nursing

1. CARE OF CHILDREN
WITH HIV/AIDS
ASHA SEBASTIAN
1ST YEAR M.Sc. NURSING

2. INTRODUCTION
HIV/AIDS continues to be a major global public health issue, having
claimed almost 33 million lives so far. In children, HIV – related illness is
different from that seen in adults. According to WHO, 2.1 million children
are living with HIV infection worldwide However, with increasing access
to effective HIV prevention, diagnosis, treatment and care, including for
opportunistic infections, HIV infection has become a manageable chronic
health condition, enabling people living with HIV to lead long and healthy
lives.

3. WHAT IS HIV?
 HIV - Human Immunodeficiency Virus
 HIV is a virus spread through certain body fluids that
attacks the body’s immune system, specifically the CD4
cells, often called T cells.
 HIV is a retrovirus , Genetic material – single stranded
RNA
 Two types - HIV-1 and HIV-2.

4. WHAT IS HIV?...
 Spherical, diameter 4-100nm
 Three layer- outer envelope, matrix, capsid
 Outer envelope is consisting of glycoprotein
 Two glycoprotein- Inner GP 41, Outer GP 120
 Three enzymes- Reverse transcriptase, Integrase,
Protease

5. HISTORY
 First detected in 1959 Kinshasa, Democratic Republic of
Congo.
 Similarity with SIV (Simian Immunodeficiency Virus) attacks
the immune systems of monkeys and apes
 HIV-1 is closely related to a strain of SIV found in
chimpanzees, and HIV-2 is closely related to a strain of SIV
found in sooty mangabeys.
 In 1999, researchers found a strain of SIV (called SIVcpz) in a
chimpanzee that was almost identical to HIV in humans.

6. Transmission from chimps to humans
 Hunter theory
 Chimps being killed and eaten, or their blood getting into
cuts or wounds on people in the course of hunting.
 The virus adapted itself within its new human host and
became HIV-1.
 HIV-2 comes from SIVsmm in sooty mangabey monkeys
rather than chimpanzees.

7. 1984
The National
Cancer Institute
(USA) identified
HIV as the cause
of AIDS

8. AIDS
AIDS- Acquired Immunodeficiency Syndrome
 One of the largest pandemics in the world
 A disease that can develop in people with HIV. It’s the
most advanced stage of HIV. But just because a person
has HIV doesn’t mean they’ll develop AIDS.
 No vaccine is available

9. DEFINITION
Acquired immunodeficiency syndrome, a syndrome caused by
infection with the human immunodeficiency virus (HIV), with
ensuing compromise of the body’s immune system.

10. EPIDEMILOGY
• Approximately 37.9 million people living with HIV at the
end of 2018.
• 62% of adults and 54% of children in low- and middle-
income countries - receiving lifelong antiretroviral therapy
(2018)
• 82% of pregnant and breastfeeding women receive ART
• 770 000 people died from HIV-related causes in 2018 and
1.7 million people were newly infected.

11. EPIDEMILOGY…
• In June 2019, 24.5 million people were accessing
antiretroviral therapy.
• Between 2000 and 2018, new HIV infections fell by 37%
and HIV-related deaths fell by 45%, with 13.6 million lives
saved due to ART.

12. EPIDEMILOGY…
 Reported number of children (0-14 years) receiving
antiretroviral therapy – 56.6 lakh
 Estimated number of children needing antiretroviral
therapy -18 -23 lakh
 Antiretroviral therapy coverage among children – 28%
Source: WHO,UNICEF,UNAIDS

13. ROUTES OF TRANSMISSION
In children there are three main routes of transmission
 Perinatal or vertical route
o In utero by trans placental route after 15 weeks of
gestation
o During delivery due to mixing of maternal and foetal
blood or through the birth canal
o Postnatal through breast feeding

14. ROUTES OF TRANSMISSION …
 Parenteral transmission
 Transfusions of HIV-positive blood
 Injections with unsterilized needles
 Sexual transmission
o Sexual abuse or promiscuous sexual behaviour in
adolescents

15. PATHOPHYSIOLOGY

16. PATHOPHYSIOLOGY…
 Human immunodeficiency virus (HIV) is a spherical virus with
an envelope having glycoproteins and the core having a single
stranded ribosomal RNA
 Enzymes- Reverse Transriptase, Integrase, Protease
 The HIV has a specific affinity for certain groups of cells such
as lymphocytes, macrophages, capillary endothelium, etc.
where it binds the cell surface by interacting with the CD4
molecule.
 It then enters the host cell, gets uncoated and double-stranded.

17. PATHOPHYSIOLOGY…
 DNA is synthesized from RNA by reverse transcriptase. This
provirus is incorporated into host cell nucleus, where it stays
permanently.
 HIV infection of the cells results in latent infection or its
destruction by various mechanisms, like cytopathic effects or
autoimmune mechanism or syncytium formation

18. CLINICAL STAGING OF HIV/AIDS FOR
CHILDREN (WHO-2010)
 CLINICAL STAGE 1 (Asymptomatic)
 Asymptomatic
 Persistent generalized lymphadenopathy
 CLINICAL STAGE 2 (mild symptoms)
 Unexplained persistent hepatosplenomegaly, mild skin
infections, local infections of oral cavity, herpes zoster,
chronic ARI

19.  CLINICAL STAGE 3 (Advanced symptoms)
 Unexplained moderate malnutrition, persistent diarrhoea(>14
days),persistent fever (>1 month) or persistent oral candidiasis,
severe pneumonia, tuberculosis, unexplained anaemia,
neutropenia, or/and thrombocytopenia
 CLINICAL STAGE 4 (severe symptoms)
 Unexplained severe malnutrition, pneumocystis pneumonia,
recurrent severe presumed bacterial infections, sever unusual
viral, fungal tubercular, parasitic or protozoa infections,
Hodgkin lymphoma, leucoencephalopathy, nephropathy or
cardio-myopathy.

20. DIAGNOSIS
 Diagnosis of HIV infected children over 18months can
be made by antibody test (ELISA and confirmatory
tests)
 Specific diagnosis in children less than 15 -18months
can be made by virologic tests
 HIV DNA polymerase chain reaction (PCR)
 HIV RNAAssay
 Standard and immune complex dissociated p24 antigen
 Viral culture

21. DIAGNOSIS…
Tests should be performed at
 48 hours of age
14 days
1 – 2 months
3 – 6 months

22. DIAGNOSIS…
 HIV infection is absent if there are 2 or more negative viral
tests between the age 1 month and 6 months
 HIV infection is present if there are 2 positive viral tests on 2
separate blood samples regardless of age
In the absence of virologic tests
 2 or more negative antibody tests performed by the age of
over 6 months with an interval of at least 1 month between
tests reasonably excludes HIV infection in exposed children

23. DIAGNOSIS…
 A reactive HIV antibody test at >18 months followed by a
positive confirmatory test definitely indicates HIV
infection.

24. TREATMENT MODALITIES
 Antiretroviral therapy
 Treatment of acute bacterial infections
 Prophylaxis and treatment of opportunistic infections
 Maintenance of good nutrition
 Immunization

25. TREATMENT MODALITIES…
 Management of AIDS – defining illnesses
 Psychological support for the family
 Palliative care for the terminally ill child

26. MANAGEMENT
No curative
treatment
Fluid &
Nutritional
diet
No
vaccine

27. Antiretroviral Treatment (ART)
Goal - Maximally suppress viral replication to
on detectable levels for as long as possible
 Combination of at least three antiretroviral (ARV) drugs
 All children with HIV infection should be offered specific ART
irrespective of their clinical status
 All drugs approved for adults can be used in children

28. CATEGORIES OF DRUGS
Nucleoside/Nucleotide Reverse Transcriptase
Inhibitors (NRTIs)
 Abacavir, or ABC (Ziagen)
 Lamivudine, or 3TC (Epivir)
 Stavudine, or d4T (Zerit)
 Zidovudine or ZDV (Retrovir)

29. CATEGORIES OF DRUGS…
Non-nucleoside Reverse Transcriptase Inhibitors
(NNRTIs)
 Delavirdine or DLV (Rescripor)
 Doravirine, or DOR (Pifeltro)
 Etravirine or ETR (Intelence)
 Nevirapine or NVP (Viramune)

30. CATEGORIES OF DRUGS…
Protease Inhibitors (PIs)
 Atazanavir or ATV (Reyataz)
 Darunavir or DRV (Prezista)
 Indinavir or IDV (Crixivan)
 Tipranavir or TPV (Aptivus)

31. CATEGORIES OF DRUGS…
Integrase Inhibitors
 Bictegravir or BIC (combined with other drugs as
Biktarvy)
 Dolutegravir or DTG (Tivicay)
 Elvitegravir or EVG (Vitekta)
 Raltegravir or RAL (Isentress)

32. HAART (Highly Active Antiretroviral Therapy)
 Several classes of antiretroviral agents that act on different
stages of the HIV life-cycle.
 The use of multiple drugs that act on different viral targets is
known as highly active antiretroviral therapy (HAART)
 HAART decreases the patient's total burden of HIV,
maintains function of the immune system, and
prevents opportunistic infections that often lead to death

33. IMMUNIZATION
 All HIV-exposed infants should be fully immunized
 Infected and symptomatic infants should receive all
vaccines including measles and hepatitis B but not BCG
or Yellow fever vaccine
 Infected and symptomatic children should receive IPV
instead of OPV

34. PREVENTION OF HIV/AIDS IN CHILDREN
 Landmark paediatric clinical trails protocol- ZDV
prophylaxis to pregnant women as early as 4 weeks of
gestation, during labour and delivery and to new-born for 1st
6 weeks- reduced transmission by 75%
 Maternal HAART – decreases transmission to <2%
 Elective LSCS and maternal Zidovudine- reduces
transmission by 87%

35. PREVENTION OF HIV/AIDS IN CHILDREN…
 Single dose NVP- once to mother in labour and to infant
in 48-72 hours- reduces by 50%
 Who do not meet indications for therapy- ZDV from 14
weeks+/- SD NVP during labour and oral ZDV+ 3TC
during labour and 1 week postpartum infants ZDV/NVP
for 6 weeks

36. PREVENTION OF PARENT- CHILD
TRANSMISSION (PPTCT)
 Risk - Around 20-40%
 ART – To all HIV infected pregnant women regardless of
WHO staging,CD4 count and period of gestation

37.  Regimen
 Tenofovir(TDF0(300mg)+Lamivudine(3TC)
(300mg)+Efavirenz(EFV)(600mg)
 CS should be performed for obstetric indications only
 The services through PPTCT
 Exclusive breastfeeding up to 6 months and continued
breastfeeds in addition to complementary feeds after 6 months
up to 1 year for early infant diagnosis (EID) negative babies
and up to 2 years for EID positive babies

38.  Mixed feed is contraindicated within the first 6 months
 Postpartum ARV prophylaxis is provided in the form of daily
syrup nevirapine (NVP)for infant for minimum 6 weeks

39.  POST EXPOSURE PROPHYLAXIS CHILDREN
 >6 Months and < 13 years >10kg
 Zidovudine 9mg/kg B.D upto 300mg + lamivudine 4mg/kg B.D
upto 150 mg PO + lopinavir/ ritonavir ( lopinavir 10 mg/kg/
ritonavir 2.5mg/kg upto 400/100 mg
 ADOLESCENTS > 13 Yrs
 Above regimen or ZDV 300 mg Po B.D + 3TC 150 mg PO B.D
+ TDF 300mg PO O.D Or ZDV 300 mg PO B.D +FTC200 mg
PO OD + TDF 300mg PO OD

40. NURSING CARE OF A CHILD WITH
HIV/AIDS
 Emotional Assistance
 Parental Reaction
 When HIV infection or AIDS is diagnosed in a Child, the
family reactions may be shock, denial, guilt, anger, grief, and
lowered esteem.
 The parents may show symptoms of emotional trauma,
hampered psychological attachment with the child, feeling of
anger, guilt, tensions of financial burden, marital conflicts
and fear of child dying.

41.  The siblings may Withdraw from the ill child and may express
hostility and anger
 Child’s Reaction
 In an infant, there may be severed emotional bonding between him
and his parents. A toddler may have delayed basic self-help skills
like feeding, dressing, etc.
 A pre-school Child may have impaired social skills, loss of bowel
and bladder functions, express temper tantrums and aggression.
 In a school-going child, learning abilities and participation of the
child in academic and extracurricular activities are hampered.

42.  Support Measures
 Nurses should be able to recognize the signs of poor
adaptation, poor coping abilities in the child such as sadness,
fearfulness, anxiety, irritability, loss of developmental skills,
aggression and isolation.
 They can help the child to understand according to his level
of understanding the reasons for hospitalization, restrictions
imposed on them, severity of illness, therapies administered
to them and outcome of the illness.

43.  They should encourage the family to be more responsible for
the child's care.
 They should reinforce the fact that it is not only the child's
health which matters but family resources are equally
important in the progress of the child.
 They should offer logical explanations and sincere advice

44.  GENERAL CARE
 Maintain good nutritional status
 According to 2013 WHO guidelines, exclusive breastfeeding is
advised to infants up to 6 months and continued breastfeeds in,
addition to complementary feeds after 6 months up to 1 year for
early infant diagnosis (EID) negative babies and up to 2 years
for EID positive babies. Mixed feeding is contraindicated within
the first 6 months.
 Maintain regular growth monitoring

45.  Early diagnosis and therapy of infections
 Treat common infections such as measles and otitis media
vigorously
 Hospitalization is necessary, if the infection is unresponsive to
treatment
 Immunization
 Infants With clinical symptoms of HIV infection should not be
given tuberculosis vaccine (BCG). Instead of oral polio vaccine,
these children should be given IPV. Rest of the vaccines can be
given as usual. Sterilization procedures for immunization
equipment should be strictly followed

46.  Ensure Good Quality of Life
 Encourage the family to ensure that the child leads as
normal a life as possible

47. NURSING CARE IN HOSPITAL
 Any spillage of body fluids on floor should be mapped with
paper using gloved hands, which is then disposed in a sealed
plastic bag, which should be burnt or incinerated. The floor
should be disinfected with 1% sodium hypochlorite
 Wet waste including gauze, bandages and cotton soaked in
body fluids, should be packed in plastic bags, sealed,
transported by gloved hands, incinerated or bent

48. NURSING CARE IN THE HOSPITAL …
 Reusable instruments should be washed by gloved hands with
soap and water and then put in 2% gluteraldehyde for 20
minutes
 Needles should never be recapped .They should be sterilized
with sodium hypochlorite before being disposed in a
puncture-proof plastic container

49. NURING CARE IN HOSPITAL…
 Thermometers should be disinfected with spirit for 1 minute
before being reused
 All equipment and tubes to be inserted in mouth or body cavity
should preferably not be reused. In case of reusable equipment
like laryngoscope, ventilation devices, endotracheal tubes, etc.,
they should be carefully cleaned and sterilized before being
reused
 If there are open cuts, wounds or oozing dermatitis, direct patient
contact and operative procedure should be avoided.

50. NURSING DIAGNOSES
 Imbalance nutritional status less than body requirements
 Interventions
 Assess patient’s ability to chew, taste, and swallow.
 Assess the weight in terms of premorbid weight. Compare
serial weights and anthropometric measurements.
 Provide small, frequent meals and snacks of nutritionally
dense foods and non-acidic foods and beverages, with choice
of foods palatable to patient.
 Provide frequent mouth care

51.  Encourage as much physical activity as possible.
 Record intake and output
 Administer medications as per order
 Fatigue related to Decreased metabolic energy production/
increased energy requirements
 Assess sleep patterns and note changes in thought processes
and behaviour
 Encourage the child to do play and other activities

52.  Monitor physiological response to activity: changes in BP,
respiratory rate, or heart rate.
 Encourage nutritional intake.
 Provide supplemental O2 as indicated.
 Acute pain related to tissue inflammation/destruction or
infections
 Assess pain reports, noting location, intensity, frequency, and
time of onset. Note nonverbal cues like restlessness,
tachycardia, grimacing, crying.

53.  Encourage verbalization of feelings
 Provide diversional activities
 Administer analgesics as per order
 Social isolation
 Spend time talking with the child during and between care
activities. Be supportive, allowing for verbalization. Treat with
dignity and regard for their feelings.
 Give psychological support and education to the family about
the care of the child

54.  Risk for infection
 Monitor vital signs, including temperature.
 Follow aseptic techniques during procedures
 Provide a clean, well-ventilated environment. Screen visitors
and staff for signs of infection and maintain isolation
precautions as indicated.
 Examine skin and oral mucous membranes for white patches
or lesions.
 Administer medications as per order

55. Growing up with HIV
 Adults should talk to children about the disease in a way
that fits their age to help make it less scary.
 Kids need to know that it's not their fault they're sick
and have to take medicine every day, and that they won't
be left alone.
 Social, financial, and emotional support for the whole
family is important, especially in communities without a
lot of resources.

56. Growing up with HIV…
 Kids with HIV and AIDS can safely go to school. But
they may face bullying and discrimination unless the
other students and teachers understand how HIV
spreads.
 Awareness and education programs help break down the
stigma around HIV so that children can have friends and
feel normal growing up.

57. THANK YOU…