Hiv In Paediatrics

More rapid clinical progression 30% have aggressive disease & rapid progression to AIDS How does it differ from adult HIV? CNS involvement Early PCP Recurrent bacterial infections Growth failure

• Incidence • People living with HIV 40.3 Million – World wide • People living with HIV in India 5.1 million • Children (< 15 yrs) estimated to be living with HIV 2.5 Million • Estimated AIDS Cases in India < 15 yrs 4854 Cases

Asymptomatic Recurrent or more severe common infections Failure to thrive/growth failure PCP Parotitis LIP LAB : Anemia, thrombocytopenia, lymphopenia, elevated LFTs, hypergammaglobulinemia

STAGE 1 Asymptomatic Generalized LAN STAGE 2 Unexplained chr. Diarrhea Severe persistent / rec. candidiasis Weight loss / failure to thrive Persistent fever Rec.severe bacterial infections

STAGE 3 AIDS defining opportunistic infections Severe failure to thrive Progressive Encephalopathy Malignancy Recurrent septicemia or meningitis

MAJOR Weight loss/abnormaly slow growth Chr.diarrhoea more than 1m Pyrexia more than 1m MINOR Generalised LAN Oropharyngeal candidiansis Rec.common bacterial infections Persistent cough more than 1m Generalised dermatitis Confirmed HIV infection in mother 2 major + 2minor in the absence of other known cause of immunodeficieny

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Intrauterine 25-40% Intrapartum 60-75% Added risk of breast feeding 12-14% In the absence of ART transmission rates 16-40% • AZT prophylaxis & use of HAART in pregnant women transmission rates 5-6%

Diagnostic difficulties I. 1st 18 months- transplacental passage of IgG HIV Abs II. Cord blood samples may be contaminated with maternal blood III. Difficulty in obtaining large volume of blood required for some diagnostic tests

Viral HIV 1 DNA PCR(cells) HIV 1 RNA PCR(plasma) HIV 1 p24 Ag(plasma) HIV 1 culture Non viral HIV 1 IgM or IgA Abs In vitro Ab production

ELISA Confirmatory Western blot HIV PCR Qualitative(presence of pro-viral DNA) Quantitative(HIV RNA copies in sample)

Primary care of HIV infected children: Maintain good nutrition Growth monitoring regularly Rx infections as early as possible Emphasis on early diagnosis & Rx of suspected Tb for all family members Rx the child as normal Immunisation Give comfort when in pain & distress

RT inhibitors • Zidovudine(AZT) • Didanosine(ddi) • Epivir(3TC) • Zerit(d4T) • Abacavir • Tenofovir

NNRTI’s •

Nevirapine

•

Efaviren

PI’s •

Nelfinavir

•

Ritonavir

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Sequinavir

2RTI + 1PI; 2RTI + 1 NNRTI; 2PI ? Advantages Increased efficacy Supress viral load Increased CD4 Delays development of viral resistance Problems Tolerability Cost PK problems- metabolism,dose Need different formulations

Infants Failure to thrive AIDS defining illnesses(cat.C) Asymp. with CD4% <15 or CD4 <750 Symptomatic with CD4% <20 Children Failure to thrive AIDS defining illnesses(cat.C) Asymp. with CD4% <15 or CD4 <200

• Early HIV infection (<3m) • Early occurrence of 1st HIV related condition • Failure to thrive as presenting complaint • High peak viral load by RNA,p24 Ag • High maternal viral load at delivery

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Identify HIV infected pregnant women Prevent vertical transmission by perinatal chemoprophylaxis with AZT 1. After 1st tr PO 100mg 5 times/day 2. Peripartum i.v 2mg/kg stat followed by 1mg/kg/hr 3. Newborn 1st 6 weeks PO 8mg/kg/day in div.dose 6th hourly • Prevent horizontal transmission

• 4-6 wks – all infants born to HIV infected women • Infants of unknown HIV status – until 12m/until HIV infection is excluded • HIV infected child 1-5yrs CD4 +<500 • HIV infected child 6-11yrs CD4 +<200 • Co-trimox 150mg/m2/day

• Annual tubercular skin test- 24m for all HIV + • INH proph. 10-15mg/kg (max 300mg)×9m for HIV+ children,children <3y who are in contact with an adult diagnosed with TB • INH CI Previously received INH proph Previously Rx for TB Suspected of having active TB

Nelson textbook of paediatrics Textbook of paediatrics- Suraj Gupte Textbook of paediatric & adolesent AIDSScott.W.Henggeler Textbook of HIV/AIDS diagnosis & management-Dr.Vinay Kulkarni Preventive & social medicine- Park & park Indian journal of paediatrics- March ’06 Paediatrics today - Jan ‘05