Review of HIV and Opportunistic Infections (OI) in Children

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

2. 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

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

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

5. 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)

6. 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

7. 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

8. 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

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

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

11. Case #1 - PCP • PCP • 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)

12. 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

13. 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.

14. 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

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

16. Case #3 - Herpes

17. 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

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

19. Case # 4 - Candida

20. 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

21. 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

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

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

24. Case #5-6 TB /MAC

25. Case # 5-6 TB/MAC

26. 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)

27. 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

28. SEX

29. Needle sticks

30. 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

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

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

33. Blood transfusion

34. Ways you can not get HIV

35. Shaking Hands

36. Hugging

37. Coughing

38. Kissing

39. Eating or Drinking together

40. Mesquitoes/ Insects/ Animals

41. Sitting next to someone with HIV

42. Living with someone with HIV

43. 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

44. THANK YOU!