3. PEDITRIC HIV / AIDS
► 1982 A syndrome of immunodeficiency with opportunistic infections in
children .
► 1983 First publication of Ped.HIV / AIDS.
► Incidence of HIV is fastly ↑ in women of child bearing age, hence Ped.HIV
cases ↑ rapidly.
► Since start of epidemic out of total 11.7 million deaths ,2.7million (23%)-ped.
► Up to now 5.1 million children affected with HIV world wide.
► 1997-2.2million died globally.4,60,000 (20%) were children<15yrs of age.
Total new cases -5.8 million , 5,90,000 were children.
30.6millon people living HIV world wide ,1.1 million (3.6%) children. 90% are
in developing countries.
2000->6,00,000 children HIV infected ,90% from Africa.
According to WHO about 10 million children <10 yrs will be
orphaned,beacause of perinatal HIV infection &consequently Ped.AIDS is now
a biggest threat..
4.
5.
6. ROUTES OF INFECTION
1 MOTHER TO CHILD TRANSMISSION
► Predominant route of infection.
► Infected Mother can transmit HIV infection to child during
PREGNANCY,LABOUR&DELIVERY or through BREAST FEEDING
► Estimated risk of HIV transmission in %
Timing No Breast F. BF th 6mo. BF th 18-24mo
During Preg. 5-10 % 5-10% 5-10%
During Labour 10-20 % 10-20 % 10-20 %
Th.BF first2mo. --------- 5-10 % 5-10 %
Th.BF after2mo
-------- 1-5 % 5-10 %
Over all 15-30 % 25-30 % 30-45 %
7. About 2.5 lakh mothers getting pregnant every year are HIV +ve
If risk of transmission is 30%, 80,000 infants each year HIV +ve
8. ► VERTICAL TRANSMISSION INFLUENCED BY (15-48 %)
A. Maternal Factors B. Foetal Factors
-Viral Load -Foetal Distress.
-Biological prottype of virys -Foetal scalp electrode,
-unprotected Sex during Preg. -scalp blood sampling
-Smoking - Umbilical Blood Sampling
-Maternal level of CD4 & Lymph.Count -Duration of exposure (I-twin)
-Low Level of VIT.-A -Duration of Breast Feeding.
-Presence of STD / RTI
-Time of rupture of memb.& Choriomemingitis
-Episiotomy &Op.Vaginal delivery
-Presence & amount of Virus in Genital tract.
2- TRANSFUSION OF BLOOD &BLOOD PRODUCTS.
-Thalassemia, Sickle cell anaemia, Haemophilia.etc.
3- SEXUAL CONTACTS.
-Sexually active Teenage girls , Presence of STD , Unprotected SEX.
9. CINICAL FEATURES
► HIV infected children differ from HIV infected Adults in numerous ways.
► MUCH MORE RAPID RATE OF DISEASE PROGRESSION IN CHILDREN.
► AVERAGE TIME TO AIDS DIAGNOSISIS 8-17 MONTHS COMPARED TO
► 8-11 YEARS IN ADULTS.
CLINICAL STAGES OF HIV DISEASE :-
Stage I : Acute (Primary ) infection (SERO CONVERSION ).
-Asymptomatic, incubation Period 2-6 weeks (up to 36 wks ),
-Phase of VIRAEMIA &up to 50 % have s/s viral syndrome, high fever,
lymphadenopathy,pharyngitis, rash&myalgia. Illness lasts 2 weeks/ less.
10-20 % may have head ache,meningoencephalitis,neuropathy,
myelopathy,GBS,Bells palsy oral thrus etc.
- CD4 ↓ , HIV Antibody test NEGATIVE
- Diagnosed by detecting viral antigen i.e. p24 antigen & PCR tests.
Stage II :-Early (Asymptomatic ) Disease (CD4 >500 /mm3)
-Longest Period 5-7 yrs in india ( 8-10 yrs ),
-Asymptomatic & apparently Healthy. Skin menifestations seen.
-Symptomless Persistent generalized Lymphadenopathy (PGL).
-TLC ↓,Platelet ↓ ,C D4 ↓,HIV Antibody tests POSITIVE
-chances of progression to AIDS within 2 yrs is less than 5% without
treatment.
10. ► Stage III :- Intermediate HIV Infection (CD4 Count 200-500 /mm3).
-Subtle Symptoms & Signs of Immunodeficiency,opportunistic
Infections
HSV &HZV (Shingles ) ,oro pharyngeal / vaginal andidiasis.Tuberculosis
,TBM etc.
-Viral Antibodies Detectable, CD4 ↓ to 200 /mm3
-30-50 % chances of developing AIDS without treatment.
Lasts 2-3 years
Stage IV :- Late Stage HIV Disease (CD4 Count 50-200 /mm3)
-Defined as Case of AIDS,
-opportunistic Infections eg.Cerebral Toxoplasmosis ,PCP
Cryptococcal meningitis,Cytomegalo virus retinitis etc.
-Antibodies may /may not be Detectable
Stage V :-Advanced HIV Disease (CD4 Count < 50 /mm3 )
-Even with Therapy pt .DIES WITHIN 2YEARS
IN CHILDREN ;- NORMAL T-CELL COUNTS ARE HIGHER &FLUCTUATE
GREATLY ,SO DIFFICULT TO DETERMINE .
* High Viral load due to high T –cell Count.
*High incidence of recurrent invasive bacterial infections
11. Common symptoms those are encountered are:
•Significant weight loss
•Persistent fever
•Persistent diarrhea
•Persistent cough
•Persistent generalized lymphadenopathy
12. Case definition of AIDS for children up to 12 years of age:
Two positive tests for HIV infection (by ERS test) in children older then
18 months or confirmed maternal HIV infection for children < 18
months.
Presence of at least two major and two minor signs in the absence of
known cause of immune suppression.
Major Signs:
1.Loss of weight or failure to thrive, which is not known to be due to
medical causes other then HIV infection.
2.Chronic diarrhea (intermittent or continuous) > 1 month.
3.Prolonged fever (intermittent or continuous) > 1 month.
Minor Signs:
1.Repeated common infections. 2. Generalized lymphadenopathy.
3. Oropharyngeal candidiasis. 4. Persistent cough for more then 1
month. 5. Disseminated maculo-papular dermatitis.
13. Why to go for laboratory investigation?
• To confirm a diagnosis/to exclude a diagnosis
• To find out prognosis
• To establish safety
• To decide course of action
• To help epidemiological study
• Research purpose
14. • ELISA
• Rapid
• Dot blot assay
• Particle agglutination
• HIV spot and comb test
• Fluorimetric microparticle technologies
• Simple
16. •Detection of specific antigens:
• p24 antigen detection
• reverse transcriptase assay
• Detection of viral nucleic acid:
• in situ hybridization
• Polymerase chain reaction-
•genotyping of HIV
• viral load assay
• Isolation/culture of virus
• sysncitium inducing
• nonsyncitium inducing
• Indirect prediction of HIV infection:
•CD4 cell count
•Serum neopterin
•B2 microglobulin
•IL2 receptors
17. Viral
load
Mean time of
progression to AIDS
<4530 copies
4531-13020
copies
13021-36270
copies
>36270 copies
8 years
6.5 years
4.5 years
2.5 years
Condition CD4Count/
microlitre
M. Tuberculosis
Bacterial Pneumonia
Suppu. Lung or sinus disease
Pneumo.Carini Pneumonia
Myco. Avium complex
Cytomegalovirus
<400
<250
<100
<200
<100
<100
18. Natural History:
Stage 1: Seroconversion / Acute primary infection
Stage 2: Early (asymptomatic) disease-CD4 count >500/cmm
Stage 3: Intermediate HIV infection-CD4 count 200-500/cmm
Stage 4:Late stage HIV disease- CD4 count 50-200/cmm
Stage 5: Advanced HIV disease-CD4 count <50/cmm
20. Causes of false positive HIVEIAs
Haematologic malignancies
DNA viral infections
Autoimmune disorders
Multiple myeloma
Primary biliary cirrhosis
Alcoholic hepatitis
Influenza vaccination
Passively transferred antibodies
Antibodies to clII lymphocytes
Renal transplantation/
Chronic renal failure
Stevens Johnson syndrome
Causes of false negative HIV EIAS
Window period
Immunosuppressive therapy
Replacement transfusion
Malignant disorders
B cell dysfunction
Bone marrow transplantation
Kits that primarily detect
p24 antibodies
Laboratory glove starch powder
21. DIAGNOSIS&CLINICALCARE
* Anti HIV antibodies from the Mother can be detected in the child’s Blood
for 13.3month(10.4-1606 mo.).
► Before this HIV Infection can be diagnosed by HIV Culture ,HIV PCR, or HIV
antigen (p24) or the Child meets the criteria for clinical AIDS Case
Definition.
► General ped.Care, Immunization as per NIS,Developmental&Neurological
evaluation every 3 month.
► CD4 counts at 1-2 & 6 mo. Than every 3mo.to 6 mo., CD4 Counts <500
generally associated with opportunistic inf. ,encephalopathy, common-
Bacterial inf. &poor Prognosis. Drug Prophylaxis (CMZ) for PCP.
Anti retroviral Therapy :-
Indicated for –Symptomatic HIV Infection.
- CD4 Counts Below 1500(Infants),1000 (18-24mo.),
750(2-6yrs),500(.6yrs).
Therapy is similar as In Adults . HAART started promptly.
AZT(Zidovudine),ddl(Didanosine),d4t(Stavudine),ritonavir&nefinavir
22. PREVENTION
► PREVENTING INFECTION AMONG WOMEN.
(Safer SEX,Use of CONDOM, Behavoural change,Controlling STD/RTI)
• PREVENTING UNWANTED PREG.IN HIV INF.WOMEN.
• PREVENTION OFMOTHER TO CHILD Transmission .
1- Anti Retro Viral Drugs :-
ZDV (Zidovudine)-Preg. From 14th wk , 100mg Five times daily
- Intrapartum 2mg/ kg IV over 1hr,than 1 mg / kg per hr
-Infant 2 mg / kg orally 6 hrly for 6 wks .
↓ MTCT by 70 % (NO BF.) With LSCS risk is only 2 %.
NVP (Nevirapine) -200 mg single oral dose at onset of Labour &Single
oral dose 2 mg / kg to NEWBORN With in 72
hrs .
↓ MTCT by 50 %.
2 –Elective LSCS ↓ MTCT by 50-60 %. Avoid PROM, Episiotomy etc.
3-supplementation of VIT. A during Preg. ↓ MTCT
4-Exclusive Breast Feeding up to 6 month ,than abrupt Weaning.
23. •Breast feeding transmits HIV.
•In developing countries more children die of
malnutrition and infection, when they are on top feed
than chance of acquiring HIV from infected mother. So
breast feeding is recommended.
•When breast feeding is supplemented with some other
food, liquid, prelacteal feed etc., chances of infection are
higher than when child is exclusively breast fed.
•So, it is recommended that mother should offer exclusive
breast feeding to the child and with abrupt weaning.
