Issues in HIV infection in children discussed

1. • Dr.C.S.N.Vittal

2. UNAIDS
2018
GLOBAL
HIV STATISTICS
On ART
23.3 million people were
accessing antiretroviral therapy.
PLHIV
37.9 million people globally were
living with HIV.
New HIV
1.7 million people became newly
infected with HIV.
Adolescent HIV
• 22% of all new HIV infections
• 81% of youth cases occurring
in young males who have sex
with males (MSM);
• 8% of cases of AIDS also
occurred in this age-group.
04
01
02
03

3. India
HIV
0
1
Third largest HIV
epidemic in the world.
0
2
National adult HIV
prevalence: 0.26% in 2015.
0
3
HIV prevalence: males
0.30%; females 0.22%
0
4
PLHIV: 21.17 lakhs
0
5
Children account for 6.54%
India
HIV

4. Mizoram, 2.04
Manipur, 1.43
Nagaland, 1.15
Telangana, 0.7
Andhra, 0.63
Karnataka, 0.47
Goa, 0.42
Maharashtra, 0.33
Delhi, 0.3 Tamilnadu, 0.22
Adult HIV Prevalence (%) 1990 to 2017, HIV Estimations 2017 -
NACO

5. Genome and Proteins of HIV
• Genome of HIV consists of 9 gene, 3 structural gene and 6 non-structural gene (regulatory gene).
• Structural gene (env,gag and pol), regulatory gene (tat,rev,nef,vif,vpr and vpu in HIV-I and vpx in HIV-2)

6. Modes Of Transmission In Children
• Intrauterine (20-30%)
• Intrapartum (70-80%)
Vertical
• 18% in women with established infection
• 29-53% in women who acquire HIV postnatally
Postpartum – Breast Feeding
• 3-6%
Blood products
• Child abuse
Sexual
• Sharps
• IVDU
Unsafe needles

7. 1 Growth and Development
1 Early infant diagnosis
Components of Care of HIV-Exposed Infant/Child
Infant feeding2
ARV prophylaxis3
Immunization and Vitamin-A Supplementation4
1 Co-trimoxazole prophylaxis5
Immediate Care at Birth11
1 Follow up
16
1
18
7

8. 01
02
03
04
The baby’s mouth and nostrils
should be wiped as soon as the
head is delivered
Infants should be handled with
gloves until all blood and maternal
secretions have been washed off
Initiate feeding within the first
hour of birth according to the
preferred and informed
choice
The cord should be clamped soon after
birth, and milking should be avoided.
Cover the cord with gloved hand and
gauze before cutting to avoid blood
splattering.
Immediate Care at Birth11

9. The 6 criteria to assess suitability for replacement feeding
Family is supportive5
Safe water and sanitation are assured1
Caregiver can reliably afford to provide sufficient and sustained replacement feeding2
Caregiver can prepare it frequently enough in a clean manner3
Exclusively give replacement feeding4
Can access health care that offers comprehensive child health services6

10. WHO
Recommendations
for
Exclusive
Replacement
Feeding

11. Estimated risk and timing of Mother to child transmission(MTCT) in the
absence of interventions
ARV prophylaxis3
• De Cook KM, et al. JAMA.2000; 283(9):1175-82
Timing of HIV Infection % of Children at risk
During pregnancy 5–10
During labour and delivery 10–15
During breast feeding 5–20
Overall risk without breast feeding 15–25
Overall risk with breast feeding to 6 months 20–35
Overall risk with breast feeding to 18 to 24
months
30–45

12. The National
PPTCT
programme
NACO
WHO
recommendations
for infant feeding
in HIV-infected
mothers.

13. • Merchant, Rashid & Lala, Mamatha. (2005). Prevention of mother-to-child transmission of HIV - An overview. The Indian
journal of medical research. 121. 489-501.

14. Pregnant women presenting in active labour
Mother Intra-partum postpartum
Presenting in active
labour, no prior ART
Initiate TDF (300 mg) + 3TC
(300 mg) + EFV (600 mg)
[1 II + 1 NRTIs + 1 NNRTI]
Continue TDF (300 mg) + 3TC
(300 mg) + EFV (600 mg)
Nevirapine prophylaxis for breastfeeding infant should be for 12 weeks, as mother did
not receive any ART during ante-natal period
• NACO - Technical ART guidelines

15. ARV Prophylaxis for Infant

16. State/UT wise PMTCT need in 2017, HIV Estimations 2017

17. Should be immunized according to the routine national immunization schedule with a few exceptions
• Should be given at birth
• If not been given at birth, it should not be given in
symptomatic HIV-infected older infants and children
BCG
• Should be avoided in all severely immune
compromised infants. (CD4 <15 %)
Live vaccines
• Recommended for use in HIV exposed infants
due to their vulnerability to diarrhoea
Rotavirus vaccine
Immunization & Vitamin-A Supplementation4
• Found to be safe for use in children with
HIV infection.
Japanese Encephalitis (JE) vaccine
• A 4-dose, double quantity schedule
recommended in view of poor sero-
conversion with routine immunization
Hepatitis B Vaccine
• Supplementation should be as per the
national immunization schedule
Vitamin A

18. An effective and proven strategy for
reducing morbidity and mortality in
children with HIV infection.
The recommended dose is 5 mg/
kg/ day as a single daily dose.
All HIV-exposed infants should
get co-trimoxazole prophylaxis
from the age of 6 weeks.
Not only protects the infants
and children from
Pneumocystis jiroveci infection,
but also from malaria,
diarrhoea due to isospora and
cyclospora, toxoplasmosis
1 Co-trimoxazole prophylaxis5

19. LENGTHWEIGHT
DEVELOPMENTCHARTS
Recorded at every visit
WHO growth reference
standard be used for assessing
a child’s growth parameters.
Should be recorded once in 3
months
Cognitive, motor, language and
social skills
Monitor
Growth &
Development
1 Growth and Development6

20. 1 Growth and Development
1 Early infant diagnosis
Components of Care of HIV-Exposed Infant/Child
Infant feeding2
ARV prophylaxis3
Immunization and Vitamin-A Supplementation4
1 Co-trimoxazole prophylaxis5
Immediate Care at Birth11
1 Follow up
16
1
18
7

21. 1 Early infant diagnosis7
1
Maternal HIV antibodies transferred passively
to the infant during pregnancy usually persist
for nearly 9-12 months in the infant.
2
More reliable indicators of the HIV infection
status of the infant are tests that detect HIV viral
RNA or antigens
3
Presence of IgA or IgM anti-HIV in the infant's
circulation can indicate HIV infection, but IgA and IgM
anti-HIV assays have been both insensitive and
nonspecific

22. Low Risk
• Mothers received standard ART
during pregnancy
• Confirmed HIV RNA level below the
lower limits of detection
• No concerns related to maternal
adherence.
High Risk
• Mothers with HIV who did not
receive prenatal care,
• Did not receive antepartum or
intrapartum arvs,
• Received intrapartum ARV drugs
only,
• Mothers who initiated ART late in
pregnancy
• Diagnosis of acute HIV infection
during pregnancy, had detectable
HIV viral loads close to the time
of delivery
Recommended Virologic Testing Schedules for Infants Exposed to HIV by
Perinatal HIV Transmission Risk

23. Recommended Virologic Testing Schedules for Infants Exposed to HIV by
Perinatal HIV Transmission Risk

24. Diagnosis Recommendation
N
A
C
O

25. RNA PCR
• Provides
additional
quantitative
information on
virological status
• Done on plasma
DNA PCR
• A qualitative test
• Done on dried
blood film (DBF)
.
Nucleic Acid Tests
(NATs)
1 Early infant diagnosis7
Sensitivity and
specificity of both the
techniques almost
similar

26. A presumptive diagnosis of severe HIV disease where
there is no virologic testing (DNA PCR) available
With two or more of the following:
1) Oral thrush; 2) Severe pneumonia; 3) Severe sepsis.
Recent HIV-related maternal death
Advanced HIV disease in the mother
CD4 in the child < 20%.
Clinical criteria for presumptive diagnosis of severe :HIV infection

27. 1 Follow up18
Nutrition
Clinical
Developmen
t
Labs
Psycho-
social
Anthropometry
History / PE
DQ in all
parameters
Hb%, CUE, CBC, CD4
counts
Overall health
01
05
04
03
02
At
ICTC

28. Immune Classification
(CELLS/μL)

29. Nucleoside reverse
transcriptase
inhibitors
• Zidovudine (AZT/ZDV)*
• Stavudine (d4T)
• Efavirenz*(EFV)
• Lamivudine (3TC)*
• Abacavir (ABC)*
• Didanosine (ddl)
• Zalcitabine (ddC)
• Emtricitabine (FTC)
(NsRTI)
Antiretroviral Agents
Non-nucleoside
reverse
transcriptase
inhibitors
• Nevirapine* (NVP)
• Efavirenz*(EFV)
• Delavirdine (DLV)
(NNRTI)
Protease Inhibitors
• Saquinavir (SQV)
• Ritonavir (RTV)*
• Nelfinavir (NFV)
• Amprenavir (APV)
• Lopinavir (LPV)*
• Atazanavir (ATV)*
• Darunavir (DRV)*
(PI)
Integrase Inhibitors
• Raltegravir (RGV)*
• Elvitegravir (EVG)
II
Fusion inhibitors
• Enfuvirtide (T-20)
FI
Integrase Inhibitors
• Tenofovir (TDF)*
Fusion inhibitors
• Maraviroc
NtRTI
CCR5
Entry
Inhibitor

30. ARV Drugs
&
Targets
• Walker BN, Colledge NR, Ralston SH, Penman I, editors: Davidson's principles and practice of medicine, ed 22, London, 2014, Churchill Livingstone

31. ART – in Management

32. • Dr.C.S.N.Vittal