Chapter 8Children with HIV/AIDS

Case study: ThomasThomas, 8-month old boy was brought to hospital with history of fever for eight days. He looked small for his age and unwell. He had not been able to eat or drink much for 2 days because of sores in his mouth. His weight at triage was 6.4 kg

What are the stages in the management of and sick child?

Stages in the management of a sick child (Ref. Chart 1, p. xxii)

1. Triage

2. Emergency treatment

3. History and examination

4. Laboratory investigations, if required

5. Main diagnosis and other diagnoses

6. Treatment

7. Supportive care

8. Monitoring

9. Discharge planning

10. Follow-up

What emergency and priority signs have you noticed?

Triage

Emergency signs (Ref. p. 2, 6)

• Obstructed breathing• Severe respiratory distress• Central cyanosis• Signs of shock• Coma• Convulsions• Severe dehydration

Priority signs (Ref. p. 6)• Tiny baby• Temperature• Trauma• Pallor• Poisoning• Pain (severe)• Respiratory distress• Restless, irritable, lethargic • Referral• Malnutrition• Oedema of both feet• Burns

What emergency treatment does Thomas need?

Emergency treatment

History

Thomas was well until 5 months of age. Since then he had two episodes of pneumonia that needed several days of hospital treatment with intravenous antibiotics. Since the first admission he had had poor weight gain. He has not been able to eat or drink much in the last week because of mouth sores, which had been there for 4 weeks

History (continued)

Thomas had had frequent episodes of watery diarrhoea since he was 5 months old. Each episode of diarrhoea lasted for 10-14 days, mostly watery diarrhoea with some mucus in the stool.

Nutrition history

Family historyThomas is the second child of his parents. His father is 24 years old and is a truck driver. His mother is 20 years old and she is a housewife. His 18 month-old sister is healthy. They live in a small rented room.

Thomas is still breastfed. He was exclusively breastfed till 5 months of age and then weaning food was introduced. The weaning food mainly contained rice, vegetables, and occasionally meat. Not feeding well in last week because of mouth sores

ExaminationThomas was alert and active but miserable. He was a little pale and had muscle wasting, but was not cyanosed or jaundiced.He had bilateral enlarged inguinal, axillary and submandibular non-tender lymph nodes, all measuring 1-1.5cm.Vital signs: temperature: 38.50C, pulse: 120/min, RR: 40/min, Weight: 6.4 kgEar-Nose-Throat: white plaques over the buccal mucosa, gums and posterior oropharynxSkin: dry, flaky skinChest: no respiratory distress, clear to auscultationCardiovascular: both heart sounds were audible and there was no murmur Abdominal examination: liver was palpable 3 cm below the right costal margin and spleen was enlarged 5 cm below the left costal marginNeurology: conscious; no neck stiffness

• List possible causes of the illness

• Main diagnosis

• Secondary diagnoses

• Use references to confirm

Differential diagnoses

Differential diagnoses

• Recurrent infections

• Oral thrush due to antibiotics

• HIV

• Congenital immune deficiency

• Primary malnutrition accompanied by various infections

Further examination based on differential diagnoses

Look for:

• Recurrent infections

• Oral thrush – without antibiotic treatment, or lasting over 30 days despite treatment

• Chronic parotitis

• Lymphadenopathy and hepatomegaly

• Persistent and/or recurrent fever

• Herpes zoster

• Dermatitis

• Chronic suppurative lung disease

• Malnutrition

• Persistent diarrhoea

(Ref. p. 226-227)

What investigations you would like to do?

Investigations

• FBE

• Ulcer swab

• HIV antibody test– After counseling the parents and seeking consent– Interpretation of a positive test

Effect of age (antibody and viral particle assay)

Need for repeat test for confirmation

• Full blood count:

- Haemoglobin: 8.9 g/l (105-135)

- Platelets: 255 x 109/l (150 – 400)

- WCC: 14.6 x 109/l (6 – 18.0)

- Neutrophils: 12.2 x 109/l (1.0 – 8.5)

- Lymphocytes: 1.4 x 109/l (4.0 – 10.0)

- Monocytes: 1.0 x 109/l (0.1 – 1.0)

Investigations (continued)

• Thomas, his parents and his elder sister’s (Rachel) HIV status were tested after the obligation to maintain confidentiality was assured. (Ref. p. 228).

• The parents were encouraged to have a HIV test and the implications of the diagnosis were explained to them.

• Thomas, his mother and father had positive HIV antibody test by ELISA assay.

• Rachel had a negative HIV antibody test.

Investigations (continued)

Diagnosis

Summary of findings:• History: persistent diarrhoea• Examination: recurrent infection, oral

thrush, generalised lymphadenopathy, hepatosplenomegaly

• Blood examination shows mild anaemia, lymphopenia

• Chest X-ray: bilateral lymphadenopathy• HIV antibody test by ELISA assay:

positive

What stage of the disease is Thomas at? see Table 22, p. 231

How would you treat Thomas and his family?

Antiretroviral treatment

There are three main classes (Ref. p. 234):• Nucleoside reverse transcriptase inhibitors

– AZT (zidovudine), lamivudine, stavudine, didanosine, abacavir

• Non-nucleoside reverse transcriptase inhibitors– Nevirapine, efavirenz

• Protease inhibitors:– Nelfinavir, lopinavir/ritonavir, saquinavir

Usually two NRTIs plus one NNRTI

Antiretroviral treatment (continued)

• Consider:– Resistance to single or dual agents is

quick to emerge, at least 3 drugs are the recommended minimum standard for all settings

– Fixed dose combination therapy now used: e.g. Trimmune

– Access to treatment needs to be ensured for other family members as well

– High level of compliance and close follow-up are necessary

Antiretroviral treatment (continued)

• Who needs the treatment?– Age and certainty of diagnosis

Clinical stages ART

4 Treat

Presumptive stage 4 Treat

3 Treat

1 and 2 Treat only where CD4 available and child: <18 month and CD4 <25%18-59months and CD4 <15%>5 years and CD4<10%

(Ref. p. 235)

Treatment (continued)

□ Oral thrush

Nystatin / ketaconazole (gentian violet) (Ref. p. 246)

□ Treatment of persistent or bloody diarrhoea

Albendazole, tinidazole, azithromycin (cryptosporidium) and zinc

What supportive care is required?

Supportive care

• Nutrition:

– Nasogastric feeds with breast milk

– Multivitamins, vitamin A, zinc

• Immunization:

– Asymptomatic HIV infection: give all vaccines

– Symptomatic HIV infection (clinical AIDS): give all vaccines except BCG, measles and yellow fever (Ref. p. 240)

• Prophylaxis:

• Cotrimoxazole

• Consider isoniazid

Supportive care (continued)

• Palliative care:

– Pain control

– Antiemetics

– Mouth care

– Prevention of pressure areas

– Care, kindness and consideration

• Psychological and social support

Follow-up

HIV-infected children should, when not ill, attend MCH clinics like other children. In addition they need regular clinical follow-up at first-level facilities several times a year to monitor:– Clinical condition– Neurological development– Growth and nutrition– Immunization status– Social support for the family– Psychological well being

Summary

• The management of children with HIV infection is mostly similar to that of other sick children

• Antiretroviral treatment has improved the lives of many HIV affected children

• Cotrimoxazole prophylaxis is indicated at all ages

• Consider INAH prophylaxis

• Quality and duration of life can be improved with prompt treatment of inter-current infections and nutrition support

• Effective and inexpensive prevention of parent-to-child transmission is available

Prevention• Prevention of Parent-to-child-transmission (PPTCT):

– Pre-test counseling

– Screening at antenatal care

– Post-test counseling

– Effective drug regimens (evolving)

– Breast feeding counseling

– Contraception