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Morning Report: Friday, January 20th
 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
 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!
 Lentivirus in the retrovirus
Family
 Infection occurs when the
virus enters the body and
binds to the CD4 receptors
on host T lymphocytes
 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!!
 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
 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
 So what do we do?!
 *Mother-to-child
 ART
 Intrapartum zidovudine
 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
 *Remember that all infants
Born to HIV-positive mothers
Will test positive for the HIV
Antibody due to maternal
Transfer of Ig
 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
 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!
 First step: referral to an HIV specialist!
 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
 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
 Prevention of Opportunistic Infections
 Pneumocystis jiroveci pneumonia (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
 Prevention of opportunistic infections
 Toxoplasmosis
 Less common in children
 Bactrim prophylaxis in:
 Toxoplasma IgG positive individuals with severe
immunosuppression (CD4%< 15% or CD4 count < 100 cells/mm3
 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
 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
 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
 http://aidsinfo.nih.gov
 Thanks so much for your attention!!
 Noon conference: Lung Function, Dr. Edell