Morning Report: Friday, January 20th

Welcome Applicants!!

HIV Infection in Children and Adolescents

Epidemiology, diagnosis, preventionand treatment of HIV/AIDS has changed dramatically over the past 25 years

Rates of new infections in infants hasplummeted

Effective screening and prevention strategiesChildren born with HIV are surviving into

young adulthoodAdolescents acquiring HIV at an alarming rate

An Introduction…

Worldwide:33.2 million people living with HIV

2.5 million are children younger than 15In 2007, 2.1 million AIDS deaths occurred

330,000 were childrenIn the US:

In 2006, 2181 cases of AIDS were reported among children and adolescents through age 24 Only 38 cases were in children <13yoPediatric burden of infection now rests in the

adolescent population!

Epidemiology

Lentivirus in the retrovirusFamilyInfection occurs when thevirus enters the body and binds to the CD4 receptorson host T lymphocytes

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!!

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 negativeHIV RNA positive

Seroconversion occurs b/t 10-14 days and 6 months after infection

Pathogenesis

Transmission by two principal modes*Mother-to-child

Antepartum: transplacental transferIntrapartum: exposure to maternal blood,

amniotic fluid or cervicovaginal secretions during delivery

Postpartum: BreastfeedingBehavioral

Unprotected sexTraumatic sexActive genital ulcer diseaseDouching before sex

Injection drug use

Preventing Transmission

So what do we do?!*Mother-to-child

ARTIntrapartum zidovudineNeonatal zidovudineSafe replacement feedingElective C/S before the onset of labor in women

with persistent viremiaBehavioral

*COUNSEL, COUNSEL, COUNSEL!!Abstinence Consistent and correct use of condoms

Preventing Transmission

*Remember that all infantsBorn to HIV-positive mothersWill test positive for the HIVAntibody due to maternalTransfer of Ig

Laboratory Testing

HIV-exposed infantsHIV DNA/RNA PCR at 2 weeks, 2 months, and

4 monthsDefinitive exclusion of infection

Negative results for two virologic tests First at age 1 month or olderSecond at 4 months of age or olderConfirmatory antibody test at 12-18 mos optional

HIV-positive mothers and BFTesting should continue throughout period of BF

and 6 months after

Laboratory Testing

Children and adolescentsAll children of HIV-positive mothers should be

screenedAdolescents should be screened as a part of

routine health careAge 13 and olderHigh-risk adolescents should be screened yearly!

Laboratory Testing

First step: referral to an HIV specialist!

Evaluation and Staging

Clinical Conditions (con't)

Antiretroviral therapyGoals: (maximize quality and longevity of life)

Complete suppression of viral replicationPreservation or restoration of immunologic

functionPrevention of or improvement in clinical disease

Treatment

AntiretroviralsWhat to start?

ART should be planned and monitored in collaboration with an HIV specialist

Triple-drug combination ART3 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 adherenceNon-detectable viral load within 3-6 monthsFailure to achieve this goal strongly suggests

suboptimal adherence rather than resistance

Treatment

Prevention of Opportunistic InfectionsPneumocystis jiroveci pneumonia (PCP)

Most common OIBactrim 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 complexAzithromycin 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

Treatment

Prevention of opportunistic infectionsToxoplasmosis

Less common in childrenBactrim prophylaxis in:

Toxoplasma IgG positive individuals with severe immunosuppression (CD4%< 15% or CD4 count < 100 cells/mm3

Treatment

Immunization schedule same as for healthy children with a few small exceptions:CD4 percentage< 15% or CD4 count< 200

cells/mm3= NO VARICELLA OR MMROnly killed, injectable formulations of the

influenza vaccine

Immunizations

Coping with the diagnosis and prognosisOffer hope and reassurance about the availability of effective treatment

*Disclosure of HIV Infection statusPlanned disclosure to family and friends can

increase support for the HIV-positive personSexual partners can make informed decisions

about how to protect themselvesAdherence to Care and Treatment

Requires 90-100% adherence to drug regimens to avoid the development of resistance

Counseling and Support

School and sports participationHIV-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 careComplete and coherent medical record

Advance care planning and palliative care

Counseling and Support

http://aidsinfo.nih.govThanks so much for your attention!!

Noon conference: Lung Function, Dr. Edell

A Last Thought…