Welcome Applicants!! 

1. Welcome Applicants!! Morning Report: Friday, January 20th

2. HIV Infection in Children and Adolescents

3. An Introduction… • Epidemiology, diagnosis, prevention and treatment of HIV/AIDS has changed dramatically over the past 25 years • Rates of new infections in infants has plummeted • Effective screening and prevention strategies • Children born with HIV are surviving into young adulthood • Adolescents acquiring HIV at an alarming rate

4. Epidemiology • Worldwide: • 33.2 million people living with HIV • 2.5 million are children younger than 15 • In 2007, 2.1 million AIDS deaths occurred • 330,000 were children • In the US: • In 2006, 2181 cases of AIDS were reported among children and adolescents through age 24 • Only 38 cases were in children <13yo • Pediatric burden of infection now rests in the adolescent population!

5. Pathogenesis • Lentivirus in the retrovirus Family • Infection occurs when the virus enters the body and binds to the CD4 receptors on host T lymphocytes

6. Pathogenesis • Binding fusion of HIV envelope with lymphocyte cell membrane viral RNA and enzymes (RT) enter host cell viral RNA reverse transcribed into DNA viral DNA enters host cell nucleus integration into host cell genome activation of host cell virion production and release spread to other cells • This viremic phase preceeds antibody response and is the period of HIGHESET INFECTIVITY!!

7. Pathogenesis • Viremic phase corresponds with the acute retroviral syndrome: • Fever, LAD, rash, myalgias/ arthralgias, HA, diarrhea, oral ulcers, leukopenia/ thrombocytopenia, transaminitis • During this “window period” between host cell infection and antibody response: • HIV antibody test negative • HIV RNA positive • Seroconversion occurs b/t 10-14 days and 6 months after infection

8. Preventing Transmission • Transmission by two principal modes • *Mother-to-child • Antepartum: transplacental transfer • Intrapartum: exposure to maternal blood, amniotic fluid or cervicovaginal secretions during delivery • Postpartum: Breastfeeding • Behavioral • Unprotected sex • Traumatic sex • Active genital ulcer disease • Douching before sex • Injection drug use

9. Preventing Transmission • So what do we do?! • *Mother-to-child • ART • Intrapartumzidovudine • Neonatal zidovudine • Safe replacement feeding • Elective C/S before the onset of labor in women with persistent viremia • Behavioral • *COUNSEL, COUNSEL, COUNSEL!! • Abstinence • Consistent and correct use of condoms

10. Laboratory Testing • *Remember that all infants Born to HIV-positive mothers Will test positive for the HIV Antibody due to maternal Transfer of Ig

11. Laboratory Testing • HIV-exposed infants • HIV DNA/RNA PCR at 2 weeks, 2 months, and 4 months • Definitive exclusion of infection • Negative results for two virologic tests • First at age 1 month or older • Second at 4 months of age or older • Confirmatory antibody test at 12-18 mos optional • HIV-positive mothers and BF • Testing should continue throughout period of BF and 6 months after

12. Laboratory Testing • Children and adolescents • All children of HIV-positive mothers should be screened • Adolescents should be screened as a part of routine health care • Age 13 and older • High-risk adolescents should be screened yearly!

13. Evaluation and Staging • First step: referral to an HIV specialist!

15. Clinical Conditions (con't)

16. Treatment • Antiretroviral therapy • Goals: (maximize quality and longevity of life) • Complete suppression of viral replication • Preservation or restoration of immunologic function • Prevention of or improvement in clinical disease

17. Treatment • Antiretrovirals • What to start? • ART should be planned and monitored in collaboration with an HIV specialist • Triple-drug combination ART • 3 drugs from 2 categories: one non-nucleoside reverse transcriptase inhibitor (NNRTI) OR protease inhibitor PLUS two nucleoside or nucleotide reverse transcriptase inhibitors • Viral load to monitor adherence • Non-detectable viral load within 3-6 months • Failure to achieve this goal strongly suggests suboptimal adherence rather than resistance

18. Treatment • Prevention of Opportunistic Infections • Pneumocystisjirovecipneumonia (PCP) • Most common OI • Bactrim prophylaxis for: • All HIV-exposed infants until infection is reasonably excluded • All HIV-infected infants <12mos • All HIV-infected children and adolescents with severe immune suppression • CD4 percentage< 15% or CD4 count< 200 cells/mm3 • Mycobacterium avium complex • Azithromycin prophylaxis for: • Age≥ 6yo with CD4 count <50 cells/mm3 • Ages 2-5yo with CD4 count <75 cells/mm3 • Ages 1-2 yo with CD4 count <500 cells/mm3 • Age< 1yo with CD4 count <750 cells/mm3

19. Treatment • Prevention of opportunistic infections • Toxoplasmosis • Less common in children • Bactrim prophylaxis in: • ToxoplasmaIgG positive individuals with severe immunosuppression (CD4%< 15% or CD4 count < 100 cells/mm3

20. Immunizations • Immunization schedule same as for healthy children with a few small exceptions: • CD4 percentage< 15% or CD4 count< 200 cells/mm3= NO VARICELLA OR MMR • Only killed, injectable formulations of the influenza vaccine

21. Counseling and Support • Coping with the diagnosis and prognosis • Offer hope and reassurance about the availability of effective treatment • *Disclosure of HIV Infection status • Planned disclosure to family and friends can increase support for the HIV-positive person • Sexual partners can make informed decisions about how to protect themselves • Adherence to Care and Treatment • Requires 90-100% adherence to drug regimens to avoid the development of resistance

22. Counseling and Support • School and sports participation • HIV-infected children and adolescents can participate fully in the educational and extracurricular activities at school • *No obligation to notify school personnel of student’s HIV infection status • Some experts advise athletes with a detectable viral load to avoid high-contact sports (boxing, wrestling) • Transition to adult health care • Complete and coherent medical record • Advance care planning and palliative care

23. A Last Thought… • http://aidsinfo.nih.gov • Thanks so much for your attention!! • Noon conference: Lung Function, Dr. Edell