Chapter 8 Children with HIV/AIDS

Case study: Thomas Thomas, 8-month old boy was brought to hospital with history of fever for eight days. He had not been able to eat or drink anything for 2 days because of sores in his mouth.

Stages in the management of a sick child (Ref. Chart 1, p. xxii) Triage Emergency treatment History and examination Laboratory investigations, if required Main diagnosis and other diagnoses Treatment Supportive care Monitoring Discharge planning Follow-up

Triage Weight at triage was 6.4 kg (check z-score WFA). He looked small for his age and unwell. Temperature 38.2° C No respiratory distress, no cyanosis, SpO2 95%, capillary refill 2 seconds, limbs warm, alert and irritable.

Triage No Emergency signs, so go on to History and Examination 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 No Emergency signs, so go on to History and Examination

History Thomas was well until 5 months of age. Since then he had two episodes of pneumonia that needed 3 days of hospital treatment with antibiotics. Since the first admission he had had poor weight gain. Sores in his mouth for 4 weeks, not been able to eat or drink much in the last week.

History 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 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 farmer. His mother is 20 years old and she is a housewife. His 3 year-old sister Rachel is healthy. They live in a small rented room.

Examination Thomas was alert but miserable. He was a little pale and had muscle wasting, but was not cyanosed or jaundiced. He had enlarged lymph nodes: inguinal, axillary and submandibular, measuring 1-1.5cm. Vital signs: temperature: 38.2°C, pulse: 120/min, RR: 30/min, Weight: 6.4 kg (check z-score) Ear-Nose-Throat: white plaques over the oral mucosa, gums and posterior pharynx 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 palpable 3 cm below the right costal margin and spleen was enlarged 5 cm below the left costal margin

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 would you do?

Investigations Full blood count Mouth swab for fungal microscopy HIV test After counseling the parents and seeking consent Interpretation of a positive test Effect of age (antibody and viral particle PCR assay) Need for repeat test for confirmation

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: 0.9 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.

What stage of the disease is Thomas at? see Table 23, p. 231 Diagnosis Summary of findings: History: persistent diarrhoea Examination: recurrent infection, oral thrush, generalised lymphadenopathy, hepatosplenomegaly Blood examination shows mild anaemia, lymphopenia HIV viral test by PCR assay: positive What stage of the disease is Thomas at? see Table 23, p. 231

Thomas has stage 3 HIV 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 Other affected family members need to have access to treatment also High level of compliance and close follow-up are necessary

Antiretroviral treatment (continued) Who needs the treatment? Age and certainty of diagnosis (Ref. p. 235) Clinical stages ART 4 Treat Presumptive stage 4 3 1 and 2 Treat only where CD4 available and child: <18 month and CD4 <25% 18-59 months and CD4 <15% >5 years and CD4<10%

Treatment □ Oral thrush □ Persistent or bloody diarrhoea  Nystatin / ketaconazole / fluconazole (Ref. p. 246) □ Persistent or bloody diarrhoea Albendazole, tinidazole, azithromycin (for cryptosporidium) and zinc

What supportive care is required?

Supportive care Nutrition: Immunization: Prophylaxis: 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 Psychological and social support, kindness

Outpatient monitoring and follow-up HIV-infected children should attend MCH clinics like other children. In addition they need regular clinical follow-up monthly to monitor: ART adherence Growth and nutrition Immunization status Social support for the family Development and psychological well-being Detect other infections

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 Quality and duration of life can be improved with prompt treatment of inter-current infections and nutrition support Effective prevention of parent-to-child transmission is available