The document outlines key topics related to paediatric HIV including epidemiology, transmission, pathogenesis, clinical manifestations, diagnosis, and management. It discusses mother-to-child transmission, care for HIV-exposed infants, opportunistic infections, and use of antiretroviral therapy. The goal is to provide an overview of paediatric HIV and strategies to prevent transmission from mother to child and properly manage infected children.

1. PAEDIATRIC HIV
Presenter: Dr. Kayina Vincent
1

2. OUTLINE
 INTRODUCTION
 EPIDEMIOLOGY
 ETIOLOGY
 TRANSMISSION
 PATHOGENESIS
 CLINICAL MANIFESTATIONS
 LABORATORY DIAGNOSIS
 MANAGEMENT OF HIV
 eMTCT AND MNCAH
 CARE OF THE HIV-EXPOSED INFANT/CHILD
 OPPORTUNISTIC INFECTIONS IN HIV
 IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME
 REFERENCE
2

3. Introduction
 The WHO (2013), 3.2 million children younger than 15 yr, 90%
of whom were from sub-Saharan Africa.
 children have been orphaned by AIDS,
 Children experience more rapid disease progression than
adults,
 Up to half of untreated children dying within the 1st 2 yr of life.
3

4. Epidemiology
4

5. Etiology
 HIV-1 and HIV-2
 HIV-1 is more common worldwide
 HIV-2
 is less easily transmitted,
 less pathogenic,
 has shorter duration of infection,
 MTCT is relatively rare ,
 Found in West Africa, Mozambique, and Angola, but increasing numbers of cases are
reported from Europe and southern Asia
5

6. Etiology
 HIV is a member of the Retroviridae family and belong to the
Lentivirus genus
 HIV-2 and HIV-1 have a similar life cycle, but HIV 2 is known
to cause infection in several monkey species.
6

7. HIV Structure
7

8. Transmission
 The primary route in pediatrics is vertical transmission.
‒ Intrauterine (20-30%)
‒ Intrapartum (70-80%)
‒ Breastfeeding (10%)
 Sexual contact (Adolescents), Parenteral exposure to blood,
and Vertical transmission from mother to child.
8

9. Transmission cont’d
 Risk factors influencing rate of vertical transmission:
‒ Maternal viral load at delivery
‒ Preterm delivery (<34 wk gestation)
‒ Low maternal antenatal CD4 count
‒ High viral load
‒ Prom
‒ Instrument delivery
9

10. Pathogenesis
 HIV infection affects most of the immune system and disrupts
its homeostasis
 When the mucosa serves as the portal of entry for HIV, the 1st
cells to be affected are the dendritic cells.
 These cells collect and process antigens introduced from the
periphery and transport them to the lymphoid tissue.
10

11. Pathogenesis
 In the lymphatic tissue (e.g., lamina propria, lymph nodes), the
virus selectively binds to cells expressing CD4 molecules on
their surface, primarily CD4+ Th cells and cells of the
monocyte-macrophage lineage.
 Additional factors (coreceptors) are necessary for HIV fusion
and entry into cells E.g the chemokines CXCR4 (fusion) and
CCR5.
11

12. Pathogenesis
 Usually, CD4+ lymphocytes migrate to the lymphatic tissue in
response to viral antigens and then become activated and
proliferate, making them highly susceptible to HIV infection.
 This contributes to the generalized lymphadenopathy
characteristic of the acute retroviral syndrome in adults and
adolescents
12

13. Pathogenesis
 When HIV replication reaches a threshold (3-6 wk), a burst of
plasma viremia occurs.
 This intense viremia causes flu or mononucleosis-like
symptoms
 With establishment of a cellular and humoral immune
response within 2-4 mo, the viral load in the blood declines
substantially, and patients enter a phase characterized by a
lack of symptoms and a return of CD4 cells to only
moderately decreased levels.
13

14. Replication phases
14

15. Replication phases
 Steps in the HIV life cycle includes:
 Binding
 Fusion
 Reverse transcription
 Integration
 Transcription
 Assembly
15

16. Replication phases
 Attachment to the CD4 receptor,
 Binding to the CCR5 or CXCR4 co-receptor or both
 Membrane fusion.
 The HIV reverse transcriptase enzyme catalyze transcription of HIV
RNA into double stranded HIV DNA,
 The HIV integrase enzyme facilitates incorporation of DNA into the
chromosomes
 After transcription and translation of the genome, immature virions
are produced and bud from the cell surface.
 The HIV protease enzyme cleave polypeptide chains, allowing the
virus to mature.
16

17. Clinical manifestations
Clinical variations
 Rapid progression (25–30%),
 Die before their first birthday
 Acquired the infection in utero or during the early postnatal period
 Children who develop symptoms early in life,
 then follow a downhill course
 Die at the age of 3–5 years (50–60%)
 Long-term survivors
 Live beyond 8 years of age (5–25%);
 Tend to have lymphoid interstitial pneumonitis and
 Stunting, with low weight and height for age.
17

18.  Recurrent infection: ≥ 3 severe episodes of a bacterial
infection in the past 12 months
 oral thrush:
– After the neonatal period
– Lasting > 30 days
– Extends beyond the tongue or presents as oesophageal candidiasis.
 Chronic parotitis: Unilateral or bilateral for ≥ 14 days
 Generalized lymphadenopathy. 2 or more extrainguinal with
no underlying cause
Signs Indicative of possible HIV
Infection
18

19.  Hepatomegaly with no apparent cause: in the absence of
concurrent viral infections such as CMV
 Persistent and/or recurrent fever: fever (> 38 °C) lasting ≥ 7
days or occurring more than once over 7 days.
 Neurological dysfunction: progressive neurological impairment,
microcephaly, delay milestones, hypertonia or mental confusion
 Herpes zoster (shingles)
 HIV dermatitis: erythematous papular rash E.g Extensive fungal
infections of the skin, nails and scalp and extensive molluscum
contagiosum
 Chronic suppurative lung disease
Signs Indicative of possible HIV Infection
19

20.  Pneumocystis jiroveci pneumonia (PJP)
 Oesophageal candidiasis
 Lymphocytic interstitial pneumonia
 Kaposi sarcoma
 Acquired recto-vaginal fistula (in girls)
Signs/Conditions specific to HIV-Infection
20

21.  Chronic otitis media (≥ 14 days)
 Persistent diarrhea
 Moderate or severe acute malnutrition
– weight loss or a gradual but steady deterioration in weight gain
from that expected, as indicated on the child’s growth card.
– breastfed infants < 6 months old with failure to thrive.
Signs common in HIV-infected children but which also
occur in ill children with no HIV infection
21

22. Infections.
 The most common serious infections : bacteremia, sepsis,
and bacterial pneumonia, accounting for more than 50% of
infections in these patients.
 Milder recurrent infections,: such as otitis media, sinusitis,
and skin and soft tissue infections, are very common and may
be chronic with atypical presentations.
 Less frequently: Meningitis, UTI, deep-seated abscesses, and
bone/joint infections occur.
22

23. WHO Pediatric Clinical Staging
Stage I.
 Asymptomatic
 Persistent generalized lymphadenopathy
Stage II.
‒ Hepatosplenomegaly
‒ Papular pruritic eruptions
‒ Seborrhoeic dermatitis
‒ Fungal nail infections
‒ Angular cheilitis
‒ Linear gingival erythema
‒ Extensive human papillomavirus infection or
molluscum infection (> 5% body area)
Stage II. cont’d
‒ Recurrent oral ulcerations (two or more episodes
in 6 months)
‒ Parotid enlargement
‒ Herpes zoster
‒ Recurrent or chronic upper respiratory tract
infection (otitis media, otorrhoea, Sinusitis; two or
more episodes in any 6-month period)
23

24. WHO Pediatric Clinical Staging
Stage IV
‒ Unexplained severe wasting or severe
malnutrition that does not respond to
standard therapy
‒ PCP
‒ Recurrent severe presumed bacterial
infections (two or more episodes within 1
year, e.g. empyema, pyomyositis, bone or
joint infection, meningitis, but excluding
pneumonia)
‒ Chronic orolabial or cutaneous herpes
simplex infection (lasting > 1 month)
Stage III
 Unexplained moderate malnutrition that does not
respond to standard therapy
 Unexplained persistent diarrhoea (> 14 days)
 Unexplained persistent fever (intermittent or constant,
for > 1 month)
 Oral candidiasis (outside neonatal period)
 Oral hairy leukoplakia
‒ Pulmonary TBSevere recurrent presumed bacterial
pneumonia (two or more episodes in 6 months)
‒ Acute necrotizing ulcerative gingivitis or periodontitis
‒ Lymphoid interstitial pneumonia
‒ Unexplained anaemia (< 8 g/dl), neutropenia (<
500/mm3) or thrombocytopenia (< 30 000/mm3) for > 1
month
‒ HIV-related cardiomyopathy
‒ HIV-related nephropathy
24

25. WHO Pediatric Clinical Staging
Stage IV.
‒ Disseminated or extrapulmonary TB
‒ Kaposi sarcoma
‒ Oesophageal candidiasis
‒ Symptomatic HIV seropositive infant < 18
months with two or more of the following: oral
thrush, severe pneumonia, failure to thrive,
severe sepsis
‒ Cytomegalovirus retinitis
‒ CNS toxoplasmosis
‒ Any disseminated endemic mycosis
including: cryptococcal meningitis (e.g.
extrapulmonary cryptococcosis,
histoplasmosis, coccidiomycosis,
penicilliosis)
‒ Cryptosporidiosis or isosporiasis (with
diarrhoea lasting > 1 month)
‒ Cytomegalovirus infection (onset at age >
1 month in an organ other than liver,
spleen or lymph nodes)
‒ Disseminated mycobacterial disease
other than TB
‒ Candida of trachea, bronchi or lungs
‒ Cerebral or B cell non-Hodgkin lymphoma
‒ Progressive multifocal
leukoencephalopathy
‒ HIV encephalopathy
25

26. Laboratory Diagnosis
HIV serological antibody test (ELISA or rapid tests)
 For diagnosis in children > 18 months with perinatal exposure
and non-perinatal exposure
 Children < 18 months:
‒ Detecting exposure
‒ Excluding HIV infection in non-breastfeeding children
‒ SAM or TB or any other serious clinical event in high HIV
prevalence)
26

27. Virological tests
 Tests for HIV-specific RNA or DNA
 HIV DNA on whole blood or DBS
 HIV RNA on plasma or DBS
 The most reliable in children < 18 months of age.
Laboratory Diagnosis
27

28. MANAGEMENT OF HIV
28

29. ELIMINATION OF MOTHER TO CHILD TRANSMISSION OF HIV (eMTCT)
AND IMPROVING MATERNAL, NEWBORN, CHILD AND ADOLESCENT
HEALTH (MNCAH)
 The eMTCT strategy comprises a package of interventions
summarized in 4 approaches:
- Primary prevention of HIV infection
- Prevention of unintended pregnancies among women living
with HIV
- Prevention of HIV transmission from women living with HIV to
their infants
- Provision of treatment, care, and support to women infected
with HIV, their children, and their families
29

30. 30
Element Target group Additional information
Prong 1:
Primary
prevention
of HIV
infection
Women and
men of
reproductive
age including
adolescents
This prong aims to prevent HIV in men, women of reproductive age and adolescents.
Interventions:
 HIV testing services for pregnant and non-pregnant women of reproductive age
 Couple counseling and partner testing & retesting for the HIV negative
 Routine HIV testing services for pregnant and non-pregnant adolescents
 Behavioral change communications and risk reduction counseling to avoid high-risk
sexual behavior including
o Safer sex practices, including dual protection , delay of onset of sexual activity
o Health information and education about risky behavior and life skills and benefits of
HTS
o SMC, PrEP for discordant couples, GBV screening, and management
o STI and HBV screening and management
Prong 2:
Prevention
of
unintended
pregnancies
among
women
living with
Women
including
adolescents
living with HIV
and their
partners
 FP counseling & voluntary services (informed decision)
 HIV testing and counseling in RH/FP services
 Safer sex practices, including dual protection (condom use promotion)
 Pre-conception counseling and referral for infertility investigations and treatment

31. Element Target group Additional information
Prong 3:
Prevention of
HIV
transmission
from women
living with HIV to
their infants
Pregnant and
breastfeeding
women including
adolescents living
with HIV
This element focuses on:
 Quality antenatal, labour and delivery and postnatal care
 Access to HTS during ANC, Labour, delivery, and postpartum period
 Early initiation of ARVs for prevention of HIV transmission and mother’s
health
 Adherence counseling and support
 Retention monitoring
 Viral load testing and monitoring
 ARV prophylaxis for HIV-exposed infants
 Safe delivery practices to decrease risk of infant exposure to HIV
 Infant and young child feeding counseling.
 Community outreach and efforts to support partner involvement and
testing.
 TB screening, diagnosis, and treatment
 INH prophylaxis
 STI screening and treatment
Prong 4:
Provision of
treatment, care,
and support to
women infected
Women living with
HIV and
their families
This element addresses the treatment, care and support needs of HIV-
infected women, their children and families (family –centered approach)
31

32. 32

33. During pregnancy
 All women living with HIV identified during pregnancy, labour or
while breastfeeding should be started on lifelong ART irrespective
of CD4 counts or WHO clinical stage.
 ART should be initiated on the same day, and adherence counseling
should be initiated and sustained intensively for the first three
months then maintained for life.
 Initiate mother on once-daily FDC of TDF+3TC+EFV
 ART should be initiated and maintained in Mother Baby care point in
MCH.
33

34. During labour and delivery
 Observe safe obstetric practices
 Give ART:
 Continue the same ART regimen ( already on treatment)
 Initiate ART for mothers not yet on treatment.
 Continue to provide HIV care services to the mother.
 Initiate NVP prophylaxis for the infant at birth :
 Low risk: counsel mother and provide NVP syrup for 6 weeks
 High risk: Counsel mother and provide NVP syrup for up to 12
weeks.
34

35. During labor and delivery
 High-risk babies are breastfeeding infants whose mothers:
 Have received ART for four weeks or less before delivery; or
 Have VL >1000 copies in 4 weeks before delivery; or
 Diagnosed with HIV during 3rd trimester or breastfeeding
period (Postnatal)
35

36. CARE OF THE HIV-EXPOSED
INFANT/CHILD
 HIV-exposed infants should receive care until they are 18
months of age.
 The goals of HIV-exposed infant care services are:
 To prevent the infant from being HIV infected through MTCT
 Among those who get infected, to diagnose HIV infection early
and treat.
 Offer child survival interventions to prevent early death from
preventable childhood illnesses.
36

37. CARE OF THE HIV-EXPOSED
INFANT/CHILD
 Provide 1st PCR within 6 - 8 weeks or the earliest opportunity
thereafter
 Provide 2nd PCR 6 weeks after cessation of breastfeeding.
 Do DBS for confirmatory DNA PCR: for all infants who test positive
on the day they start ART.
 Do a DNA PCR test for all HEI who develop signs/symptoms
suggestive of HIV during follow-up, irrespective of breastfeeding
status.
 And conduct rapid HIV test at 18 months for all infants who test
negative at 1st or 2nd PCR.
37

38. Some special considerations
─ BCG: when considering BCG vaccination at a later age,
Exclude symptomatic HIV infection they should not receive BCG.
─ Measles:
 should be given at 6 and nine months even when the child has
symptoms of HIV.
─ Yellow Fever ( at 9 months): Do not give yellow fever vaccine
to symptomatic HIV-infected children
38

39. Some special considerations
Cotrimoxazole prophylaxis
 significantly reduces the incidence and severity of Pneumocystis jiroveci
pneumonia.
 Protects against common bacterial infections, toxoplasmosis, and malaria.
 should be provided to all HIV-exposed infants from 6 weeks of age until
they are proven to be uninfected.
 HIV infected infant should continue to receive CTx for life.
 If CTX is contraindicated, offer Dapsone at dose of 2mg/kg once daily ( up
to 100mg)
 Dose : <5kg :120 mg/5-14.9 kg : 240mg/15-29.9kg : 480mg/ >30Kg: 960 mg.
39

40. COTRIMOXAZOLE TOXICITY
 Adverse effects of cotrimoxazole are rare but include; skin rash,
Stevens-Johnson syndrome, anaemia, neutropenia, and
jaundice.
40

41. Some special consideration.
Isoniazid (INH) preventive therapy(IPT)
 Give INH for six months to HEI who are exposed to TB after
excluding TB disease
 For newborn infants, if the mother has TB disease and has been on
anti-TB drugs for at least two weeks before delivery, INH
prophylaxis should not be given.
Malaria prevention:
 In all HEI and HIV-infected children should receive ITNs and
Cotrimoxazole.
 Using both reduces risk of malaria by 97%
41

42. Feeding
HIV-exposed but
uninfected
infants/unknown HIV
status
 Should be exclusively breastfed (EBF) for the first six months,
 Then, introduce appropriate complementary foods after that,
 Continue breastfeeding for the first 12 months of life while being fully
supported for ART adherence.
 Breastfeeding should then only stop once a nutritionally adequate and safe
diet without breast milk can be provided.
 Establish the HIV exposure status of those infants with unknown status
HIV-infected infants  HIV-infected mothers should exclusively breastfeed (EBF) their infants for the first
six months of life,
 introducing appropriate complementary foods after that,
 and continue breastfeeding until 24 months of life while being fully supported for
ART adherence.
42

43. Antiretroviral therapy
43

44. Antiretroviraux therapy
44

45. Classes of Antiretrovirals
 Fusion inhibitor
 CCR5 antagonist
 Reverse Transcriptase inhibitors
 Non-nucleosides (NNRTIs)
 Nucleoside( NRTIs)
 nucleotide (NRTIs)
 Integrase inhibitor
 Protease inhibitors
45

46. Classes Sides effects
NRTI
Abacavir (ABC)
Didanosine (ddI)
Emtricitabine (FTC)
Lamivudine (3TC)
Stavudine (d4T)
Tenofovir (TDF)
Zidovudine (AZT, ZDV)
Lactic acidosis and hepatic steatosis (highest incidence with d4T, then ddI
and ZDV, lower with TDF, ABC, 3TC, and FTC) , Lipodystrophy (higher
incidence with d4T)
NNRTI
Delavirdine (DLV)
Efavirenz (EFV)
Etravirine (ETR)
Nevirapine (NVP)
Rilpivirine (RPV)
All NNRTIs: Rash, including Stevens-Johnson syndrome
Hepatotoxicity (especially NVP)
Drug-drug interactions
PI
Atazanavir (ATV)
Darunavir (DRV)
Fosamprenavir (FPV)
Hyperlipidemia
Lipodystrophy
Hepatotoxicity
GI intolerance
Possibility of increased bleeding risk for hemophiliacs
46

47. Classes of ARV
Classe Side effect
Integrase Inhibitor (II)
Raltegravir (RAL)
Nausea
Headache
Diarrhea
CPK elevation, myopathy, rhabdomyolysis
Rash
Fusion Inhibitor
Enfuvirtide (ENF, T-20)
CCR5 Antagonist
Maraviroc (MVC)
47

48. ARV regime for children
Patient category 1st line 2nd line
Children <3 years of age ABC+3TC+LPV/r
Children 3-9.9 years old ABC+3TC+EFV ABC+3TC+NVP
Adults and adolescents aged 10 years and older TDF+3TC+EFV TDF+3TC+DTG3 or
ABC+3TC+DTG3
48

49. Monitoring
 The purpose of monitoring patients on ART is to assess:
1. Response to ART and diagnose treatment failure.
2. Safety of the medicines- side effects and toxicity.
3. Adherence to ART.
49

50. OPPORTUNISTIC INFECTIONS IN HIV
50

51. OPPORTUNIC INFECTIONS.
 TUBERCULOSIS
 Pneumocistis jirovecii PNEUMONIA
 LYMPHOID INTERSTITIAL PNEUMONITIS
 CRYPTOCOCCAL MENINGITIS.
 FUNGAL INFECTION
 KAPOSI SARCOMA
 TOXOPLASMOSIS.
51

52. Tuberculosis
 HIV is the strongest risk factor for developing TB disease.
 PLHIV are 20 to 37 times more likely to develop TB than HIV-
uninfected individuals.
 All HIV-positive infants and children who have any of the
symptoms including cough of any duration, persistent fevers,
poor weight gain and history of TB contact should be assessed
for TB.
52

53. Tuberculosis
 The Xpert MTB/RIF (GeneXpert) test is the recommended
initial TB diagnostic test for all HIV-infected infants and children.
 If Xpert MTB/RIF is not available, smear microscopy (Ziehl
Nielsen/Fluorescent microscopy) TB test should be performed
and a second sample referred for GeneXpert testing using the
transport Hub system.
 Chest radiography is another useful investigation.
53

54. Tuberculosis
Site of TB disease Regimen
Intensive phase Continuation phase
All forms of TB
(excluding TB meningitis and Bone TB)
2RHZE 4RH
TB meningitis
Bone (osteoarticular) TB
2RHZE 10RH
 If the patient is already on ART, start TB Medicine
 If the patient is not on ART, initiate anti-TB Medicine immediately and start ART at two weeks of TB
Treatment.
54

55. Tuberculosis
 Prophylaxis
 BCG: when considering BCG vaccination at a later age,
Exclude symptomatic HIV infection they should not receive
BCG.
 Give INH for six months to HEI who are exposed to TB after
excluding TB disease
 For newborn infants, if the mother has TB disease and has
been on anti-TB drugs for at least two weeks before delivery,
INH prophylaxis should not be given.
55

56. Pneumocystis jiroveci pneumonia
 Suspect in any HIV-positive infant with severe pneumonia.
 The classic clinical presentation of Pneumocystis pneumonia includes:
acute onset of fever, tachypnea, dyspnea, and marked hypoxemia;
 Chest x-ray findings :
 interstitial infiltrates or diffuse alveolar disease, which rapidly progresses.
Nodular lesions, streaky or lobar infiltrates, or pleural effusions may
occasionally be seen.
 Diagnosis is established by demonstration of P. jiroveci with appropriate
staining of induced sputum or bronchoalveolar fluid lavage; rarely, an
open lung biopsy is necessary.
56

57. Pneumocystis jiroveci pneumonia
 The 1st-line therapy for Pneumocystis pneumonia is IV
trimethoprim-sulfamethoxazole (TMP-SMZ) (15-20 mg/kg/day
of the TMP every 6 hr IV) with adjunctive corticosteroids if the
Pao2 is <70 mm Hg for a total of 21/7 while the corticosteroids
are weaned.
 Alternative : IV Pentamidine (4 mg/kg/day).
57

58. Lymphoid Interstitial pneumonitis
 The child is often asymptomatic in the early stages but may
later have:
 Persistent cough, with or without DIB
 bilateral parotid swelling
 persistent generalized lymphadenopathy,
 hepatomegaly and other signs of heart failure
 finger-clubbing.
 Chest X-ray : Bilateral reticulonodular interstitial pattern
Distinguish from PTB and bilateral hilar adenopathy.
58

59. Lymphoid Interstitial pneumonitis
 Give a trial of antibiotic treatment for bacterial pneumonia before
starting prednisolone.
 Start steroids only if the chest X-ray shows LIP, plus any of the
following signs:
– fast or difficult breathing
– cyanosis
– pulse oximetry reading of oxygen saturation ≤ 90%
59

60. Cryptococcal meningitis.
 Suspect in any HIV-infected child with signs of meningitis
 Presentation is often sub acute, with chronic headache or only
mental status changes
 An India ink stain of CSF confirms the diagnosis
 Treat: Amphotericin at 0.5–1.5 mg/kg/day for 14 days, then
Fluconazole 6–12 mg/kg (maximum 800 mg) for 8 weeks.
 Start fluconazole 6 mg/kg daily (maximum 200 mg) prophylaxis
after treatment.
60

61. Fungal infections
Oral candidiasis
 Nystatin (100 000 U/ml) suspension. Give 1–2 ml into the
mouth 4 times a day for 7 days.
 If this is not available, apply 1% gentian violet solution.
 If these are ineffective, give 2% miconazole gel at 5 ml twice a
day, if available.
61

62. Fungal infections
 Oesophageal candidiasis: Difficulty or pain while vomiting or
swallowing, is reluctant to take food, is salivating excessively or
cries during feeding
 May occur with or without evidence of oral thrush
 RX
Oral fluconazole (3–6 mg/kg once a day) for 7 days
Amphotericin B (0.5 mg/kg once a day) by IV infusion for 10–14 days
62

63. Kaposi sarcoma
 Consider KS in children presenting with nodular skin lesions,
diffuse lymphadenopathy and lesions on the palate and
conjunctiva with periorbital bruising
 Diagnosis usually clinical, confirm by a needle biopsy of skin
lesions or lymph node.
 Suspect also in children with persistent diarrhoea, weight loss,
intestinal obstruction, abdominal pain or large pleural effusion.
63

64. TOXOPLASMOSIS
 CNS Toxoplasmosis is exceedingly rare in young infants,
 but may occur in HIV-infected adolescents and is typically
associated with serum antitoxoplasma IgG as a marker of
infection.
64

65. IMMUNE RECONSTITUTION INFLAMMATORY
SYNDROME (IRIS)
65

66. IMMUNE RECONSTITUTION INFLAMMATORY
SYNDROME
 IRIS is a spectrum of clinical signs and symptoms thought to be
associated with immune recovery brought about by a response to
ART.
 Is more commonly observed in patients with progressive disease
and severe CD4+ T-lymphocyte depletion.
 Occurs among 10–30% people within the 1st 4–8 weeks after
initiating therapy.
 IRIS should be considered only when the presentation cannot be
explained by a new infection, the expected course of a known
infection or drug toxicity.
66

67. IRIS
 Risk factors
 A low CD4+ cell count (<50 cells/mm3) at ART initiation.
 Disseminated OI or tumors and
 A shorter duration of therapy for OI before ART starts.
 Treatment
 Iris is generally self-limiting, and interruption of ART is rarely
indicated.
 Treat the infection
 If the symptoms are protracted, reassure the patient to prevent
discontinuation of or poor adherence to ART.
67

68. References
 Benjamin Young, MD PhD, Medication side effects, 2015
 Nelson Textbook of Pediatrics – 20th Edition (vol 2) (2015)
 WHO. Pocket Handbook for Children (2015)
 Ministry of health, consolidated guidelines for prevention and
treatment of HIV in Uganda , 2016
68