Communicable Diseases Module: 28. HIV in Children

Study Session 28  HIV in Children

Introduction

In Study Session 27, you learnt that mother-to-child transmission of HIV during pregnancy, delivery and labour, and breastfeeding are the main sources of HIV infection in children. In this study session, we will focus on the consequences of HIV infection in children. You will first learn about the key differences in chronic HIV care between adults and children. The immune system in young children is still developing, and as a consequence HIV-infected children suffer from many more opportunistic and common infections, and also progress more rapidly to AIDS than HIV-infected adults. For these reasons, early diagnosis and treatment of HIV infection is particularly important in children.

Within your health post, you will have to establish a link between your own family-focused care and HIV care services. To do so, you will need to learn how to routinely discuss and recommend HIV testing for children born to HIV-infected mothers, and when it is appropriate to refer them. Finally, we will briefly describe important issues concerning the care of HIV-infected children, namely their nutritional status and psychosocial needs. You will learn more on the diagnosis of HIV in children, and the care for HIV-exposed infants and HIV-infected children in the Integrated Management of Newborn and Childhood Illness (IMNCI) Module.

Learning Outcomes for Study Session 28

When you have studied this session, you should be able to:

28.1  Define and use correctly all of the key words printed in bold. (SAQ 28.1)

28.2  Describe the key differences in diagnosis of HIV status and chronic HIV care between adults and children. (SAQs 28.1 and 28.2)

28.3  Explain when to refer HIV-exposed infants born to HIV-positive mothers for early diagnosis. (SAQ 28.3)

28.4  Describe the nutritional and psychosocial needs of children with HIV. (SAQ 28.3)

28.1  Critical issues in HIV infection and progression to AIDS in children

There are important differences in HIV infection and progression to disease between adults and children. These have implications for the care needed by HIV-infected children (explained further in Section 28.3). We will describe here the main issues related to HIV/AIDS and children that will help you provide the best care for HIV-infected children in your community.

28.1.1  Minimising risk of infection in children

The most important thing for you to remember in the context of HIV prevention in children is that mother-to-child transmission is the main source of HIV infection. Children at any age who continue to be breastfed from HIV-positive women are at risk of acquiring HIV infection through contaminated breastmilk throughout the time they are breastfed. You should provide feeding advice to mothers according to the national guidelines on infant feeding (this is covered in detail in the Integrated Management of Newborn and Childhood Illness Module).

Where one child is HIV positive, it is possible that other family members, including siblings (brothers and sisters), are already infected. Therefore, you should always encourage HIV testing of parents, and young, siblings of HIV-exposed infants and HIV-infected children. You should appreciated that unless an HIV test result is confirmed, infants born to HIV-positive mothers are called HIV-exposed infants, and HIV-infected children are those whose HIV test results are confirmed as being positive.

28.1.2  Early diagnosis of HIV

There are differences in disease progression and diagnosis of HIV infection between adults and children. The main differences in disease progression and diagnosis are listed below:

• Young children have immature immune systems and thus are more susceptible to common childhood infections, as well as opportunistic infections.
• Early diagnosis of HIV infection in children is essential, as the infection in infants and children progresses faster than that of adults Although HIV-infected infants are generally symptom-free at birth, in the absence of any intervention, most of them develop severe symptoms in the first two years of life, and die. Therefore, early diagnosis and management of HIV-exposed and HIV-infected children is key to ensure maximum benefit from ART, and to reduce AIDS-related morbidity (the presence of an illness or disease) and death in children.
• In HIV-exposed infants, maternally acquired antibodies make the diagnosis of HIV challenging. The antibodies present in the blood of an HIV-exposed infant may originate from the mother and not the infant itself. Therefore, a positive rapid HIV test is not definitive for the diagnosis of HIV infection in children below the age of 18 months. However, a rapid test, done six or more weeks after the complete cessation of breastfeeding, which gives a negative result, is more useful, because it excludes HIV infection in HIV-exposed infants.

28.1.3  Differences in the management of children and adults with HIV

The management of HIV in children, especially the young ones, differs from that of adults. Below are some of these differences:

• Normal CD4 counts are higher in young children than in adults, and decrease with age to reach adult levels around the age of six years. In children younger than six years, it is better to use the percentage of CD4 cells in the blood as a criterion to start ART. This is more stable than the CD4 cell count used in adults.
• Once started on ART, children need to be followed-up more frequently than adults. Their response to ART should be checked by regular monitoring of growth and development (Figure 28.1 illustrates the profound improvement that can be seen in HIV-positive children given ART).
• ARV drug dosages need to be adjusted regularly to account for changing body weight and growth as children develop.
• Communication with children can be challenging. This regards issues related to disclosure, counselling and explaining the need for long-term treatment, particularly adherence to the treatment regimen.

Figure 28.1  A South African child living with HIV. The image on the left was taken immediately prior to ART and the photo on the right shows the marked improvement achieved after only six months of therapy. (http://www.tac.org.za/community/taxonomy/term/49)

28.2  Providing care for HIV-exposed infants and HIV-infected children

Routine childhood services, e.g. immunization, nutrition, OPD (out-patient department) and in-patient (hospital ward) services, are entry points for HIV-exposed and infected children. Health workers should use these services as opportunities to provide access to early diagnosis of HIV for families with children at risk.

As we discussed above, HIV-exposed infants/children should be enrolled into HIV care services and receive a regular follow-up at a health centre or hospital. They should also be given cotrimoxazole prophylaxis to prevent severe infections such as pneumocystis pneumonia (a fungal infection of the lungs), which can cause death in HIV-infected children. Cotrimoxazole prophylaxis is given to HIV-exposed children starting from four to six weeks of age, until a diagnosis of HIV infection is definitely excluded. Those who present late to a health facility should also be given cotrimoxazole prophylaxis.

Remember that a rapid HIV test is not a reliable test to diagnose HIV infection in children under the age of 18 months. This is because there are maternally acquired antibodies in the blood of the child, and these antibodies can give a false positive HIV test result. Therefore, the best test for diagnosing HIV infection in children less than 18 months of age is a DNA PCR test (see Figure 28.2). This test detects the presence of viral components in blood. However, you are not required to know the details of this test.

Figure 28.2  Blood samples are collected from a baby for a DNA PCR test. The samples are collected as a series of ‘dry blood spots’ which will then be tested for the presence of the virus.(Photo: courtesy of UNICEF UK, Lesotho 2007/Gideon Mendel)

The Federal Ministry of Health of Ethiopia has already started a DNA PCR service at several regional laboratories, where blood samples can be sent for analysis to aid early infant diagnosis. DNA PCR can be done as early as six weeks of age. Therefore, you, as a health worker, should encourage the family of an HIV-exposed infant/child to take the infant/child to a nearby health centre for early diagnosis.

When you encounter such children, either when visiting a household or at the health post, you should inform the family or caregiver about the importance of follow-up care and cotrimoxazole prophylaxis for the HIV-exposed child. The caregiver might not easily recognise the importance of cotrimoxazole prophylaxis and follow-up care, particularly if the child appears to be healthy. Your role is to coordinate the care of the HIV-exposed child with that of the mother.

28.3  Nutritional and psychosocial support for children with HIV

HIV-exposed infants and HIV-infected children need special nutritional and psychosocial support, both at the level of the health facility and the community. Below we will discuss why they need this special support.

28.3.1  Nutritional needs of HIV-infected children

The nutritional status of a child will significantly affect the incidence and severity of HIV-related illnesses, such as tuberculosis and diarrhoea. In addition, HIV-related illnesses also have severe nutritional consequences that commonly precipitate appetite loss, weight loss and wasting. Clinical situations that may impair the nutrition of HIV-infected children are recurrent or chronic infection, fever, intestinal infections, oral or oesophageal lesions, and persistent diarrhoea. Box 28.1 summarises some of the key issues that need to be considered when thinking about the nutritional needs of HIV-infected children.

28.3.2  Providing psychosocial support to children infected with HIV

Beyond disease management, children infected with HIV face a number of problems that impact upon their social, educational and emotional development and wellbeing. These children require psychosocial support, which includes a range of interventions that enable individuals and families to cope with the overwhelming feelings that result from their experiences with long-term disease and death. Providing psychosocial support may include addressing self-esteem, adaptation to illness and its consequences, communication, social functioning and relationships — these topics will be discussed in more detail in Study Session 30 (Providing Palliative Care for people living with HIV.)

Health facility-based and home-based stimulation of children improves their mental, social and emotional development. Remember, encourage family members to play and talk with the children. This will help provide an enriching and stimulating environment that will greatly enhance and support the children’s psychosocial development.

Children’s development will flourish when they form secure attachments to a responsive caregiver. Furthermore, children need to be provided with psychological (relating to both the mental and social aspects of life) and emotional support within their family or through other caregivers, and to be able to communicate openly about their own or their family member’s condition, so as to give relief to deep fears that may be difficult to share.

For caregivers to provide this support to children, they must themselves be provided with psychosocial support. This can be done when you do home visits, or through community-based organisations or peer support groups. It is important for you to ensure adequate linkage of families with these groups, and to pay attention to the psychosocial needs of the whole family on each visit.

Summary of Study Session 28

In Study Session 28, you have learned that:

1. There are differences between HIV infection in adults and children. The main differences are the mode of transmission of HIV, disease progression, diagnosis of HIV infection, especially among children less than 18 months of age, and that CD4 counts are higher in children compared with adults.
2. ARV drugs are handled differently in children’s bodies, affecting the doses that are needed. Dosages in children need to be adjusted to the child’s weight as the child grows.
3. Communication, adherence and disclosure in children are challenging.
4. Infants and children born to HIV-positive parents should be tested for HIV as early as possible. If not, they may die of common childhood illnesses and opportunistic infections in a shorter time. You need to refer such infants/children to a nearby health centre/hospital for early infant diagnosis.
5. HIV-infected children need special psychosocial and nutritional support.

Self-Assessment Questions (SAQs) for Study Session 28

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

Read Case Study 28.1, and then answer the questions that follow it.