Review of HIV and Opportunistic Infections (OI) in Children MCCC/HAKS Pediatric Staff Training October 2007

Review of HIV What is HIV? Human Immunodeficiency Virus A virus is a germ or microbe It enters the body and starts to grow bigger and bigger

Review of HIV (2) The Immune system is like a house that protects a patient

Review of HIV (3) HIV enters the body and takes over the normal immune defenses

Review of HIV (4) When HIV takes over a person’s immune system they can not defend themselves against infections that normally do not cause bad disease (Opportunistic Infections)

Review of HIV (5) HIV grows and the person starts to: Lose weight Cough Fevers Diarrhea Difficulty breathing Skin Rashes Night sweats And many other problems

Review of HIV (6) When a child with HIV develops certain infections or if their immune (CD4) cells drop below a certain percentage, they have AIDS Acquired Immunodeficiency Syndrome Can not be cured If they take medicine every day they can become better and stay well for a long time

Review of HIV (7) ARV medicine rebuilds the immune system by fighting the HIV Virus OI medicine helps prevent infection until the immune system is strong again

Case #1 6 mo female, mother HIV+, child not tested Fever to 39 RR 70 Retractions Cough O2 saturation 85% XRay

Case #1 - PCP Differential Diagnosis Bacterial pneumonia Viral pneumonia (CMV) Fungal pneumonia (cryptococcus, candida) TB PCP

Case #1 - PCP PCP Prophylaxis Treatment Most common AIDS indicator disease of children (33%) Peak incidence age 3-6 months CD4 count not correlated with PCP infection Prophylaxis All children born to HIV+ women should be started on Trimethoprim/Sulfamethoxazole Treatment Trimethoprim/Sulfamethoxazole 15-20mg/kg divided 3 times a day x 21 days (IV or PO) Oxygen, Prednisone 1mg/kg x bid for 5 days, 0.5 mg/kg bid for 5 days, 0.5mg qd for 5 days (give albendazole to treat strongyloides infection prior to prednisone)

Case #2 5 yo male with HIV+, not on ARV, CD4 count 100 (8%), presents with 3 weeks of Blurry vision Persistent Right red eye No pain in eyes Fatigue Weight Loss

Case #2 - CMV Retinitis Approximately 50% of AIDS patients will have some form of ocular involvement during the course of their disease. Remain highly suspicious of any such patient complaining of a vision change. They may be harboring CMV retinitis, Toxoplasmosis or even candidiasis to name but a few. A fundus exam followed by a referral is strongly recommended.

Case # 2 - CMV More likely to present with low CD4 count (< 100) CMV/HIV coinfection worse prognosis Often no symptoms in young children, older children complain of blurry vision,floaters Can affect lungs, liver, Gastrointestinal tract Treatment: Ganciclovir 5mg/kg/dose IV twice a day for 21 days OR Intraocular Ganciclovir injections

Case #3 1 year old female, mother HIV+, child not yet tested presents with Fever Poor feeding Irritability Mouth & tongue ulcers

Case #3 - Herpes

Case #3 - Herpes HIV+ children can have recurrent ulcers in mouth and tongue With severe disease can affect All skin Brain Esophagus Intestinal tract Treatment intravenous acyclovir (5-10 mg/kg/dose three times daily) or oral acyclovir (20 mg/kg/dose three times daily) for 7--14 days

Case # 4 7 yo male, HIV+, not on ARV, CD 4 count 50 presents with Weight loss Difficulty swallowing Sore throat

Case # 4 - Candida

Case #4 - Candida Most likely in low CD4 count (<100) Presents with difficulty or pain with swallowing, eating, weight loss Can disseminate to other organs (liver, spleen) Treatment (for esophageal disease) Fluconazole (6 mg/kg/day administered once on day 1, then 3--6 mg/kg administered once a day for a minimum of 14--21 days) Prophylaxis for CD4 <50

Case # 5-6 8 yo male, HIV+, on ARV for 3 years, now CD4 decreasing (150) and viral load increasing (> 150,000) presents with Fever Night Sweats Cough Lymphadenopathy Weight loss Abdominal pain

Case #5-6 TB Diagnosed with miliary TB, treated for 9 months according to national protocol

Case #5-6 TB Cough improves but continues to have: Fevers Night sweats Weight loss Lethargy Abdominal distension

Case #5-6 TB /MAC

Case # 5-6 TB/MAC

Case #5-6 TB / MAC Mycobacterium Avium Complex Treatment Change ARV to second line since is failing first line Treat MAC drugs: clarithromycin or azithromycin plus ethambutol (AI). Clarithromycin 7.5--15.0 mg/kg body weight orally twice daily (maximum dose: 500 mg twice daily) Or Azithromycin 10--12 mg/kg orally once daily (maximum dose: 500 mg daily) Plus Ethambutol is adminstered at a dose of 15--25 mg/kg and is adminstered in single oral dose (maximum dose: 1.0 g)

Review of HIV transmission When a person has contact with the: Blood Semen Vaginal secretions Breast milk Of a person who is infected with HIV

SEX

Needle sticks

Needle sticks Sharing needles with other people - drug users - people who reuse needles over and over on many people Accidentally sticking yourself with a needle that someone else used

Wounds/cuts If someone has a cut and you have a cut and their blood touches your cut

Pregnant women with HIV can give HIV to their baby During Pregnancy During Labor & Delivery Breastfeeding

Blood transfusion

Ways you can not get HIV

Shaking Hands

Hugging

Coughing

Kissing

Eating or Drinking together

Mesquitoes/ Insects/ Animals

Sitting next to someone with HIV

Living with someone with HIV

Conclusion The best way to prevent HIV infection in children PMTCT Safe blood transfusions Safer sexual practices The best way to keep a child with HIV healthy is to MAKE THE DIAGNOSIS!!! Test all suspicious cases! Ensure treatment and adherence with ARV Identify and treat Opportunistic Infections

THANK YOU!