Management of HIV/AIDS in Children: A Case Study of Thomas

1. Chapter 8Children with HIV/AIDS

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

3. 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

4. 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.

5. Triage 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

6. History Thomas was well until 5 months of age. Many visits to the clinic since then. Two episodes of pneumonia that needed treatment in hospital with antibiotics. 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. 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.

7. 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.

8. Nutrition 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.

9. 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

10. Differential diagnoses • Recurrent infections • Oral thrush due to antibiotics • HIV • Congenital immune deficiency • Primary malnutrition accompanied by various infections

11. 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)

12. What investigations would you do?

13. 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

14. Investigations • Full blood count: Haemoglobin: 8.9 g/l (10.5 - 13.5) Platelets: 255 x 109/l (150 - 400) WCC: 14.6 x 109/l (6 - 18.0) Neutrophils: 12.3 x 109/l (1.0 - 8.5) Lymphocytes: 0.8 x 109/l (4.0 - 10.0) MCV 67 (74 - 85)

15. Provider-initiated counselling and testing Thomas, his parents and his elder sister’s (Rachel) HIV status were tested after they were reassured of confidentiality. (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.

16. 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

17. Thomas has stage 3 HIVHow would you treat Thomas and his family?

18. Antiretroviral treatment There are three main classes (Ref. p. 234), plus a new class • Nucleoside reverse transcriptase inhibitors • Zidovudine (AZT), lamivudine (3TC), abacavir (ABC), tenofovir (TDF), emtricitabine • Non-nucleoside reverse transcriptase inhibitors • Nevirapine, efavirenz • Protease inhibitors: • Lopinavir/ritonavir • Integrase inhibitors • Dolutegravir

19. Antiretroviral treatment • At least 3 drugs recommended for all settings, resistance quick to appear, usually 2 NRTI + 1 NNRTI; or 2 NRTI and 1 PI • Fixed dose combination therapy now used: e.g. ABC + 3TC + NVP • Other affected family members need to have access to treatment also • High level of adherence and close follow-up are necessary

20. Antiretroviral treatment • When to start treatment? • <5 years of age: all HIV-infection confirmed children should start treatment • >5 years of age: CD4 count <500 cells / mm3 should definitely start. If no CD4 testing, commence in all HIV-infection confirmed children

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

22. What supportive care is required?

23. Supportive care • Nutrition: • Feed with breast milk if possible • Multivitamins, vitamin A, zinc • Iron supplements (anaemia and low MCV) • Immunization: • Give all vaccines, except BCG (Ref. p. 240) • Prophylaxis: • Cotrimoxazole • Consider isoniazid-preventative therapy • Psychological and social support, kindness

24. Supportive care • Look for complications of ART (ref Table 26, p236) • Anaemia, neutropenia • Rashes • Abdominal pain • Hepatitis

25. 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

26. 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