Chapter 8 Children with HIV/AIDS

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Chapter 8Children with HIV/AIDS
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Case study Thomas
Thomas, 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
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• What are the stages in the management of and sick
  child?

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

• Triage
• Emergency treatment, if required
• History and examination
• Laboratory investigations, if required
• Differential diagnoses
• Main diagnosis
• Treatment
• Supportive care
• Monitoring
• Plan discharge
• Follow-up, if required

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What emergency and priority signs have you
noticed?
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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

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What emergency treatment does Thomas need?
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Emergency treatment
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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
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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.
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Nutrition history
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
Family history
Thomas 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.
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Examination
Thomas 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
kg Ear-Nose-Throat white plaques over the buccal
mucosa, gums and posterior oropharynx Skin dry,
flaky skin Chest no respiratory distress, clear
to auscultation Cardiovascular 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 margin Neurology
conscious no neck stiffness
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Differential diagnoses

• List possible causes of the illness
• Main diagnosis
• Secondary diagnoses
• Use references to confirm

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Differential diagnoses

• Recurrent infections
• Oral thrush due to antibiotics
• HIV
• Congenital immune deficiency
• Primary malnutrition accompanied by various
  infections

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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)
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What investigations you would like to do?
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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

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Investigations (continued)

• 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)

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Investigations (continued)

• Thomas, his parents and his elder sisters
  (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.

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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
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How would you treat Thomas and his family?
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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
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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

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Antiretroviral treatment (continued)

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

(Ref. p. 235)
Clinical stages ART
4 Treat
Presumptive stage 4 Treat
3 Treat
1 and 2 Treat only where CD4 available and child lt18 month and CD4 lt25 18-59months and CD4 lt15 gt5 years and CD4lt10
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Treatment (continued)

• ? Oral thrush
• ? Nystatin / ketaconazole (gentian violet)
  (Ref. p. 246)
• ? Treatment of persistent or bloody diarrhoea
• Albendazole, tinidazole, azithromycin
  (cryptosporidium) and zinc

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What supportive care is required?
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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

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Supportive care (continued)

• Palliative care
• Pain control
• Antiemetics
• Mouth care
• Prevention of pressure areas
• Care, kindness and consideration
• Psychological and social support

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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

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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

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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