Pediatric AIDS contribute 2% of all HIV infected case in developed countries as compared with 15-20% in developing countries.
At the end of 2007, there were 2.5 million children living with HIV around the world.
420,000 children became newly infected with HIV in 2007.
Of the 2.1 million people who died of AIDS during 2007, more than one in seven were children. Every hour, around forty children die as a result of AIDS.
Because HIV infected mothers are likely to dies of AIDS,10 million children orphaned thus far and an estimated 20 million will be orphaned by 2010.
In India approximately 30000 of that 27 million deli varies occur in seropositive women & between 6000-8000 infant are thought to be perinatelly infected with HIV.
All above data shown that HIV infection in children progress more rapidly than in adults ,and some untreated children die with in the first 2 yr of life.
AIDS was first reported June 5 , 1981 , when the U.S. Centers for Disease Control and Prevention recorded a cluster of Pneumocystis carinii pneumonia (now still classified as PCP but known to be caused by Pneumocystis jirovecii ) in five homosexual men in Los Angeles .
Three of the earliest known instances of HIV infection are:
A plasma sample taken in 1959 from an adult male living in Kinshasa , today part of the Democratic Republic of the Congo.
HIV found in tissue samples from " Robert R. ", a 15 year old African-American teenager who died in St. Louis in 1969.
HIV found in tissue samples from Arvid Noe , a Norwegian sailor who died around 1976.
First pediatric case of AIDS globally was recognised in 1982.
In india first AIDS patient was recognised in 1986.
AIDS is caused by a virus called HIV, the Human Immunodeficiency Virus.
When HIV virus was first identified it was called “Lymphadenopathy associated virus” (LAV) by the French scientist.
Researcher in USA called it Human T lymphocytic virus III ( HTLV III).
In may 1986, the international committee on taxonomy gave it a new name HIV.
An enveloped virus, approximately 120 nm in diameter.
Sub family :- Lentivirus
Two species of HIV infect humans: HIV-1 and HIV-2 .
HIV-1 is more virulent and more easily transmitted.
HIV-1 is the source of the majority of HIV infections throughout the world, while HIV-2 is not as easily transmitted and is largely confined to West Africa. Both HIV-1 and HIV-2 are of primate origin.
The origin of HIV-1 is the Central Common Chimpanzee ( Pan troglodytes troglodytes ) found in southern Cameroon . It is established that HIV-2 originated from the Sooty Mangabey ( Cercocebus atys ), an Old World monkey of Guinea Bissau , Gabon , and Cameroon.
HIV 2 has about 40% sequence homology with HIV 1.
HIV genome is single stranded RNA 9.8 in size.
Both the ends have identical regions that contain regulation & expression genes of HIV. The remainder genome has 3 major section :-
Gag region –encode for viral protein
Pol region – produce viral enzyme.ex: Reverse transcriptase,protease,integrase etc
Env region – encode for viral envelop protein
Other regulatory protein such as tat,rev,vif,vpr,hef,vpw are involved in transactivation,viral mRNA expression, viral replication, promotion of nuclear import of viral reverse transcription.
Complexes down regulation of cell surface receptor CD4 & class I major histocompatibility complex, proviral DNA synthesis & virus release.
The important one include glycoprotein gp120 which has knob like structure,inteact with protruding loop on CD4 protein forming CD+-gp120 complex,gp41(envelop protein) & p24(core protein).
CXCR -4 act as co receptor for HIV attachment to lymphocyte.
CCR-5 a beta chemokinine co receptor that facilitate HIV into macrophage.
HIV virus is easily killed by heat(56 C for 30 min). It is readily inactivated by ether,acetone,20%ethanol,.2%sodium hypochlorite,1%gulatealdehyde,beta propioacetone(1:400 dilution).
It is relatively resistant to ionizing radiation & ultra violet light.
HIV binds via the viral envelop protein gp120 to CD4 receptor on the target cell.
Virus fuses with the host cell membrane & is internalized in an endosome.
Viral RNA genome Double helical DNA
Transported to host nucleus
Integrated into host genome (proviral DNA)
The virus are assembled at cell membrane & are release by budding. The host cell either ruptures releasing virions is attached by the immune system & continued to produce virions.the virus spread to infect other cell,most of which express the CD4 protein.
Unlike HBV which is highly infectious, the HIV virus has less infectivity. Probably because relatively small number of infectious particle (I.P) circulating in blood.10-50 IP/ml of HIV are present in plasma of infected person as compared to 100000000 IP/ml of HBV.
However, the likely hood of becoming infected with HIV after receiving an HIV +ve blood product is nearly 100%.
The initial outcome of HIV infection depends on host’s immune reaction to virus either through falling of the infected cells or through suppression of further HIV multiplication.
The viruses has been found in greatest concentration in semen, blood & CSF.
Lower concentration have been detected in tears,saliva,breast milk,urine,cervical & vaginal secretions.
HIV has also been isolated in brain tissue, lymph nodes, bone marrow cells & skin.
Cases & carrier are one.
Once a person is infected, virus remains in the body life long. since HIV infection can take years to manifest itself. The symptom less carrier can infect other people for years.
Persons engaging in unprotected sex
Sexual partners of those who participate in high-risk activities (such as anal sex)
Intravenous drug users who share needles
Infants born to mothers with HIV who don't receive HIV therapy during pregnancy
People who received blood transfusions or clotting products between 1977 and 1985 (prior to the beginning standard screening for the virus in the blood)
The causative virus is transmitted from person to person most frequently through :-
Blood & blood product
This horizontal transmission however accounts for only 10-15% cases of AIDS in children.
HIV infection are acquired from infected mother resulting in vertical transmission to her offspring.
Rate of vertical transmission is 13-50%.
HIV is transmitted to infant-during gestation( in utero 30-40%),during delivaries(intrapartum 60-70%),postpartum(through breast feeding 14%).
Potentially routes of infections includes admixture of maternal fetal blood or viral infection across placenta alternately or extensive mucocutaneous exposure to maternal blood & vaginal secretion intranately.
Factors which may increase rate of vertical transmission :-
High level of viremia
Maternal seroconversion just before delivery
Vitamin A deficiency in mother
>4 hr duration of PROM
Delivary before 34 week
Birth weight <2500gm
Detectable P24 antigen in maternal serum
Absence of neutralizing antibodies in maternal serum
Maternal CD 4 +count <700/cubic mm
Placental membrane inflammation
First born twin
Lack of anti viral therapy to infected women
HIV -1 has been detected by culture & by PCR method in cellular & acellular component of breast milk.
The colostral viral lode appears to be particularly high.
Fetal gut cells are susceptible to infection with HIV-1,such a route is facilitated by the absence of an cid environment in newborn baby’s stomach that allow HIV -1 to retain its infectivity.
Shorter incubation period
LIP is common
Acute HIV syndrome almost never identified.
*LIP- lymphocytic interstitial pneumonitis
Larger incubation period
LIP is rare
Acute HIV syndrome can be seen 4-6 week after transfusion.
HIV Infected :-
A child less than 18 months of age who is HIV seropositive or born to HIV infected mother & has seropositive results on two separate determination from one or more of the following test:
HIV specific PCR
Clinical criteria for AIDS diagnosis
A child 18 month of age or older born to HIV infected mother or infected by blood,blood product or other known mode of transmission. who is HIV antibody+ve by:
A child who dose not meet above criteria but who is HIV seropositive by:
< 18 month of age at the time of testing
Unknown antibody status, but was born to HIV infected mother
Sero reverter :-
A child born to HIV infected mother & who has been documented as HIV antibody negative ie
2 or more –ve ELISA test performed at 6-18 month of age
One –ve ELISA test after 18 month of age
And has no other lab evidence of infection & has not had an AIDS defining condition.
INCUBATION PERIOD –
From a few month to 10 years or even more.
The clinical manifestation of HIV infection varies widely among infant, children & adolescents.
In most of infants physical examination at birth is normal.
Failure to thrive
Chronic or recurrent diarrhea
SYMPTOMS more commonly found in children than adults are-
Recurrent bacterial infection
Chronic parotid swelling
Early progressive neurological deterioration
HIV classification system is used to categorize the stage of pediatric disease by using 2 parameters-
Cryptosporidiosis or isopsoriasis with diarrhea for >1 month
Recurrent or persisent sinusitis or
Persisentor recurrent diarrhea
HSV infection >1 month
Recurrent HSV stomatitis(>2 incident in 1 yr)
HSV bronchitis,pneumonitis,esophagitis with onset <1 month of age
Recurrent herpis zoster
Primary lymphoma in brain
LIP or pulmonary lymphoid hyperplasia complex
Pneumocystitis carini pneumonia
Persistent fever >1 month
Recurrent salmonella septicemia
Toxoplasmosis onset before 1 month of age
Toxoplasmosis of brain onset at>1 month age
Severe weight loss
* Category N - Asymptomatic
Use of CD4 counts to asses HIV associated immunosuppresion in children are not free from problems, since:
Normal CD4 counts are higher in infants & younger children & decline over the first few year of life.
Children may develop opportunistic infection at higher level than adults.
Nevertheless, CD4 levels are apparently useful to asses the immunological status of HIV infected children.
Immunological Categories Age of child Cells/micro liter <12 month 1-5 years 6-12 years No evidence of suppression >1500 >1000 >500 Evidence of moderate suppression 750-1499 500-999 200-499 Severe suppression <750 <500 <200
Most common serious infection is -
Deep seated abscess
Bone & joint infection –less frequently
OPPURTUNISTIC INFECTION -These infection are generally seen in children with severe decrease CD4 count
originally known as Pneumocystis carinii pneumonia, and still abbreviated as PCP, which now stands for P neumo c ystis p neumonia) is relatively rare in healthy, immunocompetent people, but common among HIV-infected individuals. It is caused by Pneumocystis jirovecii .
Incidence- occur at age of 3-6 month with highest mortality rate in children <1yr of age.
C / F-
Acute onset of fever
X-ray-There is increased white (opacity) in the lower lungs on both sides.
Diagnosis- Demonstration of P.Carini in the bronchoalveolar lavage.
Treatment –initially TMP 15-20mg/kg+SMZ 75-100mg/kg QID IV
on improvement therapy continue for next 21 days.
TMP + Dapsone
Clindamycin + Primaquin
Major pulmonary illnesses
MAC ( Mycobacterium avium intracellular complex )
Causative organism – Mycobacterium avium
It causes disseminated disease in HIV infected children who are severely immunosupressed.
Incidence in children with <100 CD4 cells/cubic mm- 10%
Symptom - fever, malaise, weight loss, night sweats, diarrhea, abdominal pain, rarely perforation or jaundice (due to biliary tract obstruction by Lymphadenopathy.
Diagnosis- Isolation of AC from blood, bone marrow. (Isolation of MAC from stool is not diagnostics)
Clarithromycin /Azithromyccin +Ethambutol
Rifabutin,(Rifampicin –in resistant case )+ ciprofloxacin
Oral canadidiasis is most common fungal infection in HIV infected children.
Oral Nystatin susp 2-5 ml QID
In resistant case oral Amphotercine susp.
Flucanozole 4-6 mg/kg/24 hr for 14 days in case of esophageal canadidiasis.
Disseminated histoplasmosis,coccidiomycosis,cryptococcosis are rarely seen in pediatric patient.
CNS involvement in perinatelly infected children is 50-90% in developing countries but lower in developed countries with a median onset 19 month of age.
Most common presentation is progressive encephalopathy. It may result of severe immune suppression.
With progression of encephalopathy marked apathy,spasiticity,hyperreflexia,gait disturbances may occur, as well as loss of language, fine & gross motor skill.
Older children show behavioral disorder & learning disabilities.
It consists of a combination of 2 NRTI & 1 Protease inhibitor.
ZDV + ddI
ZDV + 3 TC
D4t + ddI
D4t + 3 TC
RTV / NFV in liquid formulation
NFV / IDV in capsules /tablets
Response to therapy is monitered byHIV copy number & CD4 lymphocyte count.
Maximum response occur in 12-16 weeks.
Growth failure is a prominent feature of untreated HIV infection.
Stunting, or low height for age, is more prominent than wasting.
Growth velocity clearly increases with effective antiretroviral therapy but often does not return to normal.
Nutritional assessment is important in all infected children to maximize growth. It is particularly important in children with advanced disease who may suffer poor appetite, nausea, gastro paresis, increased metabolic demands, diarrhea, or malabsorption.
Comprehensive nutritional assessment is useful for all HIV-infected children. Growth hormone has been used to treat persistent growth failure in some children
Vertical transmission can be prevented by
Elective caesarian section
Avoidance of breastfeeding
Adequate treatment of any STD in mother
AZT given orally during II & III trimester of pregnancy in a dose of 100 mg 5 times in day, during labour & delivary 2mg/kg IV over 1 hrly followed by continued infusion of 1 mg/kg/hr until delivary,& postnatally 2-3 mg/kg/dose 6hrly for 6 weeks results dramatically 2/3 rd reduction in risk of perinatal transmission.
Recent trails with one dose of 200mg of Nevirapine administer intrapartum & 2 mg/kg single oral dose to newborn baby decrease transmission by 50%.
Horizontal transmission can be prevented by use disposable syringes and needles. Ensure you get blood that is screened and certified as HIV-free. Better still, get blood from close family members rather than professional donors whose medical antecedents are nebulous.
All HIV infected children should receive standard pediatrics Vaccination. However OPV,BCG in symptomatic children need to be with held.
At the present time, there is no cure for AIDS. It is always fatal if no treatment is provided. In the U.S., most patients survive many years following diagnosis because of the availability of HAART.
HAART has dramatically increased the time from diagnosis to death, and research continues in the areas of drug treatments and vaccine development.
Unfortunately, HIV medications are not always available in the developing world, where the bulk of the epidemic is raging, due to socioeconomic reasons.
Several vaccine are under study keeping in mind the objective for the control of AIDS.
Subunit virus vaccine-envelop protein & core protein
Live virus vector of HIV gene with vaccinia virus recombinants & adeno virus recombinants
Anti idiotype HIV vaccine.
some of these vaccine have completed phase I (safety) phase II (immunogenicity) human trail but phase III (efficacy) among HIV infected are being under trial.
This therapy required the introduction of anti HIV gene into the cells to prevent or inhibit HIV 1 viral gene expression of function & consequently to limit HIV replication & AIDS pathogenesis.
Gene also down regulate HIV in contrast to conventional drug thearpy.
To improve treatment with effective chemotherapeutics or antiretroviral agents or drug combinations.
Implement steps to prevent perinatal transmission with maternal screening.
Prevention of adolescents HIV infection with sex education, safe sex with use of condom, campaign against drugs & health education are some of the ways to curb transmission of HIV .
S No Disease Described symptom Srotas References 1 Abhinayas jawar Hattojas Ras vaha S u 39/43-45 2 Pandu Ojagunakshaya Ras vaha C c 16/4 3 Raj yakshma Kinchit oja kalapatae Ras vaha C c 8/41 4 Sosha Sosha Ras vaha S u 41 5 Premha Ojakshaya Medo vaha C n 4/37 6 Unmad Oja sanjhyetae Mano vaha C n 7/11 7 Madatya ojanaas Mano vaha C c 24/79 8 Avarita vaat Vaat vaha C c 28/208
The disease is caused by the dominant kapha dosha along with the other doshas tends to block the path for the flow of rasadi dhatus in their respective locations thus resulting in the deterioration of saptha dhatu Rasa(plasma), Rakta (blood cells),Mansa ( muscular tissue), Meda (adipose tissue), Asthi (bony tissue), Majja (bone marrow) and the Shukra (reproductive tissue). thus resulting into the disease.
Mano Gat & Sarvdahik Lakhshana (Psycho Immunological Derangements )
V P K OJO VIKRTI VISRANAS VAYAPAF KSHAYA
Dosh : Tridosha
Dusaya : Sapta dhatu
Srotas : Sarv srotas ( especially Ras vaha)
Dhamanay :Ojovah damani
Adhistan : Heart & whole body)
Vyadhi : Ojokshaya
The first step to stem the disease is to ensure a good and healthy atmosphere for the patient. He should be surrounded by well meaning friends and relatives who must affirm that the disease state is totally curable. Nothing negative should be discussed before the patient.
The patient should be given nourishing food which is easily digestible.
He should be encouraged to do easy exercise which does not strain his fragile health. He should be kept engaged in fruitful activities which strengthen the good tendencies inherent in him.
Initially, the patient is given tonics and rejuvenators (Rasayanas) to boost immunity levels and to strengthen the system and stimulate appetite.
After gaining some strength, shodhana (elimination) techniques are used to expel toxins from the body through enemas, purgation and emesis. The medications administered at this stage are not hard or drastic, but soft, ghee-based so that the patient withstands them with ease.
Secondly the blood is purified with appropriate medications. Liver corrective measures also play an important role.
A strengthening diet along with medicated ghee preparations and soups is recommended. But spicy, oily and acidic foods are to be avoided.
A little alcohol is recommended as anupana (carrier) to aid the digestive process, and also remove blockages in the flow of Rasadi dhatus, i.e. srothorodha.
Patient is advised to do regular exercise. If the patient is incapable of exercising or running due to weakness, then steaming (swedanam) is also recommended. reason behind this is 'Heated blood is said to weaken, and even destroy, the virus in some cases'.
Experience has shown that certain herbo-mineral compounds prepared as per the formulae prescribed by sages like Agasthya, Charaka, Sarangadhara and others for the treatment of Kshaya have brought about significant results in improving the condition of AIDS patients. The Rasayana and Vajikara effects of the these medicines are good for the patients.
Some of the propritery ayurvedic medicines achieving good improvement in the quality of life of patients include 'Chyavanprash', 'Raktavardhak' for Immunity building and 'Sookshma triphla tabs' to keep away the infection.