6 weeks nevirapine prophlaxis after birth.

1-36 Which HIV exposed infants should receive nevirapine prophylaxis for 12 weeks?

Nevirapine prophylaxis to infants should be extended to 12 weeks after birth if the mother has not received antiretroviral treatment before delivery:

  1. All infants born to mothers who test HIV-positive for the first time during or soon after delivery and therefore did not receive any antiretroviral treatment before or during delivery
  2. Infants born to HIV-positive mothers who started antiretroviral treatment less than 4 weeks before delivery

Infants should receive 12 weeks HIV prophylaxis if their mother has not received adequate antiretroviral treatment before delivery.

1-37 Which HIV exposed infants should receive nevirapine and zidovudine dual prophylaxis?

All infants born to HIV-positive mothers whose latest viral load was above 1000 copies/mL, should be given dual NVP and AZT prophylaxis for 6 weeks. Both drugs are used as these infants are at high risk for HIV infection. If at 6 weeks the mother’s viral load is still above 1000 copies/ml discuss further management with an experienced paediatric clinician before prophylaxis is discontinued.

Infant should receive dual prophylaxis if their mother has a high viral load and is at increased risk of transmitting HIV.

1-38 How should a breastfeeding mother who is diagnosed HIV-positive at delivery and her newborn infant be managed?

  1. The mother should be started on lifelong antiretroviral treatment, consisting of TDF + 3TC + EFV.
  2. The infant should be started on NVP and AZT dual prophylaxis. A HIV PCR test should be performed on the infant. If the HIV PCR test in negative AZT should be stopped and NVP continued for 12 weeks. However, if the infant tests HIV PCR positive a confirmatory HIV PCR should be performed and the infants referred for starting antiretroviral treatment.

1-39 How should a newborn infant be managed if the maternal HIV status is unknown?

The infant should be started on NVP prophylaxis and tested for HIV by rapid test. If the rapid test is negative the infant is not HIV exposed and NVP prophylaxis should be stopped. If the rapid test is positive an HIV PCR test should be performed on the infant. If the HIV PCR test is negative, NVP prophylaxis should be continued for 6 weeks for HIV exposure. However, if the HIV PCR test is positive a confirmatory HIV PCR should be performed and the infant referred to start antiretroviral treatment as the infant is HIV infected.

Note
Unknown maternal status may arise if the infant has been abandoned.

Feeding options

1-40 What factors may increase the risk of HIV transmission via breast milk?

  1. If the mother becomes infected with HIV while she is still breastfeeding, the risk of HIV transmission to the infant is as high as 50%. Therefore, breastfeeding women who are HIV-negative should not have unprotected intercourse.
  2. The risk is also increased in women who have a low CD4 count, high viral load or clinical signs of advanced HIV infection.
  3. Cracked or bleeding nipples and mastitis or breast abscess increase the risk of transmission. Good breast care is, therefore, important for HIV-positive women who breastfeed.
  4. Sores in the infant’s mouth, such as oral candidiasis (thrush). HIV-positive mothers should take their infants to a clinic for early treatment if they notice oral candidiasis.
  5. Mixed feeding, with breast milk plus formula feeds or solids, increases the risk of HIV transmission.
  6. Mothers on antiretroviral treatment with the most recent viral load greater than 1000 copies/mL.
  7. An HIV-positive breastfeeding mother who is not on antiretroviral treatment.

Good breast care and exclusive breastfeeding are important to reduce the risk of HIV transmission.

By preventing or treating these conditions the risk of transmission can be reduced.

In contrast, antiretroviral prophylaxis or treatment makes breastfeeding much safer.

Note
With mixed feeding, the formula or solid food is believed to cause mild inflammation of the gut which allows entry of HIV from breast milk.

1-41 Should all HIV-positive mothers formula feed their infants?

Not necessarily. There are advantages and dangers of both breastfeeding and formula feeding infants who are born to HIV-positive women. The great danger of breastfeeding, especially mixed breastfeeding, is the additional risk of HIV transmission to the infant. However, the advantages of breastfeeding are the lower risk of gastroenteritis and undernutrition, especially in poor, rural communities. The advantages of breastfeeding (especially exclusive breastfeeding), may outweigh the dangers for many HIV-positive mothers from poor communities. In contrast, it would be safer for most HIV-positive women in urban areas to formula feed their infants.

Recent studies show that the risk of HIV transmission in breast milk is low if the infant receives antiretroviral prophylaxis and very low if the mother is receiving antiretroviral treatment with three drugs.

Each HIV-positive mother should be counselled and informed of the risk and advantages so that they can make the best choice for their infant. While advice can be offered, women should not be instructed what to do. They should be encouraged to choose between exclusive breastfeeding and exclusive formula feeding. Once a woman has made her choice she should be supported in her decision by health workers. It is important that women decide on their chosen method of infant feeding before delivery. Mixed breastfeeding should be avoided if possible. Wet nursing (where the infant is breastfed by someone other than the mother) must be discouraged.

Note
In August 2011 at a National Consultative Breastfeeding Meeting, South Africa signed the Tswane declaration which states that it is a country that actively promotes, protects and supports exclusive breastfeeding even for HIV exposed and infected infants.

1-42 Is exclusive breastfeeding easy?

Unfortunately mothers need a lot of help and support from their family and healthcare workers to successfully breastfeed exclusively as this is not the traditional method of breastfeeding in most communities.

1-43 When should HIV-positive women stop breastfeeding?

If HIV-positive women choose to breastfeed, they should be counselled to exclusively breastfeed their infants for 6 months and then continue breastfeeding until their infant is 12 months of age while introducing appropriate complementary feeds. Mothers should be counselled about the increased risk of HIV transmission during the first 6 months of life from mixed feeding.

1-44 How should HIV-negative women feed their infants?

It is very important that HIV-negative women and women who do not know their status are not influenced to formula feed by advice being given to some HIV-positive women. Exclusive breastfeeding should be promoted among HIV-negative mothers.

1-45 How should a mother decide what feeding method to choose?

It is advisable that the following criteria should be met if a mother is to exclusively formula feed:

  1. It should be acceptable to her family and friends. There are social and cultural barriers to formula feeding in many poor communities. In some communities women may be afraid of not breastfeeding.
  2. It should be feasible to formula feed. The mother must have the knowledge and skills to make up formula correctly.
  3. It must be affordable to formula feed. Formula is expensive. Formula milk is not provided routinely through the PMTCT programme.
  4. It should be sustainable. Formula must be available. Mothers often live far from shops in rural areas.
  5. It should be safe. Clean water must be available. The mother should be able to prepare feeds hygienically and be able to clean the bottles, teats and cups. Access to primary healthcare is particularly important if infants are formula fed.

Formula feeding is only recommended if all the above criteria are met. If not, it would be better for women to exclusively breastfeed unless the risk of HIV transmission in breast milk is greater than the dangers of formula feeding. Women who decide to formula feed must be taught how to prepare and give formula correctly. A cup rather than a bottle should be used as cups are easier to clean.

Women should exclusively breastfeed unless the risk of HIV transmission via breast milk is greater than the dangers of formula feeding.

Note
WHO uses the acronym AFASS for acceptable, feasible, affordable, sustainable and safe.
Note
Specially designed feeding cups can be obtained from Sinapi Biomedical (chrisd@sinapi.co.za or 021 887 5260).
Note
The only National Department of Health approved HIV related medical indication where formula milk may be provided is when a mother has been on second or third line antiretroviral treatment for at least 3 months and still has a viral load above 1000 copies/ml. Mothers who are too ill to breastfeed, e.g. MDR-TB, will be provided with formula milk.

1-46 How can you tell whether an HIV-exposed infant has HIV infection?

Most HIV infected infants appear normal and healthy at birth. Therefore clinical examination cannot be used to determine which newborn infants are infected with HIV and which are not (i.e. only HIV exposed). HIV does not cause congenital abnormalities (birth defects). The clinical signs of HIV infection often appear between three and six months of age.

The rapid test detects whether HIV antibodies are present. Therefore it will be positive in all infants born to women who are HIV-positive as the maternal HIV antibodies (IgG) crosses the placenta to the fetus. All HIV exposed infants (both HIV-infected and non-infected infants) may have a positive screening test (rapid test) up to 18 months of age as the maternal antibodies may remain in the infant until this time.

The only reliable method of telling whether an infant under the age of 18 months has been infected with HIV is to perform a PCR (polymerase chain reaction) blood test on the infant. This detects HIV genetic material. HIV exposed infants should be tested by HIV PCR:

A positive PCR test should be confirmed with a second PCR test before HIV infection is diagnosed in a child less than 18 months of age.

At 18 months of age all HIV-exposed infants should be tested with a rapid HIV antibody test.

The ultra-sensitive p24 antigen test can be used instead of the PCR test.

Note
The DNA-PCR test is used to diagnose and confirm HIV infection while the RNA-PCR test is used to measure viral load and confirm the DNA test.

Post-exposure prophylaxis

1-47 How can HIV infection be prevented after a child is sexually assaulted?

Every effort must be made to prevent assault, especially sexual assault. However, should a child be sexually assaulted (rape or sodomy), post-exposure prophylaxis must be started within 72 hours to reduce the risk of HIV infection. The sooner the treatment is started the more likely it is to be effective. HIV can also be transmitted by human bites.

Usually three drugs are used for post-exposure prophylaxis. In younger children:

In children over 35 kg and 12 years TDF (Tenofovir) is used instead of ABC. All antiretroviral drugs are dosed according to the national guidelines.

Antiretroviral prophylaxis is given for 28 days. A rapid test (or PCR if the child is less than 18 months old) six weeks after the assault will indicate whether the child has become infected with HIV despite the prophylaxis. This is often repeated after a further six weeks. Usually an HIV screening test is done on the child to exclude previous infection before prophylaxis is started.

Note
Compliance with prophylaxis can be a problem, especially as lopinavir/ritonavir suspension causes side effects such as nausea, vomiting and lethargy. Nausea is less of a problem in children than adults. An antiemetic, such as oral cyclizine (Valoid) to prevent nausea may be helpful in older children. D4T (stavudine) is better tolerated than AZT and may be used when side effects to AZT develop.

1-48 Are nurses and doctors at risk of infection when caring for HIV-positive children at a clinic?

Yes, as most body fluids, especially blood, may contain HIV. Therefore, healthcare workers can become infected by HIV through needle-stick injuries or by cutting one’s finger during minor surgery. It is also possible to become infected with HIV through sores or abrasions of the skin when handling body fluids, especially blood.

1-49 How can healthcare workers reduce the risk of HIV infection?

By adopting standard (universal) precautions. This means that all body fluids should be regarded as potentially infectious in all patients. Precautions should always be taken to prevent exposure to HIV, especially when taking a blood sample.

1-50 What are the standard precautions to prevent HIV infection when caring for children?

All adults and children should be regarded as being potentially HIV-positive. Therefore, standard precautions should be taken with all children. These precautions are especially important in children known to be HIV-positive.

  1. Wash your hands, or spray them with disinfectant, after touching a patient or after handling body fluids. Wash your hands with soap and water immediately should they become contaminated with blood. Any cuts or sores on your skin should be covered.
  2. If possible, gloves should be used when taking a blood sample, especially if the patient is known to be infected with HIV.
  3. All spilt blood must be cleaned up immediately and the surface wiped with a hypochlorite solution (Biocide, Milton or Jik mixed 2:1 with water). Use paper towels, which should then be placed in an approved disposal bag for incineration.
  4. All blood specimens for the laboratory must be placed in a leak-proof packet or container.
  5. Be very careful when handling ‘sharps’ (needles, blades, lancets).
  6. Bedding, clothing or nappies contaminated with blood should always be safely disposed of in an appropriate bag or container.

Standard precautions should be adopted when managing all patients.

1-51 How should sharps be handled?

  1. Whenever sharps (needles, blades, lancets) are used, great care must be taken not to puncture or injure your skin.
  2. Handling of sharps should be reduced to a minimum.
  3. Needles must not be resheathed.
  4. Once used, always keep the sharp end of a needle, blade or lancet pointing away from you. Be careful not to stick anyone accidentally.
  5. After withdrawing the sharp from the skin, immediately place it in the sharps container. The container must be within easy reach before starting the procedure. Failure to do this is the commonest way healthcare workers are infected with HIV while on duty.
  6. Never place a used sharp on the bed or work top.
  7. Correctly designed sharps containers must always be available. Do not allow them to become overfilled. They should be collected and be disposed of in a safe manner.

Always use a sharps container for the disposal of lancets or needles and never resheath a needle.

1-52 What is the risk of HIV infection after an accidental needle-stick injury?

If the patient is infected with HIV, the overall risk is 1 in 300. Therefore, of every 300 healthcare workers who prick or cut themselves with an instrument covered with HIV-positive blood, one person will become infected with HIV. With the correct use of antiretroviral prophylaxis this risk is reduced by 80%. The risk of infection is greatest if the child has AIDS or has recently been infected with HIV (because the child will have a high viral load). It is also higher if prophylaxis is not given correctly.

1-53 What antiretroviral prophylaxis should be given to a healthcare worker accidentally exposed to HIV?

No prophylaxis is needed with blood contact with intact skin. However with non-intact skin (cuts or open sores), mucosa (eye or mouth), superficial (sharp) or deep (needle) injury prophylaxis is needed. Every effort must be made to start prophylaxis as soon as possible, up to 72 hours after exposure. Treatment is given orally for 28 days.

Three drug prophylaxis is recommended:

AZT is no longer used as it often makes the healthcare worker feel nauseous and unwell. It is important to take the full course of drugs. Usually an HIV screening test is done on the healthcare worker to exclude previous infection before prophylaxis is started. An HIV screening test six weeks after exposure will indicate whether the prophylaxis has been effective or not. This is often repeated after a further six weeks.

Note
Atazanavir/ritonavir or raltegravir causes fewer side effects and can be used instead of lopinavir/ritonavir should lopinavir/ritonavir cause severe side effects.
Note
If TDF is contraindicated then stavudine (d4T) 30 mg twice daily, 3TC 150 mg twice daily plus lopinavir/ritonavir 2 tablets twice daily may be prescribed.

1-54 What is the correct procedure after a needle-stick injury?

After a needle-stick (‘sharps’) injury the following procedure should be followed:

  1. Do not panic. Encourage bleeding from the puncture site and wash with soap and water. The mouth or eyes should immediately be washed with water after a blood splash.
  2. Notify the correct hospital or clinic authority. Every hospital and clinic must have a clear management policy for accidental HIV exposure. This should be available to all staff. Everyone must know who the correct person is to contact should an accidental HIV exposure occur.
  3. Start prophylactic antiretroviral treatment as soon as possible, within 72 hours of the accidental HIV exposure. These drugs must be readily available in all hospitals and clinics both day and night. Do not wait for the screening results.
  4. Obtain consent and collect blood samples from the child for an HIV screen. If consent is refused, assume that the child is HIV-positive.
  5. An HIV test on the healthcare worker is recommended if the patient tests positive. This is done to make sure that the healthcare worker is not already HIV-positive. If so, prophylaxis is not indicated.
  6. Notify the laboratory that two urgent HIV tests are needed for screening. The screening test must be done as soon as possible.
  7. If the HIV test on the child’s blood is negative, stop treatment. If the test is positive, continue treatment for 28 days.
  8. Repeat the HIV test on the healthcare worker after six weeks to determine whether or not he/she has become HIV-positive. If the test is negative, repeat after another six weeks.
  9. Counselling is recommended for all healthcare workers exposed to HIV-contaminated blood.

All hospitals and clinics must keep emergency packs of prophylactic antiretrovirals for staff with accidental exposure to HIV.

Case study 1

A mother brings her 20-month-old son to a local clinic as he is unwell. On examination the child has clinical signs of HIV infection and the mother’s screening test for HIV is positive. She is very upset as she did not know her positive HIV status. She is clinically well.

1. How is HIV infection usually spread between adults?

By unprotected sexual intercourse.

2. Could this mother have been infected with HIV during normal social contact?

No, as HIV is not transmitted during normal social contact such as touching, holding hands, hugging and social kissing. HIV is also not spread by toilet seats, shared cooking, drinking or eating utensils.

3. How can this mother be infected with HIV and not be ill?

Most HIV-infected adults are not ill as HIV infection usually takes years before it causes illness in adults.

4. How is HIV infection commonly spread to young children?

Most are infected from their mothers during pregnancy, labour or delivery, or through breast milk (vertical or mother-to-child transmission).

5. What is the risk of HIV infecting the unborn infant during pregnancy?

About 5% if antiretroviral prophylaxis is not used. This risk is increased if the mother is infected with HIV during pregnancy or has advanced (stage 4) HIV disease. Other risk factors during pregnancy include malaria and malnutrition, especially vitamin A deficiency.

6. Is the risk of HIV transmission higher during labour and delivery?

Yes. During normal labour and vaginal delivery without antiretroviral prophylaxis the risk of mother-to-child transmission is about 15%. The overall risk of transmission during pregnancy, labour and delivery is, therefore, about 20%.

Case study 2

Parents bring their three-year-old daughter to a general practitioner for a second opinion. The child has been diagnosed with HIV infection at the local hospital. The parents have very little knowledge about HIV infection and AIDS.

1. How common is HIV infection in South Africa?

It is estimated that 7 million South Africans are infected with HIV. Almost a third of pregnant women in South Africa are infected with HIV.

2. How many children are infected with HIV in South Africa?

About 240 000 at the end of 2015. HIV infection is one of the major causes of death in both children and adults in most developing countries.

3. What is the impact of the HIV epidemic on children in society?

Not only does HIV infection cause illness and death of children but also loss of parents. This may result in many homeless and orphaned children. Everyone in society is affected by the HIV epidemic.

4. How does HIV infection cause illness?

By damaging the body’s immune system and making one more susceptible to a wide range of other infections.

5. Why is HIV infection more serious in children than adults?

Because children have an immature immune system, the illness caused by HIV progresses more rapidly.

6. How soon can you tell whether a child has been infected with HIV?

A PCR test done on all HIV exposed infants at birth and repeated at 10 weeks will indicate whether the infant is infected or not. For infants who receive 12 weeks of NVP, the PCR test should be repeated at 18 weeks. Furthermore, if the mother breastfeeds the PCR test should be repeated on her HIV exposed infant if not on antiretroviral treatment again six weeks after she stops breastfeeding.

An HIV antibody screening test (rapid test) can reliably exclude HIV infection in children only at or beyond 18 months of age.

Case study 3

The superintendent and his staff of a small hospital plan to start a programme of antiretroviral prophylaxis in the maternity service. They are looking at various options and have asked for guidelines.

1. What antiretroviral drugs are usually used in a HIV-positive woman to prevent mother-to-child transmission?

TDF (tenofovir) + 3TC (Lamivudine) + EFV (efavirenz)

2. What prophylaxis should be given to an infant if her mother has been on antiretroviral treatment for more than 4 weeks?

NVP (nevirapine) for 6 weeks.

3.What prophylaxis should be given to an infant if his mother’s latest viral load is greater than 1000 copies/ml?

AZT (zidovudine) and NVP (nevirapine) for 6 weeks.

4. What drug prophylaxis should be offered to staff members who prick their finger while taking blood from an HIV patient?

Therapy for 28 days with TDF and 3TC/FTC daily, plus lopinavir/ritonavir twice daily.

Case study 4

An HIV-positive pregnant woman is being counselled at an antenatal clinic. She asks the midwife whether she should plan to breastfeed her infant. This mother lives in a rural community with poor facilities. She has come to town to deliver her infant and wants to return home as soon as possible after the birth.

1. How should you help this mother to make a wise feeding choice?

You should give her the necessary information so that she can make the best choice for herself and her infant. Do not simply push her into doing what you think is best.

2. Is there a risk to her infant if she decides to breastfeed?

Yes, as HIV is present in breast milk. With mixed breastfeeding (breast milk plus other liquids or solids) for two years and no antiretroviral treatment there is a 15% chance of the HIV in her breast milk infecting her infant. The risk is much less with exclusive breastfeeding for six months followed by the introduction of complementary feeding, provided that she remains on antiretroviral treatment.

3. Could formula feeding be dangerous for her infant?

Probably not if she remained in town for the first few years. However, she plans to return to a rural area where formula milk may not be available, affordable or safe. It may also not be acceptable to her family and community. The result may be malnutrition and gastroenteritis in her infant.

4. What problems with her breasts could increase the risk of HIV transmission to her infant?

Mastitis or breast abscess. These can be avoided with good breastfeeding practices. Therefore it is important to teach this mother how to breastfeed correctly.

5. What do you think would be her best feeding option?

Probably to exclusively breastfeed for six months unless she is able to safely formula feed at her rural home. Antiretroviral treatment for the mother or prophylaxis for the infant will greatly reduce the risk of HIV transmission.