HIV in children HIV in children

The course of HIV The course of HIV infectioninfection

Increased risk of Increased risk of perinatal transmission perinatal transmission CD4 and VL level of motherCD4 and VL level of mother Not-intact placentaNot-intact placenta PrematurityPrematurity Mother’s smoking, drug abuseMother’s smoking, drug abuse Other intrauterine infectionsOther intrauterine infections Mother’s STD, TBC, hepatitisMother’s STD, TBC, hepatitis

Clinical particularities Clinical particularities of pediatric HIV of pediatric HIV

20% - 20% - rapid progressionrapid progression, , mortality mortality during first year, often before 3 during first year, often before 3 months of age months of age

80% 80% - slow progression, AIDS by - slow progression, AIDS by school-age or even teenagersschool-age or even teenagers

Risk of rapid Risk of rapid progression progression

AIDS stage of pregnantAIDS stage of pregnant Low CD4 in child’s blood soon Low CD4 in child’s blood soon

after birthafter birth High VL by first month of life High VL by first month of life Possibly – early antenatal or Possibly – early antenatal or

intranatal transmissionintranatal transmission

Clinical particularities Clinical particularities of pediatric HIVof pediatric HIV

More often – bacterial infectionsMore often – bacterial infections Development deficit or function lossDevelopment deficit or function loss Lymphoid interstitial pneumonitisLymphoid interstitial pneumonitis Spontaneous anemia and Spontaneous anemia and

thrombocytopeniathrombocytopenia Cardiomyopathies Cardiomyopathies Parotitis Parotitis Tumors are rare Tumors are rare

HIV diagnosis in HIV diagnosis in children children

IFA only reliable after IFA only reliable after 18 18 months (maternal antibodies)months (maternal antibodies)

HIV diagnosis in HIV diagnosis in childrenchildren

Confirmation of diagnosisConfirmation of diagnosis:: Ag HIV Ag HIV р24р24 Positive culture of HIVPositive culture of HIV Positive PCR (RNA or DNA) Positive PCR (RNA or DNA)

PCR diagnosis PCR diagnosis

First test at 2 mo

Negative Positive

Repeat at 6 mo Repeat in 2 weeks

PCR diagnosisPCR diagnosis

Second test at 6 mo

Negative Positive

Diagnosis excluded Diagnosis confirmed

PCR sensitivity PCR sensitivity

Under Under 1 1 monthmonth – 93%; – 93%;

From From 1 1 to to 2 2 monthsmonths – 98%; – 98%;

After After 2 2 months months – 100%. – 100%.

Classification of Classification of immune suppressionimmune suppression

CD4+ Т-lymphocytes

Age

Under 12 mo 1 y – 5 y 6-12 yy

Absolute number

% Absolute number

% Absolute number

%

No immunosupression

>1500 >25 >1000 >25 >500 >25

Moderate 750-1499 15-24

500-999 15-24

200-499 15-24

Severe <750 <15 <500 <15 <200 <15

Pneumocystic Pneumocystic pneumonia (PCP) pneumonia (PCP)

Causative agent Causative agent – – Pneumocystis Pneumocystis carinii, fungicarinii, fungi

Air-borne infection, present in Air-borne infection, present in immunocompetentimmunocompetent

In In 30-40% 30-40% of children with HIV of children with HIV AIDS – indicating AIDS – indicating Often a cause of death under Often a cause of death under 3-6 3-6

months months

PCP – clinics PCP – clinics

Acute beginning Acute beginning Dry non-productive cough Dry non-productive cough Respiratory insufficiency Respiratory insufficiency Fever under Fever under 383800С С or absent or absent

PCP – examinationPCP – examination

Respiratory sounds decrease over Respiratory sounds decrease over the whole lungs the whole lungs

Scanty if any moist rales Scanty if any moist rales Focal changes not typical Focal changes not typical Signs of heart insufficiencySigns of heart insufficiency

PCP – diagnosisPCP – diagnosis

X-ray X-ray – – bilateral reticular bilateral reticular infiltrates with hyperinflated areas infiltrates with hyperinflated areas

Hypoemia, LDH increase Hypoemia, LDH increase Tracheobronchial washes or Tracheobronchial washes or

aspirates microscopyaspirates microscopy Under 1 year – gastric fluid Under 1 year – gastric fluid

microscopy microscopy Confirmation - lung biopsyConfirmation - lung biopsy

PCP – treatmentPCP – treatment

TrimetoprimTrimetoprim//sulfametoxazole sulfametoxazole (15-(15-20 20 mgmg//kgkg//dd on TMP)on TMP) РО РО or IV or IV – 21 – 21 days days

Alternatives Alternatives – – dapsone inhalation dapsone inhalation and pentamidine IVand pentamidine IV

PCP – secondary PCP – secondary prophylaxis prophylaxis

TrimetoprimTrimetoprim//sulfametoxazole sulfametoxazole (5 (5 mgmg//kgkg//dd on TMP)on TMP) РО РО daily daily – 1 – 1 monthmonth

Then Then – – 3 times a week 3 times a week permanently or until CD4 nolmal permanently or until CD4 nolmal (on HAART)(on HAART)

PCP – primary PCP – primary prophylaxisprophylaxis

TrimetoprimTrimetoprim//sulfametoxazole sulfametoxazole (5 (5 mgmg//kgkg//dd on TMP)on TMP) РО РО 3 times a 3 times a week week

At clinics appearance – dailyAt clinics appearance – daily All children starting from 2-4 All children starting from 2-4

weeks – until HIV exclusionweeks – until HIV exclusion

PCP – prognosisPCP – prognosis

Mortality Mortality 40-70%40-70% (without (without treatment) treatment)

80% 80% of HIV positive have of HIV positive have episodes of PCPepisodes of PCP

Bacterial infections Bacterial infections

Acute otitis mediaAcute otitis media Chronic otitis media Chronic otitis media SinusitisSinusitis Pneumonia Pneumonia Acute bacterial meningitis Acute bacterial meningitis Acute or chronic diarrheaAcute or chronic diarrhea Skin infectionsSkin infections UTI, etc. UTI, etc.

Viral infections Viral infections

HSV HSV – – generalized forms, skin and generalized forms, skin and mucous mucous

VZV - generalized formsVZV - generalized forms EBV – brain lymphoma EBV – brain lymphoma CMV – retinitis, pneumonia, CMV – retinitis, pneumonia,

enterocolitis, meningitis enterocolitis, meningitis

Fungi infections Fungi infections

CandidaCandida – – stomatitisstomatitis, , esophagitisesophagitis Histoplasma capsulatumHistoplasma capsulatum – –

pneumonitispneumonitis;; Cryptococcus neoformansCryptococcus neoformans – –

meningitis or pneumonitismeningitis or pneumonitis;; Coccidioides immitisCoccidioides immitis – – pneumoniapneumonia;; AspergillusAspergillus – – bronchial necrosis, bronchial necrosis,

obstruction obstruction

Parasites Parasites

ToxoplasmaToxoplasma – – encephalitis, encephalitis, myelitis, pneumonia, myelitis, pneumonia, chorioretinitischorioretinitis;;

Cryptosporidia Cryptosporidia – – gastroenteritisgastroenteritis;; Mycosporidia Mycosporidia – – enterocolitisenterocolitis;; Isosporidia Isosporidia – – enterocolitisenterocolitis

Tumors Tumors

Risk is Risk is 1200 1200 higher than in HIV-negativehigher than in HIV-negative Non-Hodgkin lymphoma Non-Hodgkin lymphoma – 65%,– 65%, Leyomyosarcoma and leyomyomaLeyomyosarcoma and leyomyoma – –

15%, 15%, Leukemia Leukemia – 6%, – 6%, Kaposi sarcoma Kaposi sarcoma – 5%, – 5%, Hodgkin lymphomaHodgkin lymphoma– 3%, – 3%, Carcinoma Carcinoma – 2%. – 2%.

VaccinationVaccination

BCG and alive polio – absolute BCG and alive polio – absolute contraindication contraindication

MMR – if CD4 preserved MMR – if CD4 preserved Inactivated polio and DPT – Inactivated polio and DPT –

indicated indicated Hepatitis B and A, influenza, HiB, Hepatitis B and A, influenza, HiB,

pneumococcus – indicatedpneumococcus – indicated