8.1 Components of comprehensive HIV Care
11.1 Prevention of Pnemocystis carinii (PCP)
11.2 Prevention of Tuberculosis (TB)
12.1 Clinical Management of Infectious Diseases in HIV-infected children
12.2 Clinical Management of Respiratory Conditions in HIV-infected children
12.3 Clinical Management of Gatrointestinal Conditions in HIV-infected children
12.4 Clinical Management of Skin and Mucosal Conditions in HIV-infected children
12.5 Clinical Management of Miscellaneous other conditions in HIV-infected children
Appendix A: Current childhood immunisation schedule (EPI)
Appendix B: Modified criteria for diagnosing aids
Appendix C: Cotrimaxazole dosing schedule for pcpc
prophylaxis
Appendix D: Treatment of children with TB
Appendix E: Age adjusted normal cd4 cell levels
These guidelines present recommendations for the treatment of HIV positive children and children with AIDS. Clinical science and the treatment of HIV positive persons and persons living with AIDS is developing rapidly. These recommendations are not intended to provide the state of the art medical care, but a practical approach for managing HIV and AIDS related diseases within health services in South Africa. Primary and secondary prevention of HIV infection should be emphasised at all opportunities.
Currently, antiretroviral therapy is not available in the public sector. The Department of Health is investigating the possible use of antiretroviral medications for HIV positive persons and as a possible therapy to prevent mother-to-child HIV transmission. Guidelines for the use of antiretroviral therapy are therefore not presented in this document. The Department of Health would like to acknowledge the valuable contribution of Dr. C. Evian who provided an early version of this guideline and the HIV and AIDS Clinician’s Society.
Most childhood HIV infections with HIV occur around the time of birth, or soon thereafter. In many cases, these children will develop symptoms and disease complications within the first 2 years of life, or within the first two years of their life. The children who survive, either with slowly-progressing HIV infection, or as the uninfected offspring of infected parents, will often outlive their parent/s as orphans. HIV is a disease that affects families and communities and presents a challenge to our society, the health services and to each individual health worker involved in trying to prevent or manage affected individuals. The possibility now exists to reduce the number of children becoming infected from mother-to-child viral transmission and it remains fundamentally important to reduce the numbers of newly infected adults through preventive strategies. Children who are infected should be given the best possibility of remaining well for as long as possible through appropriate interventions and should also be made comfortable and free from distress in the terminal stages of their illness. This guideline is intended for health care workers at all levels to guide the care of these HIV-infected children. Whilst the exact nature of this care will vary depending on the skills of the individual health care worker, the circumstance in which the care is provided, and according to the resources available, health care workers are urged to provide the best possible care within these constraints.
HIV causes immune system damage through the effects of ongoing viral replication and this ultimately leads to AIDS.
The rate at which the disease progresses differs between children, so treatment decisions should be individualised, guided by the child’s clinical status and prognosis. No child should be denied health care simply on the basis of their HIV status.
Most HIV-infected children become infected in the peri-natal period and it is now possible to reduce peri-natal HIV transmission (especially if the mother’s HIV status is known).
The time from infection to severe immunocompromise is variable. In children, HIV has a bimodal distribution of disease presentation and progresses more rapidly than in adults.
The natural history of HIV infection in children differs significantly from that seen in adults and the interval from infection to the development of AIDS, and finally to death, is generally much shorter in children compared with adults.
In sub-Saharan Africa, it is estimated that 75% of all HIV-infected children will die before their fifth birthday. A significant proportion of children will develop serious illness and die within the first year or two of life.
The clinical presentation of HIV disease is very variable: There are children who progress very rapidly to AIDS-defining conditions (or Modified CDC category C conditions – refer to appendix B) and have a rapid loss of CD4+ cells within the first 2 years of life, leading to increasingly severe complications of worsening immunocompromise, and death.
A larger group of children have a more intermediate rate of progression of HIV disease and will tend to develop evidence of severe immunosuppression by 7 to 8 years of age, with a much more gradual loss in CD4+ cell number.
A small group of patients remain healthy with minimal to no symptoms of HIV disease and a normal to minimally decreased CD4+ cell count by eight years of age.
The prognosis or survival of children infected with HIV is influenced by their age and disease severity at the time of diagnosis of disease. Based on the natural history of the infection, two main groups of children can often be identified:
Rapid progressors are those infants who become symptomatic within a few months of age, manifesting with more severe illnesses (CDC Category C diseases, such as PCP, HIV Encephalopathy, or Wasting) and dying within the first two years of life.
Slow progressors are those children who develop less severe immunocompromise during the first year or 2 of life. Although they might be symptomatic from early on, they usually present with less severe early complications (such as recurrent bacterial infections, LIP and Parotomegaly). Having milder illness and a longer median survival period, these children often survive to older childhood ages and even into their early teens.
The differentiation of children into rapid and slow progressors can be useful when setting management objectives, as their prognosis differs.
Factors associated with more rapid progression of HIV to AIDS:
HIV viral load: The higher the load the more likely that AIDS will develop.
Immune response of the individual child to infection with the virus: Immune deficiency (reflected by low CD4 cell counts) also indicates a poorer prognosis.
Virulence of the virus: Some viruses are slower progressing viruses than others.
Nutritional status of the child: Undernourished or malnourished children have a worse prognosis.
Concurrent infections in the child such as malaria, measles, tuberculosis, respiratory infections, gastroenteritis etc. tend to accelerate the progress of the disease.
Lower socio-economic status and poverty are associated with worse prognosis.
Although children with AIDS can present at any age, most studies indicate the average age is about 9 months. The clinical presentation may vary. Many of the signs and symptoms are not specific to HIV and AIDS and may occur in non HIV-infected children.
The following signs are suggestive of underlying HIV infection and indicate the need for an HIV test:
Recurrent diarrhoeal disease
Candidiasis
Failure to thrive, especially if associated with chronic or recurrent diarrhoeal disease or candidiasis
Lymphadenopathy with or without hepatosplenomegaly
Parotid gland enlargement
Recurrent pneumonia or other recurring respiratory infections of varying severity
Tuberculosis and/or atypical tuberculosis, or where the disease does not respond to appropriate treatment
Clinical and X-ray findings suggestive of Lymphoid Interstitial Pneumonitis (LIP) or Pneumocystis Carinii Pneumonia (PCP)
Severe dermatitis, particularly seborrhoeic dermatitis in young infants
Infections with unusual organisms
Anaemia and thrombocytopenia
HIV disease in infants can present in many different ways, such as:
Wasting and failure to thrive: Many factors contribute towards this syndrome, including: chronic gastroenteritis, the direct effect of HIV infection on the gastrointestinal tract, secondary opportunistic infections (such as cryptosporidium, cytomegalovirus and other viruses and bacteria) and poor nutritional intake.
Persistent generalised lymphadenopathy with or without hepatosplenomegaly and parotid enlargement.
Recurrent bacterial infections: These vary in severity and include pneumonia, septicaemia, meningitis, otitis media, tonsillitis, cellulitis and urinary tract infections. The common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae and Salmonella.
Respiratory disease: Acute bacterial pneumonia, recurrent chest infections, LIP and Tuberculosis are common.
Tuberculosis (TB): The manifestations of TB are usually no different to non HIV-infected children, except that disease may be atypical or severe in children with immune deficiency. It should be noted that TB in HIV-infected children has a wide spectrum of presentations depending on the degree of immune deficiency. Some clinical signs can also be confusing e.g. a tuberculin skin test may be falsely negative, a miliary pattern on CXR may not always be TB.
Pneumocystis carinii pneumonia (PCP): characterised by sudden onset of fever (but not always present), tachypnoea, hypoxaemia and a diffuse interstitial infiltrate on X-ray. It occurs most commonly in children under one (often in children who are well-nourished and otherwise relatively well), and is usually associated with a very poor prognosis. If treatment is started before the disease has advanced, the prognosis may be improved.
Lymphoid interstitial pneumonia (LIP): a slowly progressive interstitial lung disease of unknown aetiology. It is characterised by bilateral reticulonodular infiltrates and mediastinal lymphadenopathy on chest X-ray. LIP is commonly associated with parotomegaly and clubbing, as well as associated recurrent bacterial respiratory infections, chronic lung disease and bronchiectasis. It is often asymptomatic and usually has a good prognosis.
Neurological syndromes: These result from a variety of causes. Progressive encephalopathy may manifest as developmental delay or loss of developmental milestones, acquired microencephaly, convulsions or behavioural abnormalities. HIV Encephalopathy is a relatively common presentation of severe immunocompromise (AIDS).
Dermatitis: Skin rashes are common. These include severe nappy rash, allergic skin eruptions and non-specific skin lesions. Extensive seborrhoeic dermatitis is often a feature of HIV infection in young infants.
Opportunistic HIV-related infections: These include Pneumocystis carinii, Candida sp, cytomegalovirus, cryptosporidium, Toxoplasma gondii, Mycobacterium tuberculosis, Herpes simplex and Cryptococcus neoformans. Toxoplasmosis and Cryptococcal meningitis are rare in children.
Haematological manifestations include anaemia, neutropenia and thrombocytopenia. These conditions may result from a variety of mechanisms and may occur singly or in combination. They may present with pallor, infections or bleeding, most commonly epistaxis. Nutritional deficiencies (iron and folate) can exacerbate anaemia.
Other manifestations, which occur rarely in children, include secondary malignancies (lymphoma and Kaposi's sarcoma), hepatitis, cardiomyopathy and renal disease.
Common presentations of AIDS in children under 1 year:
Young children (under 1 year) tend to present with symptoms such as failure to thrive, lower respiratory tract infections, acute or recurrent diarrhoeal disease, severe sepsis, and HIV Encephalopathy. The severe nature of these conditions is reflected in the poor prognosis of children who present at this age.
Common presentations of AIDS in children over 1 year:
Children over 1 year of age tend to present with milder disease such as hepatosplenomegaly, lymphadenopathy, parotitis, LIP and recurrent bacterial infections.
Children who exhibit intermediate to slow progression of HIV disease may have an unremarkable clinical history or occasionally a slightly increased incidence of bacterial infections. Additionally, their physical exam may be unremarkable except for occasional lymphadenopathy. Other clinical findings that may be present even in children with very slow disease progression are: hepatosplenomegaly, increased parotid or tonsillar size, lymphoid interstitial pneumonitis (LIP) and HIV-related dermatitis.
Many people are now infected with HIV and may not even be aware that are. When their HIV infection status is known, families and children face discrimination both at schools and at home and parents may choose not to disclose their HIV status.
HIV is not spread through casual contact with infected children, but there are situations where the infection can be transmitted and appropriate precautions need to be taken.
Universal precautions for preventing HIV infection should therefore be taught and practiced both at school and in the home.
Blood-spill policies should be in place in all institutions, and should be taught to the general population at any opportunity by health care workers at all levels of care.
Parents/guardians should be encouraged to send HIV positive children to school for as long as possible and disclosure to teaching staff should be left to the discretion of the caregiver.
Careful precautions need to be taken by health care workers, particularly to prevent needle-stick injuries
HIV transmission from a mother to her child is dependent on a number of factors, including maternal viral burden, phenotype and genotype, maternal immunologic responses, and obstetrical events during labour and delivery.
Studies demonstrate that the majority of HIV vertical transmission probably occurs at the time of birth. Children can be infected in-utero, during delivery, and post-partum through breast-feeding.
Some obstetric factors include:
A decreased risk of perinatal HIV transmission when elective cesarean sections are performed.
An increased risk of HIV perinatal transmission associated with prolonged rupture of the amniotic membranes.
Prematurity as a risk factor for intrapartum acquisition of HIV infection.
It is critical to identify HIV-infected pregnant women prior to delivery to avoid perinatal transmission.
Intervention
Management
Indications
Comments / Rationale
Voluntary Counselling & HIV Testing of pregnant women
At this time a rapid, on-site HIV testing with same-day result reporting is the recommended HIV testing strategy for pregnant women
This should be done in a context where pre-test counselling or information is available, as well as post-test counselling and support
All pregnant women should be offered counselling and an HIV test
With no intervention 20% - 40% of children born to HIV positive women will be infected with the virus
A number of effective interventions exist that reduce the chances of an HIV-infected women infecting her child, and mothers should be informed of their options if they are infected
Knowledge of her HIV status may enable a woman to make informed choices about sex practices, future pregnancies, sterilisation and TOP (before 20 weeks’ gestation)
A woman who knows she is HIV Positive may also seek earlier medical care if she or her baby become ill
Avoidance of breast-feeding (substitution with Formula feeding)
Counsel the mother about the advantages and disadvantages of different feeding methods
Women who decide to breast-feed should be encouraged to breast-feed exclusively for 4 months and should try to wean rapidly after the baby is 3 months old
Formula feeding should be advised where:
- A woman has access to clean water
- A woman can afford to buy formula for 6 months
- A woman will not be stigmatised by not breast-feeding
HIV transmitted through breast-feeding can amount to 30 – 50% of all perinatal HIV infections
Mixed feeding has been shown to increase the risk of HIV transmission, and so giving additional fluids or solids should be discouraged.
Intervention
Management
Indications
Comments / Rationale
Following-up children born to HIV-infected Women
Asymptomatic children of HIV-infected mothers should have an ELISA test at 15 months, UNLESS
Symptomatic children of HIV-infected mothers should be treated as if they are HIV-infected and started on prophylactic treatment against OI’s.
Children over the age of 15 months, or younger children who reach this age, should receive a confirmatory ELISA after 15 months of age
All children born to women who are known to be HIV-infected
Asymtomatic children of mothers whose infection status is unknown should be followed up with normal well-baby care and need not be tested for HIV
HIV transmission from mother to uninfected child through breastfeeding can be reduced by avoiding breastfeeding by an infected mother / ‘wet-nurse’
Earlier diagnosis of HIV infection can improve the prognosis and quality of life of HIV-infected children through:
- Commencement of prophylactic treatments
- Provision of social and nutritional support
- Care planning
HIV Diagnosis of symptomatic children
Clinical Assessment
AND
HIV Serological Testing (see below)
All Children under 1 year of age who are admitted to hospital with Lower Respiratory Tract Infections should all preferably have an HIV Test on admission to guide management decisions
Children presenting with more than one of the following:
- Generalised lymphadenopathy
- Hepatomegaly &/or spenomegaly
- Severe oral candidiasis
- Recurrent upper respiratory infections (especially suppurative otitis media)
- Recurrent infections (e.g. lower respiratory tract, gastro-enteritis)
- Dermatitis, hair and/or nail changes
- Unusual infections (e.g. herpes zoster)
- Failure to thrive
- Failure to attain or loss of developmental milestones
- Severe Lower Respiratory Tract infection
OR
- An AIDS-defining condition
See Section 4 for further conditions associated with HIV disease and Appendix B for AIDS-defining conditions
Infected children are often the index case in families and contribute to the diagnosis of the mother and / or father.
Once the parent/s discovers their HIV infection status, this could lead to more appropriate care and social support planning and potentially reduce further spread of HIV by informing the parent/s sexual behaviour and future pregnancy decisions.
HIV Serological Testing (ELISA)
Pre and Post-test counselling of parent/s or legal guardian
AND
Informed Consent to testing from parent/s or legal guardian
AND
HIV ELISA Test
An immediate repeat ELISA test should be carried out if the first test is positive (especially in asymptomatic children over the age of 15 months), in order to eliminate false-positive results
If the test is negative and the child is not breast-fed, no follow-up test need be done (unless the child becomes symptomatic)
HIV infection suspected on clinical assessment (see above), or in a child born to an HIV-infected mother (see above)
Note: remember that breast-fed infants of HIV-infected mothers (or of infected ‘wet nurses’) can become infected at any time
Children under the age of 15 months may still have maternal antibody present that shows up as a positive ELISA without the infant actually being infected, but if they are symptomatic for HIV and ELISA positive they are considered infected.
Children exposed to HIV but who are asymptomatic before 15 months of age will be considered positive if the ELISA remains positive after 15 months of age.
All children beyond 15 months of age testing HIV ELISA positive are considered to be HIV infected.
Rapid HIV Testing
A rapid HIV test should be performed initially and confirmed with a repeat ELISA test as soon as possible
If a critically ill child’s HIV status is unknown and the HIV status will influence management decisions (e.g. whether to admit to ICU).
Children under fifteen months of age should not be considered HIV infected unless they have a positive HIV ELISA test AND clinical signs of HIV disease
Early testing of abandoned children
- Establish perinatal exposure to HIV by HIV ELISA test on the mother or baby
- Clinical examination for features of HIV disease
- HIV PCR test done at experienced laboratory. (Repeat the test if result "indeterminate")
- Assess PCR result together with clinical features and ELISA. Discuss discrepancies with the laboratory
- Children who have early PCR tests should be retested with an HIV ELISA
Abandoned children under twelve months AND over 6 weeks of age
(For children over twelve months of age, HIV status can be determined by two HIV ELISA tests and a clinical examination)
Early testing of abandoned children is encouraged so that placement can occur as soon as possible.
Children with HIV can be adopted or fostered like other children, but carers need to know so that the child is given appropriate health care.
These tests are not 100% accurate: The described protocol has a 1% chance of producing a false positive result (i.e. one child in a hundred may have a positive result but not be truly infected) and a 1.8% chance of producing a false negative result (i.e. the test is negative but the child is truly infected). False negative results tend to occur in children who have symptomatic disease, so results must be correlated with clinical findings.
Prospective parents and Social Workers must understand these risks. Prospective parents can repeat the tests for greater accuracy at their own expense.
Viral Antigen Testing (DNA-PCR and P24Ag)
DNA-PCR and P24Ag tests should be done only in consultation with the consultant/ designated doctor at each hospital.
As P24Ag has low specificity in the first few months of life, the recommended test for early diagnosis is DNA-PCR done after 6 weeks of age and repeated at 4-6 months, if negative
- To confirm a diagnosis if there are confusing or doubtful clinical features
- If it is imperative to know the HIV status early after birth (before 15 months) e.g. an abandoned child, a child who is up for adoption or a child requiring major surgery
- Where antiretroviral Therapy is being considered or monitored
These tests are expensive and not widely available. They should only be considered in specific circumstances
At present HIV infection is not curable. Specific antiretroviral (ARV) therapy combinations may suppress the HIV activity in the body and slow down, or even halt, the process of the disease. Unfortunately these medications are very costly and are not provided in public health services. Nevertheless, there are numerous interventions, which can significantly improve the child’s quality of life and survival time.
HIV care needs to take place within a holistic framework that attends to the social, psychological and physical well being of the individual. The role of household members and community support structures must be recognised and supported.
8.1 Components of comprehensive HIV care
History and physical examination of HIV-infected children with regular follow-up
Education and counselling
Social support co-ordination
Nutritional support management
Immunisation
Treatment of common clinical problems
Prophylaxis against some common and severe infections
Laboratory monitoring
Referral
Palliative and terminal care.
Children with symptomatic HIV infection should be seen regularly. This provides opportunities for:
Monitoring of growth and development
Early detection of any complications
Provision of prophylactic therapy
Monitoring of social and economic circumstances, and to provide ongoing counselling and support for mothers and other caregivers.
Follow-up of HIV-infected children can be done at local clinics.
It is advisable that a few members of the clinic staff familiarise themselves with the management of these children and take on the responsibility of ensuring that adequate counselling and management services are provided.
Alternatively, where specialist clinics are available at referral hospitals, children over 2 years of age or those with unusual problems may be referred to these clinics for specialist opinion.
Wherever possible, caregivers should be referred to local clinics for ongoing management and collection of medication.
Intervention
Management
Indications
Comments / Rationale
Clinical follow-up of Asymptomatic HIV-infected children
6-monthly follow-up at Primary Care or Specialist clinic (where available)
Asymptomatic HIV-infected children without severe immunocompromise (AIDS), especially children over the age of 1 to 2 years
Well-managed HIV-infected children are likely to require fewer admissions than children who are less actively managed.
Follow-up intervals may vary according to the condition of the child
Children on Antiretroviral Therapy require close follow-up
Clinical follow-up of symptomatic HIV-infected children
3 - monthly follow-up at Primary Care or Specialist clinic (where available)
OR
More frequent follow-up, if the condition of the child requires this
Symptomatic HIV-infected children with a degree of immunocompromise, especially children over the age of 1 to 2 years
Follow-up intervals may vary according to the condition of the child
Clinical follow-up of children with AIDS
2 to 3-monthly clinic visits, preferably at local Primary Care Clinics
Younger children (especially if sick) or those with more complex medical diagnoses should be seen more frequently
Children diagnosed with AIDS
[see appendix C for the criteria used in diagnosing AIDS]
Even though interventions are limited for these patients, caregivers need a lot of support and minor complaints can be dealt with to make these children more comfortable.
Note: No child should be denied health care simply on the basis of their HIV status.
Intervention
Management
Indications
Comments / Rationale
Social support
Counselling (preferably at the site of diagnosis)
Linkage to NGO and Community-based programmes
Welfare Grant Application (Social Worker Referral)
Opportunities for counselling and supporting HIV-infected parents and their children should be sought
Destitute families, child under age 7 and Fostered ChildrenHIV-infected families often have significant social problems including financial, job-related, and tension between parents.
Health Care Workers need to know what local community resources are available
Refer to resource list?
HIV-infected children are eligible for the following grants:
Maintenance grant R100 monthly Foster Care Grant
Primary care and prevention of common childhood illnesses
Comprehensive approach to preventing and treating common illnesses, at a primary care level
All children, as a fundamental right
Standard Paediatric Guidelines and Paediatric Essential Drugs List Treatment Recommendations are available from the Department of Health
The caretaker of the child should have a clear follow-up plan for the child and understand that, unless the child is for Terminal care, the child should be brought back as soon as possible if there is any deterioration.
Health care workers at a primary care level should be able to assess the severity of illness and decide whether the child needs admission
If there is uncertainty, it is safer to review the child more frequently or to refer to a higher level of care
Primary care and prevention of common childhood illnesses (continued)
Childhood Immunisation
As per the standard current schedule, with the exception that
BCG vaccine should not be given to children with AIDS
Growth Monitoring
As for children not infected with HIV, except for children with AIDS, who should not be administered BCG Immunisation
At all clinic & hospital visits, height and weight should be monitored and recorded on growth charts to detect failure to thrive
Children with AIDS (see section 12 ) can be excluded from growth monitoring
See Appendix A for current Immunisation Schedule
BCG given routinely at birth is not excluded
Growth failure should initiate investigations to look for a treatable cause, such as malnutrition, TB or an acute infection (chest, gastrointestinal or urinary tract).
HIV-infected children who do not have AIDS may require investigation for failure to thrive at hospital level
Medical management of HIV infection
Routine (scheduled) follow-up and monitoring that is appropriate for the stage of the disease [Refer to section 10]
All HIV-infected children
Well-managed HIV-infected children are likely to require fewer admissions than children who are less actively managed.
Follow-up intervals may vary according to the condition of the child
Medical management of HIV infection (continued)
Clinical Management of usual Paediatric Diagnoses according to the guidelines for uninfected children.
In general children with HIV infection should receive the same medical care for common conditions, as is standard practice for uninfected children.
Common infectious diseases are the most frequent cause of illness in these children and often occur with increased severity and frequency.
Standard Paediatric Guidelines and Paediatric Essential Drugs List Treatment Recommendations are available from the Department of Health
Medical management of HIV infection (continued
Prevention of Opportunistic Infections
Hospital care, as required and appropriate
All HIV-infected children, in accordance with the guidelines in section 13
General indications for admission:
- Acute life-threatening illness
- Oxygen requirement
- IV / Naso-gastric fluid therapy
- Need for frequent observation
- Specialist investigation
Prevention of PCP & TB significantly impacts on the well-being of the HIV-infected child, however this is only effective where regular follow-up and adherence can be achieved
Refer to Section 16 for descriptions of appropriate levels of care
Surgical Procedures In for HIV-Infected children
The decision to withhold surgery should ideally require the consensus of two doctors and a senior nurse
Children requiring surgery should not be discriminated against on the basis of HIV status alone. Issues to consider are the child’s prognosis, whether the surgery will improve the quality of life and the child’s risk of complications.
Children with slowly progressive HIV and CDC Category A and B disease should be considered suitable for surgical procedures
Laboratory Monitoring of HIV-infected children
Monitoring of T-cell subsets
The optimal interval between these tests depends on the individual patient, clinical condition, current treatment and stage of HIV infection. Generally useful to aid treatment decisions (such as when to continue PCP prophylaxis – such as at 1 year) and to measure response to Antiviral Therapy.
Where available, to monitor the immune function of HIV-infected children: prior to making changes in therapy, to aid care decisions or if there is clinical change
CD4+ cell absolute number and percentage are surrogate markers of disease progression in HIV and should be obtained at baseline prior to initiation of any antiviral treatment.
Note that intercurrent illness and malnutrition can change T-cell values, which should be interpreted in context
Monitoring of HIV viral load
The optimal interval between these tests depends on the individual patient, clinical condition, current treatment and stage of HIV infection. Generally useful to aid treatment decisions (such as when to start PCP prophylaxis) and to measure response to Antiviral Therapy
Where available, to monitor viral dynamics in HIV-infected children: prior to making changes in therapy, to aid care decisions or if there is clinical change
Quantification of free virus in plasma can be performed using HIV RNA assays. There are several methods available for this purpose. Since these assays exhibit different cut-off ranges, and vary in sensitivity and specificity, they should not be used interchangeably for monitoring virus load over time in the same patient
Nutritional support
Growth monitoring
All children
Malnutrition exacerbates inadequate immune function and can predispose to opportunistic infections.
In HIV-infected children there are many factors that can contribute to inadequate nutrition, including:
- Poor diet due to poverty
- oropharyngeal/oesophageal disease
- anorexia
- malabsorption
- Gastroenteritis / HIV enteropathy
Dietary advice
including information on:
- Advantages and disadvantages of breast and formula feeding
- Food preparation & hygiene
- nutritious foods
All caregivers of HIV-infected children should be given nutritional information appropriate to their cultural and economic contexts
See appendix * for recommendations of improving nutrient density of meals and low cost nutritious foods
Nutritional supplements
Where supplements are available and affordable
Emphasise the need for high calorie, high protein foods
Vitamin A supplementation:
Multivitamin preparation (containing vitamin A 5 000IU) 5ml po daily
OR
Vitamin A alone (where available):
<6 months of age - 50 000IU
6-12 months of age – 100 000IU
>1 year of age – 200 000IUAll HIV-infected children
Vitamin A supplementation can improve immune function and reduce morbidity, especially from diarrhoeal disease.
HIV-infected children have been found to be Vitamin A deficient and should be supplemented
Iron and folate supplementation:
Oral iron (elemental) supplementation: 2mg/kg tds po
Folate: 1-2mg daily po
Evaluate response to therapy by repeating Hb at 2-4 weeksChildren with suspected Iron or Folate-deficiency anaemia
Screen all children for pallor and if possible, check haemoglobin.
Low MCV values do not always indicate Iron-deficiency in HIV-infected children
Preventive therapy against common opportunistic infections has beneficial effects for the well-being and survival of children infected with HIV.
Effective prophylaxis requires adequate follow-up and adherence and it is important to establish this before starting therapy
11.1 Prevention of Pnemocystis carinii (PCP)
Intervention
Management
Indications
Comments / Rationale
Primary Prophylaxis for PCP
Trimethoprim 5mg/kg* (0.625ml/kg) orally as a daily or twice daily dose
[The CDC recommends that Co-trimoxazole be given 3 times weekly on consecutive days, however, a single dose daily regimen is recommended here to optimise adherence]
* Cotrimoxazole syrup contains 40mg trimethoprim and 200mg sulphamethoxazole per 5ml
[See dosing table in Appendix C]
Symptomatic HIV-infected children and asymptomatic HIV ELISA positive children should be treated from 4-6 weeks of age up to 15 months of age
(unless it can be proven before this time that the child is not HIV-infected - i.e. if HIV PCR status is known to be negative).
After 15 months of age prophylaxis should be continued in HIV-infected children, unless the CD4 count and percentage is known and shows a low level of immunocompromise, in which case the prophylaxis can be stopped
Children with severe immunocompromise (diagnosed clinically or on laboratory testing) require ongoing PCP prophylaxis
PCP in children commonly occurs during the first year of life, with a peak incidence between 3-6 months of age. . These children often appear well-nourished and otherwise relatively healthy.
If possible, a CD4 count at 1 year should be done to guide continued treatment if the child is asymptomatic
Prevention of Pnemocystis carinii (PCP)
Intervention
Management
Indications
Comments / Rationale
Secondary Prophylaxis for PCP
Chronic maintenance therapy should be continued indefinitely after treating a confirmed episode of PCP using the same protocol as for Primary prophylaxis
All documented cases of PCP infection
Children that have previously been treated for PCP infection require life-long prophylactic therapy
11.2 Prevention of Tuberculosis (TB)
Consensus has not been reached regarding universal prophylaxis for children with HIV infection.
TB is notoriously difficult to diagnose in children and is even more so in immunosuppressed children.
HIV-infected children are at high risk of developing TB and the concern is that TB infection may be missed and management jeopardised if prophylactic therapy is used.
It is therefore imperative to maintain a high index of suspicion for TB when managing HIV-infected children.
In general, children with HIV infection should receive the same medical care for common conditions as is standard practice for uninfected children.
Common infectious diseases are the most frequent cause of illness in these children and often occur with increased severity and frequency, as compared with uninfected children.
Many conditions can be managed at a primary level and health care workers at the primary care level should be able to assess the severity of illness and decide whether the child needs admission.
The caretaker of the child should have a clear follow-up plan for the child and understand that, unless the child is for Terminal care, the child should be brought back as soon as possible if there is any deterioration.
If there is uncertainty, it is better to review the child more frequently or to refer the child to a higher level of care
12.1 Clinical Management of infectious diseases in HIV-infected children
Intervention
Management
Indications
Comments / Rationale
Antibiotic therapy for infectious diseases
Oral antibiotics should be used in preference to IV, except when IV therapy is absolutely necessary.
Standard antibiotic regimens, as for HIV-uninfected children should be used, as described in the IMCI and Essential Drugs List Guidelines.
Antibiotic usage should be limited to conditions where a bacterial cause is almost certain, If possible, body fluids (blood, urine, stool) should be cultured before commencing antibiotics
It should be emphasised to caretakers that if antibiotics are prescribed the course should be completed
It is always important to be aware that the indiscriminate use of antibiotics promotes development of drug resistant organisms.
Isolation of HIV-infected children
HIV-infected children admitted to hospital do not pose a significant risk to other children.
However, if the HIV-infected child is immunocompromised, they could need protection from infectious disease of other children in the ward
Common childhood illnesses in other children, such as Measles and Varicella Zoster, as well as TB, are highly infectious to HIV-infected children
12.2 Clinical Management of Respiratory conditions in HIV-infected children
The respiratory system is the most frequently affected system in HIV-infected children.
Commonly these children present with upper and lower respiratory infections.
TB should be actively sought in all cases of respiratory disease, although the diagnosis may be difficult to confirm
PCP has been noted to occur either in infants under the age of a year (classically in the first 6 months) who are often well-nourished, have no other symptoms of HIV and whose CD4 counts may be normal (termed Primary PCP), or in older children who have lost their immunity and classically have low CD4 counts (termed Secondary PCP)
Intervention
Management
Indications
Comments / Rationale
Management of Upper Respiratory Tract Infection
Most common upper respiratory infections should be managed as in HIV-uninfected children and can be managed at a primary care level (Refer to IMCI / EDL)
Upper Respiratory Tract infections
Standard Paediatric Guidelines and Paediatric Essential Drugs List Treatment Recommendations are available from the Department of Health
Management of Chronic suppurative otitis media
Dry mop with ear buds/orange sticks and cotton wool 4-6hourly
AND
Ofloxacin / sofradex ear drops tds
Refer to ENT specialists if the problem is resistant to treatment, to exclude cholesteatoma
Children may also suffer hearing impairment and may need audiology assessment in complicated cases
Frequently presents in both infants and older children and can be bilateral.
This condition is often resistant to conventional therapy
Out-patient Management of Community-Acquired Pneumonia
Children under 20 kg: Amoxicillin 20-40mg/kg po tds for 7 days
Children over 20kg: Amoxicillin 250-500mg po tds for 7 days
Oral fluids and antipyretics
Children not considered sick enough for admission, should be carefully monitored daily and admitted if deteriorating
HIV-infected children are at risk of community-acquired pneumonia caused by the same organisms as in HIV-uninfected children
Admit all Neonates with suspected pneumonia and Children over 3 months of age with respiratory rate >50 breaths/min and/or inability ingest oral fluids
Children with HIV infection with pneumonia are more likely to have bacterial pneumonia than immunocompetent children.
Common organisms include:
- Pneumococcus (by far the most common)
- Haemophilus influenzae
- Staphylococcus aureus
- Gram negative organisms
- Viruses
Children with bronchiectasis may experience infections with Pseudomonas aeruginosa, which requires specific treatment
Hospital Management of Community-acquired Pneumonia
FBC, Blood culture, Chest X-ray
AND
Oxygen
AND
IV Fluids and Antibiotics:
Ampicillin 100mg/kg IVI qid changing to Amoxicillin at above dose when able to take orally, for total duration of 7 days
OR
If staphylococcal/gram negative infection suspected:
Cefuroxime 100mg/kg IVI changing to amoxycillin-clavulanic acid 20-40mg/kg po tds, when able to take orally, for total duration of 7 days.
All neonates with suspected pneumonia
Children over 3 months of age with respiratory rate >50 breaths/min and/or inability ingest oral fluids
Note: PCP CAN BE DIFFICULT TO DISTINGUISH FROM OTHER CAUSES OF SEVERE PNEUMONIA. ADD PCP TREATMENTFOR ALL SEVERE PNEUMONIAS
Specific antibiotic therapy should be given once the results of blood culture become available.
The possibility of TB should always actively be considered.
Management of suspected Pneumocystis carinii Pneumonia (PCP)
REFER SUSPECTED CASES FOR ADMISSION AND BEGIN TREATMENT FOR PCP EVEN IF THE HIV STATUS OF THE CHILD HAS NOT YET BEEN DETERMINED
Supplemental oxygen
AND
Cotrimoxazole 20mg/kg/day (of trimethoprim component)
6 hourly for 3-4weeks
AND
Prednisone 1-2mg/kg daily po for 2 weeks
Alternatives (for Sulphur senstitivity): Trimethoprim alone at same dose
All infants under12 months of age presenting with signs of:
- Fever (although not always)
- Severe tachypnoea
- Dyspnoea
- Relatively clear chest for degree of dyspnoea
- Hypoxia: appear cyanosed in room air (O2 sats often <90%)
- Chest X-ray may show bilateral diffuse alveolar infiltrate (although could have varied X-ray findings)
Pneumocystis carinii is particularly prevalent in HIV-infected small infants with a peak incidence between 3-6 months of age
Note that cotrimoxazole usage can cause erythema multiforme /Stevens-Johnson syndrome)
Note: Cotrimoxazole for treatment has been given intravenously in most research settings.
However it may be given orally if IV preparations are not available and studies are planned to investigate the efficacy of oral vs IV in treating PCP pneumonia
Management of Tuberculosis (TB)
Directly observed TB Treatment in accordance with Department of Health TB Guidelines [See Appendix D]
All children with severe forms of TB, such as: TB meningitis, miliary TB, or other extra-pulmonary TB should receive in-hospital therapy initially and subsequently considered for referral to TB hospitals to obtain maintenance treatment
Diagnosis of suspected or confirmed TB, based on Department of Health TB Guidelines
Factors that could infer a TB diagnosis:
- Mantoux Test > 5mm (although often negative in HIV children who do have TB)
- Isolation of AFB’s from gastric aspirates (under 2 years old) or sputum (over 2yrs old)
- Suggestive CXR
- Positive TB Contact
TB can be difficult to diagnose in immunocompromised children.
Note: Children with HIV and TB may all require prolonged therapy for TB but, until consensus has been established, the existing current Departmental guidelines for pulmonary TB should be followed.
Management of Lymphocytic Interstitial Pneumonitis (LIP)
No therapy is required for children who are asymptomatic
Steroids may be beneficial in children who are hypoxic (oxygen sats consistently <92%, tachypnoeic, and/or developing signs of cor pulmonale):
Prednisone 2mg/kg for 4 to 12 weeks, weaning to the lowest dose required to maintain the patient with sats >92%
(NB. All patients receiving corticosteroids should also receive PCP prophylaxis regardless of immunological staging).
Severe or progressive LIP should preferably be managed in consultation with a hospital-based clinic, although there is seldom an indication for admission to hospital.
LIP often responds to Antiretroviral Therapy, which should be considered, when available
Children with LIP may have a relatively benign course or may present with slowly progressive hypoxia, tachypnoea and exertion fatigue.
These children often have intermittent acute pneumonia with respiratory decompensation that may necessitate antibiotic cover or admission to hospital
EXCLUDE PULMONARY TB PRIOR TO TREATMENT WITH STEROIDS
LIP is a slowly progressive interstitial lung condition of unknown aetiology usually occurring in HIV-infected children beyond the first year of life.
The condition is associated with:
- generalised lymphadenopathy& parotomegaly
- hepatosplenomegaly and digital clubbing
- recurrent bacterial infections
- chronic lung disease and bronchiectasis.
Radiologically there is often a reticulonodular infiltrate, which is diffuse and bilateral, and there is often hilar adenopathy. This may be confused with miliary TB.
12.3 Clinical Management of Gastrointestinal Conditions in HIV-infected children
Intervention
Management
Indications
Comments / Rationale
Management of acute Gastroenteritis
Refer to IMCI guidelines for management of gastroenteritis in HIV-infected children
Rehydration therapy is the cornerstone of management and efforts should be made to rehydrate orally as long as the child can maintain oral fluids. If not, intravenous rehydration is required and the child will need admission.
Antibiotic usage is unnecessary except where dysentery is suspected
Acute diarrhoea and / or vomiting
Standard Paediatric Guidelines and Paediatric Essential Drugs List Treatment Recommendations are available from the Department of Health
NB: all children should receive adequate nutrition during and after a bout of diarrhoea
Management of suspected dysenteric gastroenteritis
As above, except an antibiotic could be used, such as:
Nalidixic acid 55mg/kg/day po 6 hourly for 5 days
OR
Ciprofloxacin 7.5-15mg/kg/day po 12 hourly for 5 days(expensive)
OR
Ceftriaxone 20-80mg/kg/day daily for 3-5 days, if child not tolerating oral medication
Child presents with blood and mucus in the stool
Management of Persistent or Chronic diarrhoea
Management includes:
- Correction of dehydration
- Correction of electrolyte and acid-base abnormalities
- Assessment for infection elsewhere e.g otitis media, UTI etc.
- Test stools for reducing substances*
- Send stool for culture (ask for uncommon organisms e.g. Cryptosporidium, Giardia, Isospora and microsporidium).
- Non-lactose containing feeds may be required
- Bowies regimen may be indicated:
Cholestyramine 1g 6hourly po for 5 days
AND
Gentamycin 50mg/kg/day 4 hourly po for 3 days
OR
Neomycin100mg/kg/day 4hourly po for 3 days
Persistent or chronic diarrhoea
This is a common problem in children with HIV and can be challenging to manage
*An inexpensive method of checking stool for reducing substances is to test for the presence of glucose on dipstick of stool specimen
NB: all children should receive adequate nutrition during and after a bout of diarrhoea
(Gentamycin dosage should not exceed 300mg per day)
12.4 Clinical Management of Skin And Mucosal Conditions in HIV-infected Children
Intervention
Management
Indications
Comments / Rationale
Management of Seborrhoeic Dermatitis
Usually responds to topical steroids and aqueous cream:
Betnovate 1:10 to affected areas of body b.d
AND
Procutan to affected areas of the face b.d
AND
Aqueous cream or UEA topically as soap
Severe unresponsive Seborrhoeic Dermatitis usually responds to a prolonged course of Griseofulvin 10mg/kg/day for 6-8 weeks
This is particularly common in small HIV-infected infants
Management of scabies, ringworm, impetigo
Manage as for HIV uninfected children – refer to IMCI
Common skin conditions
Standard Paediatric Guidelines and Paediatric Essential Drugs List Treatment Recommendations are available from the Department of Health
Management of Oral Candidiasis (Thrush)
Daktarin oral gel apply 4-6 hourly to oral mucosa for 7 days
OR
Mycostatin drops 1ml po 6 hourly for 7 days
For refractory oral candidiasis or if oesophageal candidiasis is suspected:
Ketoconazole 5mg/kg/day po for 7 days
OR
Fluconazole 3mg/kg/day for 7 days
Oral Thrush
NB. Suspect oesophageal / laryngeal candidiasis in children presenting with difficulty swallowing or hoarseness
This is particularly common in children with HIV infection and can often be refractory to therapy
Oesophageal candidiasis may be present without oral thrush
Management of Herpes simplex or Varicella infection .
Acyclovir 5-10mg/kg po tds 5-7 days (higher doses in disseminated infection, up to a maximum of 800mg/dose)
AND
Paracetomol 10mg/kg po 6hourly
Admission may be required for children who are unable to ingest fluids orally or when dissemination of disease is suspected (pneumonia, jaundice, abnormal CNS findings).
All immunocompromised children with herpes infections, as they have a greater risk of developing disseminated herpetic infection
Disseminated disease should be suspected in children that develop pneumonia, jaundice or neurological signs. These children should be referred to hospital.
Management of Oral Ulcers
Topical agents such as glycerine and gentian violet may be effective
For more severe ulceration, antibiotics may be required: amoxycillin alone or with metronidazole (if anaerobic infection suspected).
Add antifungals (as above) if superinfection with Candida is suspected.
Aphthous and atypical ulceration is common
12.5 Clinical Management of Miscellaneous Other Conditions in HIV-infected Children
Intervention
Management
Indications
Comments / Rationale
Management of Haematological Conditions, including Anaemia
Investigate with FBC, MCV initially
Suspected Nutritional anaemia should be managed as per section 10
Suspected Autoimmune conditions should be referred to hospital for management, steroids may be of benefit in some of these case
Recheck haemoglobin after 2 weeks after starting Iron therapy to assess response and confirm the diagnosis of nutritional anaemia
If a child looks pale, has easy bruising or bleeding, refer to hospital
Haematological abnormalities are common in HIV-infected children, ranging from nutritional forms of anaemia to autoimmune anaemia and thrombocytopaenia
A low MCV in HIV-infected children does not always indicate iron-deficiency. The response to iron therapy (Hb measured 2-4 weeks after starting therapy) can help to determine whether the anaemia is nutritional.
In complicated cases, further investigation might be necessary
Management of Dental Problems
Adequate attention needs to be paid to oral hygiene
Children with dental caries should be referred to dental services
Many HIV-infected children suffer from severe dental caries
Caries may act as a portal of entry for infection
Management of Malignancies
Suspected malignancies should be referred to Hospital for investigation & management
HIV-infected children, like adults, have a greater chance of developing malignancies, especially lymphomas and Kaposi’s sarcoma
Some clinical presentations suggestive of malignancy include:
- Abnormal swellings
- Unusual skin rashes
- Excessive weight-loss
- Bone pain
The prognosis for children with AIDS is poor and management should be aimed at relieving distress in the child, treating easily manageable complications, and in limiting hospital admissions, and the duration of hospital stay.
It is imperative to ensure that parents are adequately counselled, and staff should be sympathetic to individual needs.
Intervention
Management
Indications
Comments / Rationale
Diagnosing AIDS
Children with AIDS will be defined as such using a modified CDC revised classification system for HIV infection in children less than 13 years of age (1994) as a guideline (see appendix B).
Where it is uncertain whether a child has AIDS-defining criteria, and management decisions are required, care decisions should ideally be made by at least 2 doctors (1 of whom is a senior paediatrician, or doctor designated to assist in these decisions) and a senior nurse.
Children presenting with advanced HIV infection and / or AIDS-defining illness/es
Terminal Care of AIDS patients
Decision to withdraw Active Management
A decision to begin terminal care should ideally be made jointly by at least two doctors, one senior nurse and the child’s carer, preferably in a hospital setting to which the child has been admitted, and recorded clearly in the child’s file/card.
See section 15
The decision to begin Supportive (Terminal) Care is difficult and should be made on an individual basis for AIDS sufferers.
Examples include:
- Child with severe HIV Encephalopathy
- Respiratory failure, not responding to optimal treatment
- Child obviously suffering in whom treatment offers no relief
The aims are as follows:
- To maintain quality of life
- To keep the patient as comfortable as possible
- To support a dying patient and the grieving family emotionally
Decisions taken in the hospital setting should be clearly communicated either in the discharge summary of the patient or in a letter to the local primary care staff.
Home Care for children with AIDS
Discharge from hospital care.
The possibility of chronic/terminal care in a hospice facility should be discussed with parent/s where there may be inadequate care for the child at home
Reassurance should be given to parents that care for the child has not been abandoned, and that the child can be readmitted at any stage if necessary. Community resources should be accessed.
Hospitalised Children whose mothers / carers are willing and able to care for them at home.
The health care worker should be familiar with resources available in the community that can assist and support AIDS sufferers and their families
Hospitalisation of children with AIDS
Indications for admission:
- Hypoxia and respiratory distress requiring oxygen
- IV / Nasogastric fluid requirement
- Carer/s unable to cope at home
Clinical Investigations in children with AIDS
Keep to a minimum; testing should be limited to NA+,K+, Haemoglobin, & urine dipstick if necessary. FBC, U&E, CXR, should only be done if it is believed that doing these will shorten the duration of hospital stay or in some way contribute to the child’s ultimate comfort. Other investigations should not be done except in discussion with senior medical staff.
AIDS Children presenting to Hospital
Medical Treatment of children with AIDS
Simple Oral Antibiotic therapy
Where it is thought that a course of antibiotics could shorten the duration of hospital stay.
Children receiving Terminal Care in the community should not have antibiotics prescribed, unless a decision is made to re-start active treatment
Antibiotic therapy should be continued for 7 days for community-acquired infections or for 3 weeks where PCP is suspected. After this they should be stopped and further courses of antibiotics should not be considered.
Adjunctive Medical therapy:
- Oral steroids, when indicated
- Nasogastric drips in preference to IV for rehydration, if tolerated
- Bowie’s regime for severe diarrhoea
- Supplemental oxygen if in severe respiratory distress or if saturation <90%
AIDS children with medical complications, where medical treatment is sought for conditions such as:
- Hypoxaemia
- Dehydration
- Severe chronic diarrhoea Respiratory distress
Terminal Care for children with AIDS-defining illnesses
Terminal care will be most appropriately instituted at home or at a palliative care facility, with support from primary care staff
Children with AIDS for whom the decision to institute Terminal Care has been made (See section 15)
The patient can be discharged if the mother is willing and able to care for the child at home; she should be given information about the local clinic and reassured that she can bring the child back if necessary
The prognosis for children with AIDS is poor and management should be aimed at relieving distress in the child, treating easily manageable complications, and in limiting hospital admissions, and the duration of hospital stay.
It is imperative to ensure that parents are adequately counselled, and staff should be sympathetic to individual needs.
Children should be discharged if mothers are willing and able to care for them at home.
The possibility of chronic/terminal care in a hospice facility should be discussed with parents where there may be inadequate care for the child at home.
Reassurance should be given to parents that care for the child has not been abandoned, and that the child can be readmitted at any stage if necessary.
Decisions taken in the hospital setting should be clearly communicated either in the discharge summary of the patient or in a letter to the local primary care staff.
Intervention
Management
Indications
Comments / Rationale
Determining the Terminal Care Status of a child
A decision to begin terminal care should ideally be made jointly by at least two doctors, one senior nurse and the child’s carer
Decisions taken in the hospital setting should be clearly communicated either in the discharge summary of the patient or in a letter to the local primary care staff
The aims are as follows:
- To maintain quality of life
- To keep the patient as comfortable as possible
- To support a dying patient and the grieving family emotionally
Children with AIDS, as defined using a modified CDC revised classification system for HIV infection in children less than 13 years of age (1994) as a guideline (see appendix B) should be considered for Terminal Care
The decision is difficult and should be made on an individual basis. Examples include:
- Child with severe HIV encephalopathy
- Respiratory failure even on optimal treatment
- Child obviously suffering in whom treatment offers no relief
Terminal care implies the withdrawal of active management, but the provision of support, care and symptom relief. It implies that all intravenous and painful procedures are discontinued, but feeding/therapy /rehydration are continued orally or via nasogastric tube
Care of Terminal Care Patients at home or in Palliative Care facilities Terminal care will be most appropriately instituted at home or at a palliative care facility, with support from primary care staff. Such a decision should always be communicated to the local clinic in writing.
The child’s carer should be given information about the local clinic and reassured that she can bring the child back if necessary.
The patient can be discharged if the mother is willing and able to care for the child at home
Hospital Admission of Terminal Care Patients The objective for admission should be clearly stated
Care decisions, particularly those relating to Terminal Care, should be clearly documented
Indications for admission include:
- Hypoxia and respiratory distress
- Inability to take oral fluids
- Mother unable to cope at home
Emphasis should be placed on relieving distress in the child, treating easily manageable complications, and in limiting the duration of hospital stay
Investigations in Terminal Care Patients Keep to a minimum; testing should be limited to NA+,K+, Haemoglobin, or urine dipsticks if necessary.
FBC, U&E, CXR, should only be done if it is believed that doing these will shorten the duration of hospital stay or in some way contribute to the child’s ultimate comfort. Other investigations should not be done except in discussion with senior medical staff.
Medical Treatment of Terminal Care Patients Limit antibiotics to common oral antibiotics as far as possible:
Antibiotic therapy should be continued for 7 days for community-acquired infections or for 3 weeks where PCP is suspected.
After this they should be stopped and further courses of antibiotics should not be considered.
Where it is thought that a course of antibiotics, or adjuvant treatment may shorten the duration of hospital stay
Medical Treatment of Terminal Care Patients (continued) Adjunctive therapy:
- Oral steroids when indicated
- Nasogastric drips in preference to IV for rehydration, if tolerated
- Bowie’s regime
Supplemental oxygen if in severe respiratory distress or if saturation <90%
Management of pain & discomfort in Terminal AIDS care Step 1: Simple analgesics, such as Paracetamol
Step 2*: Opioids
Morphine Sulphate oral solution
OR
Valoron drops
AND
Psychological & emotional support
Children with advanced AIDS, for whom the decision to institute palliative care has been made
*Codeine preparations are not readily available in the correct formulations for children
Opioids have the advantage of also relieving diarrhoea & cough
Morphine doses should be increased incrementally until relief is obtained. No absolute maximum dose.
Health services will cope better with rising numbers of patients if they are organised within a comprehensive framework linking hospitals, clinics, home based care providers, NGOs, and other community services.
Hospitals should be aware of community resources available and actively plan & manage how their services are utilised to reduce the HIV patient load.
Communication between different levels of care is very important. It provides continuity and consistency of management between the different service providers. This is especially important when decisions about terminal care have been made.
Standardised communication protocols and forms could be used.
Having access to the results of TB and other investigations or recent HIV tests saves health workers time and money and these must be communicated to other health facilities involved in the patient’s care, whilst respecting confidentiality.
Intervention
Management
Indications
Comments / Rationale
Primary Care of HIV-infected children
Provision of general care activities important for HIV-infected children and their families that are best done at Primary Health Care Facilities
- Provision of routine immunisation
- Monitoring of growth and development
- Advice about feeding, immunisation and minor ailments
- Provision of formula for women choosing to formula feed their infants
- Treatment of minor ailments and childhood infections
- Referral of acutely ill and those requiring further investigation
- Consultation with referral centres e.g. telephonic contact for advice on management (hospitals may wish to have designated doctors "on-call" to advise peripheral centres)
- Follow-up of patients discharged from hospital
- Investigation for TB as per Department of Health protocols
- Supervision of TB therapy and tracing of contacts where applicable
- Issuing of condoms and family planning advice
Provision of HIV-related care activities that could be done at Primary Health Care Facilities
- Pre and post-test counselling
- Taking blood for ELISA testing
- HIV and STD education
- Psychosocial support to families affected by HIV
- · Provision of prophylactic medication e.g. Bactrim, including commencing such prophylaxis at 6 weeks of age (without necessarily having to consult at the hospital)
Provision of palliative care for HIV terminal patients
Most of the conditions affecting the child with HIV infection can be managed in the primary care setting, and this is likely to be most convenient for the family
More difficult problems and seriously ill children should be dealt with either in consultation with experienced health care workers or by referral to the hospital setting.
Intervention
Management
Indications
Comments / Rationale
Hospital-based care for HIV-infected children
Investigations in hospital:]
Keep investigations to a minimum and do only those that are likely to alter management.
Referral to hospital may be necessary (provided the child is not for terminal care) if:
- The child is severely ill and requires admission using the same criteria as for other children, e.g. hypoxia requiring oxygen, intravenous fluid requirement
- (NB: not all children referred will be admitted – try to speak to the doctor on duty to save the patient being shunted around)
- A decision is required as to whether terminal care should be instituted
- The child is not responding to conventional therapy for any clinical problem
- Unexplained persistent fever, if investigation is not available at primary care level
- Unusual complications, if treatment is not available at primary care level
- Investigations not available at primary care level are required
Hospital services would be most efficiently utilised if admissions were for those patients that have reversible, rapidly treatable conditions.
Length of stay must be actively reduced by ensuring efficient collection of laboratory and HIV results, reducing waiting time for consultations and encouraging prompt collection by relatives on discharge.
Management of HIV-Infected children in Short-stay Wards
Admission usually limited to 72 hours or less
Children appropriate for admission to a short stay facility include those with:
- Mild/moderate dehydration
- Mild respiratory distress
- Requirement for observation e.g. seizures
- Illness likely to stay for less than 72 hours
- Terminal nursing requirements whilst awaiting placement / home support
- Carer acutely unable to cope at home (respite care)
A short-stay facility should be developed at all hospitals to reduce the burden on regular wards
Management of HIV-infected children in Hospital Outpatient Clinics
Access to specialist HIV Clinics should be restricted to those children who would most benefit from Specialist attention and should be gained by appropriate referral only.
Many Specialist clinics only see patients on an appointment basis
Children over two years of age may benefit from regular 6 monthly checks at a Specialist HIV clinic if this is available
Children with unusual HIV-related problems requiring Specialist attention
HIV children can usually be managed in the ordinary outpatient setting, or Primary Care clinic
Intervention
Management
Indications
Comments / Rationale
Tertiary Referral for selected HIV-infected cases
Usually Tertiary referral should only be undertaken by the referral hospital
Very infrequently, super-specialist referral may be required. This includes Oncology, Neurology or Opthalmology
Intensive Care Management of Selected HIV-infected children
The decision to admit such a children to the ICU should depend on the nature of their disease and should ideally be made in consultation with at least two doctors and a senior nurse
Children with CDC Category B and C disease will not normally be offered a bed in ICU, however children over one year who do not have CDC Category B and C/AIDS defining illness should not necessarily be denied access to ICU treatment.
Children thought to be HIV infected who have already survived for one year have a better prognosis than those under a year of age. They are more likely to recover from an intercurrent infection and go on to have reasonable quality of life
If intensive care has been commenced, withdrawal might be considered if (Royal College criteria):
- The child has such severe disease that life sustaining treatment is simply delaying death without alleviation of suffering
- The family feels that in the face of progressive disease, further treatment is more than can be tolerated
The following general principles for ICU admission may be applicable:
- The acute illness for which the child is being admitted is reversible
- There is a reasonable prognosis (predicted mortality of >75% on PRISM score – see Appendix.)
- There is reasonable quality of life should the child survive the current illness
If a critically ill child’s HIV status is unknown, a rapid HIV test should be performed (see section 7) and confirmed with a formal ELISA test. In the absence of clinical features of HIV disease, however, the child should be regarded as negative until proven otherwise
AGE
VACCINE
Birth
BCG, OPV
6 weeks
DTP, OPV, HBV, Hib
10 weeks
DTP, OPV, HBV, Hib
14 weeks
DTP, OPV, HBV, Hib
9 months
Measles
18 months
Measles, DTP
4-5 years
OPV and DT
OPV- oral polio vaccine
DTP- diptheria, tetanus, pertussis
HBV-hepatitis B vaccine
Hib- Haemophilus influenzae
If available, pneumococcal and influenzae vaccines could be considered, although their value has not yet been proven.
The conjugate Hib vaccines can be administered in conjunction with DTP as follows:
Children presenting with any of the following (modified) CDC category C conditions will be considered to have AIDS:
- Serious bacterial infections, multiple or recurrent (i.e. any combination of at least 2 culture-confirmed infections within a 2-year period), of the following types: septicaemia, pneumonia, meningitis, bone or joint infection, or abscess of an internal organ or body cavity (excluding otitis media, superficial skin or mucosal abscesses, and indwelling catheter related infections).
- Encephalopathy(at least one of the following progressive findings present for at least 2 months in the absence of a concurrent illness other than HIV infection that could explain the findings): a) failure to attain or loss of developmental milestones or loss of intellectual ability; b) impaired brain growth or acquired microcephaly, demonstrated by head circumference measurements or, if available, CT or MRI; c) acquired symmetric motor deficit manifested by 2 or more of the following: paresis, pathological reflexes, ataxia, or gait disturbance.
- Pneumocystis carinii pneumonia (PCP) as suspected in young infants (with peak incidence 3-6 months) with severe respiratory distress and hypoxia, and a paucity of auscultatory signs, or in whom induced sputum confirms the presence of the organism
- Wasting syndrome in the absence of a concurrent illness other than HIV infection that could explain the following findings: a) persistent weight loss >10% of baseline, OR b) downward crossing of at least 2 percentiles on the weight-for-age chart, OR c) below 5th percentile on weight-for-height chart on 2 consecutive measurements, more than30 days apart, PLUS a) chronic diarrhoea (i.e. at least 2 loose stools per day for >30 days), OR b) documented fever for >30 days, intermittent or constant.
- Extrapulmonary or disseminated TB
- Opportunistic infections as documented in the CDC revised classification system for HIV infection in children less than 13 years of age (1994)
- Malignancies: lymphoma, kaposi’s sarcoma
Approximate doses:
WEIGHT
COTRIMOXAZOLE (ml)
<5kg
2.5ml
5-9.9kg
5ml
10-14.9kg
7.5ml
15-21.9
10ml or 1 tablet
>22kg
15ml or 1.5-2 tablets
NB. TB Therapy should be administered within the philosophy and framework of the National Tuberculosis Programme Guidelines that emphasises Directly Observed Treatment Schedules (DOTS)
Intensive phase for 2 months
5-10 kg
11-20 kg
21-30 kg
Rifampicin/INH Combination tablet (150/100mg)
½ tablet
1 tablet
2 tablets
Pyrazinamide (500 mg)
½ tablet
1 tablet
2 tablets
Continuation phase for 4 months
5-10 kg
11-20 kg
21-30 kg
Rifampicin/INH Combination tablet (150/100mg)
½ tablet
1 tablet
2 tablets
Source: S.A Tuberculosis Control Programme: Practical Guidelines (1996)
<12 months Age of child Immunologic category CD4 l 1-5 years 6-12 years (%) CD4 l (%) CD4 l (%) 1. No immunosuppression
³ 1500
(³ 25)
³ 1000
(³ 25)
³ 500
(³ 25) 2. Moderate immunosupression
750-1499
(15-24)
500-999
(15-24)
200-499
(15-24) 3. Severe immunosuppression
<750
(<15)
<500
(<15)
<200
(<15)
Note that Infection and Malnutrition can affect CD4 Count values and these should be interpreted in context