HIV/AIDS in Pediatrics

By Azene Bantamlak
(MSc in Pediatrics and Child health )

1
 Presentation outline
 Introduction
 WHO clinical staging
 ART, follow-up and advice for HIV positive
children
 Pediatric eligibility criteria for ART
 Tuberculosis in HIV positive children
 Opportunistic infections and prophylaxis
 Diarrheal disease in HIV positive children
 Adherence in children

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 Definition
HIV:
 HIV is a virus that attacks the immune system and
damages the body's ability to fight infections.
 Acquired Immunodeficiency Syndrome
 HIV is the virus that causes AIDS
AIDS:
 AIDS is a potentially fatal condition (No Cure) that
develops in the most advanced stage of HIV.
 Disease limits the body’s ability to fight infection.
 A person with AIDS has a very weak immune system

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 Overview of HIV/AIDS in Paediatric
 Globally 37 million people are living with HIV
 2.6 million are under the age of 15.
 17.4 million are women.
 Every day about 5,600 people contract HIV—
 More than 230 every hour
 In 2015, 1.2 million people died from AIDS
 150,000 are children under the age of 15 years.

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 Con’t
 (97%) HIV cases reside in low- and middle-income
countries,
 (70%) in Sub-Saharan Africa (SSA)
 25.8 million, live in sub-Saharan Africa.
 Children in sub-Saharan Africa consists 88% of the
world’s HIV-positive children

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 Cont…
The four major strategies of preventing mother to child
HIV transmission (PMTCT):
1. primary prevention of HIV among women of
childbearing age.
2. prevention of unintended pregnancies among women
living with HIV.
3. prevention of HIV transmission from a woman living
with HIV to her infant.
4. provision of appropriate treatment, care and support
to women living with HIV and their Children and
families.
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7
Steps in HIV replication are illustrated in
the diagram.
1.Binding of gp120 to CD4 and co-receptor on the
cell surface
2.Fusion of the viral envelope with the cell
membrane
3.Release and disassembly of the viral core in the
cytoplasm
4.Reverse transcription (Reverse transcriptase
enzyme translates HIV’s single stranded RNA into a
provirus made of double stranded DNA)
5.Viral DNA moves into cell nucleus m
8
7. Viral DNA is integrated (by Integrase enzyme) into
host genome to form HIV provirus
8. HIV provirus DNA is transcribed back to both viral
genomic RNA and viral mRNA , the latter which is
translated to HIV polyproteins.
9. The RNA virus and polyproteins are assembled
beneath the cell membrane
10.The assembled package becomes enveloped in the
host cell membrane as it buds off to form an HIV
virion.
11.Further assembly and maturation occurs outside
the cell by the protease enzyme, rendering the HIV
virion infectious 9
 HIV/AIDS mode of transmission
 >95% of transmission is via Mother to child.
During pregnancy 5-10%
During labor/delivery 10-20%
During breast feeding 5-20%
Overall without breastfeeding 15-30%
Overall with breast feeding for 6 mo 25-35%
Overall with breast feeding 18-24 mo 30-45%
The probability of transmission through breastfeeding
was estimated to be 0.00064 per liter of breast milk
ingested and 0.00028 per day of breastfeeding

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The rest includes:
 Sexual transmission
Child abuse
Adolescent
 Via infected blood
Blood transfusion
Unsterile needle sharing
Scarification by traditional healers

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 Disease Progression in Children
 Disease progression is much more rapid in children than in adults
because:
 Children’s immune system is immature and still developing
 Infants have more CD4 cells, which allow more targets for
the HIV virus
 Vertically infected children have three patterns of disease
progression
 10-25% are rapid progressors. Rapidly progress to AIDS
and die with in the first year of life (6 – 9mo)
 Majority (50 – 60%) have slower progression to AIDS with
a mean-time of 3 to 8 years
 5 - 15% are long-term non-progressors may not exhibit
symptoms for > 8 years
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 Immunological Differences in Children
 CD4 count is much higher in children
In the first year of life the absolute CD4 count is
more than 3 times than in adults
This gradually decreases to adult level by age 6
 Immature immune system makes children more
vulnerable to minor and invasive bacterial pathogens
 Immune systems in younger children may have a
greater capacity to reconstitute than adults.
Children usually have a good immunological
response to ART

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 Infant / child diagnosis
 HIV DNA PCR at 4-6 weeks
Identifies >95% of HIV positive infants
 HIV antibody tests at 9-18 months
Will identify exposed infants
Will confirm HIV negative if not breastfeeding
within last 6 weeks
 HIV antibody tests ≥ 18 months confirm HIV infection
if positive

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 New WHO staging

Clinical WHO Clinical

Classification stage
Asymptomatic I
Mild II
Advanced III
Severe IV

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Revised WHO Clinical Staging of HIV/AIDS
for Infants and Children

Stage 1:
 Asymptomatic
 Persistent generalized lymphadenopathy

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 WHO Clinical Stage 2
 Unexplained persistent hepatosplenomegaly
 Unexplained persistent parotid enlargement
 Papular pruritic eruptions
 Extensive wart virus infection
 Extensive molluscum contagiosum
 Fungal nail infections
 Angular cheilitis
 Lineal gingival erythema (LGE)
 Recurrent oral ulcerations
 Herpes Zoster
 Recurrent or chronic URTIs (otitis media, otorrhoea,
sinusitis, tonsillitis) 17
 WHO Clinical Stage 3
 Unexplained moderate malnutrition or wasting not adequately
responding to standard therapy
 Unexplained persistent diarrhea (14 days or more)
 Unexplained persistent fever (above 37.5°C, intermittent or
constant, for longer than one month)
 Unexplained anemia (<8g/dl), neutropenia (<0.5 x 109/L) and/or
chronic thrombocytopenia (<50 x 109/L)
 Persistent oral candidiasis (after first 6-8 weeks of life)
 Oral hairy leukoplakia
 Tuberculosis (Lymph node and Pulmonary)
 Severe recurrent bacterial pneumonia
 Symptomatic lymphoid interstitial pneumonitis (LIP)
 Chronic HIV-associated lung disease including brochiectasis
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 WHO Clinical Stage 4
 Unexplained severe wasting, stunting or severe
malnutrition not responding to standard therapy
 Pneumocystis pneumonia
 Recurrent severe bacterial infection (e.g. empyema,
pyomyositis, bone or joint infection, meningitis, but
excluding pneumonia)
 Chronic herpes simplex infection (orolabial or
cutaneous for > 1 month or visceral at any site)
 Oesophageal candidiasis (or candidiasis of trachea,
bronchi or lungs)
 Extrapulmonary TB
 Kaposi sarcoma 19
 WHO Clinical Stage 4
 CMV infection; retinitis or CMV affecting another organ, with
onset at age older than 1 month
 CNS toxoplasmosis (after the neonatal period)
 Extrapulmonary cryptococcosis (including meningitis)
 HIV encephalopathy
 Disseminated endemic mycosis (coccidiomycosis,
histoplasmosis)
 Disseminated non-tuberculous mycobacterial infection
 Chronic cryptosporidiosis (with diarrhea)
 Chronic herpes simplex infection;
 Chronic isosporiasis
 Cerebral or B cell non-Hodgkin lymphoma
 Progressive multifocal leukoencephalopathy (PML)
 Symptomatic HIV associated nephropathy or HIV-associated
cardiomyopathy 20
Counseling

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 Pre-test Counseling
 Transmission
 Prevention
 Risk Factors
 Voluntary & Confidential
 Reportability of Positive Test Results

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 Post-test Counseling
 Clarifies test results
 Need for additional testing
 Promotion of safe behavior
 Release of results

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 Steps to ART Initiation
 Confirm diagnosis
 Clinical evaluation (Clinical staging)
 Immunologic evaluation (immunological staging)
Then determine eligibility ??? Now all are
eligible
 Base line laboratory investigations
CBC,LFT,RFT
 Assess family readiness
 Choose appropriate drug regimen

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Antiretroviral Medicines Available for Children

NRTI NNRTI PI
Zidovudine Nevirapine(NV Lopinavir/
(AZT)* P)* ritonavir
Lamivudine Efavirenz(EFV (LPV/
(3TC)* )* r)*(Kaletra)
Emtricitabine Ritonavir(RTV
(FTC) )*
Didanosine Nelfinavir(NF
(ddI)* V)*
Abacavir Indinavir(IDV)
(ABC)* Atazonavir
 Medical Contraindications for ART
 Severe anemia: Hb < 6.9gm/dl; do not use
ZDV/AZT/
 Severe neutropenia: Absolut neutrophil count (ANC)
< 250 /mm3; ZDV use requires close monitoring,
 Hepatic insufficiency: LFT’s > 5 times normal; do not
use NVP; use EFV in children older than 3 years
 Renal insufficiency: creatinine > 3 times normal;
patient not eligible for ART
 Prior history of ART use:
potential for resistance,

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 Preferred and alternative fist-line regimens for
children currently
Children <3 years:
ABC or AZT + 3TC + LPV/r
Alternative: ABC or AZT + 3TC + NVP
Children 3–9 years and adolescents (<35 kg):
ABC + 3TC + EFV
Alternative: ABC or AZT or TDF + 3TC (or FTC) + NVP
or EFV
Adolescents (10–19 years) ≥35 kg
TDF + 3TC (or FTC) + EFV
Alternative: ABC or AZT or TDF + 3TC (or FTC) + NVP
or EFV
Why do not we use TDF , EFV for Children <3 years ???
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 Option A,B and B+
Treatment Prophylaxis Infant receives
(for CD4 count < (for CD4 count> 350
350 cells/mm3)
cells/mm3)
Option Triple ARVs starting Antepartum: AZT starting as Daily NVP from birth until 1
A early as 14 weeks gestation week after cessation of all
as soon as
Intrapartum: at onset of labour, breastfeeding; or, if not
diagnosed, continued
single-dose NVP and first dose breastfeeding or if mother is
for life of AZT/3TC on treatment, through age 4–6
Postpartum: daily AZT/3TC weeks
through 7 days postpartum
OPTION Triple ARVs starting Triple ARVs starting as early as Daily NVP or AZT from birth
B 14 weeks gestation and through age 4–6 weeks
as soon as regardless of infant feeding
continued intrapartum and
diagnosed, continued method
through childbirth if not
for life breastfeeding or until 1 week
after cessation of all
breastfeeding
OPTION Triple ARVs starting as Triple ARVs starting as soon as Daily NVP or AZT from birth
B+ soon as diagnosed, diagnosed, continued for life through age 4–6 weeks
continued for life regardless of infant feeding
method

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Drug Common Side effects
Abacavir potentially fatal hypersensitivity reaction
(ABC)
Didanosine lactic acidosis with peripheral neuropathy,
pancreatitis .
(ddI)
Lamivudine Safest of all NRTI’s,HA, nausea, abdominal pain.
(3TC)

Zidovudine (AZT neutropenia, anemia, granulocyptopenia,.

or ZDV)
Nevirapin (NVP) skin rash, Steven Johnsons syndrome, TEN, fatal hepatitis.
Efavirenze (EFV) Insomnia, abnormal dreams, confusion,
hallucinations.increased LFTs, Teratogenicity
Lopinavir/ increase in blood lipids
ritonavir pancreatitis, diabetes,hepatic toxicity, fat redistribution.
(kaletra)
Nelfinavir diarrhea, nausea, vomiting,asthenia,…
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TUBERCULOSIS IN HIV
POSITIVE CHILDREN

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Definition
 Tuberculosis (TB) is a potentially fatal
contagious disease that can affect
almost any part of the body but is
mainly an infection of the lungs.
 It is caused by a bacterial
microorganism, the tubercle bacillus
or Mycobacterium tuberculosis(road-
shaped,acid-fast)
 AIDS patients are much more likely to
develop tuberculosis because of their
weakened immune systems
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TB: A Growing Concern for PLWHA
 Approximately 1/3 of the
world population is
infected with TB
 Globally, 1/3 of PLWHA are
HIV
co-infected with TB
 TB is one of the leading HIV & TB
causes of death in people
with HIV, particularly in
low-income countries
TB

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The Effects of TB on HIV Progression
 TB increases HIV progression
 Dually infected persons often have very high
HIV viral loads
 Immuno-suppression progresses more
quickly, and survival may be shorter despite
successful treatment of TB
 Persons who were co-infected have a shorter
survival period than persons with HIV who
never had TB disease.

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The Effects of Immune Suppression on TB
Progression
 HIV+ person has a greater risk of reactivation of latent TB
infection (LTBI)
 HIV+ person is more likely to progress to TB disease
following infection
 HIV+ person has a high risk of becoming sick again after
treatment
 HIV+ person with LTBI has a 5-10% annual risk of
developing active TB (versus 10% lifetime risk among
HIV-negative persons)

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The Effects of HAART on TB
Progression
 Highly Active Anti-retroviral Therapy (HAART) alone
can reduce the risk of latent TB infection progression to
active TB disease by as much as 80%–92%

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Mycobacterium tuberculosis
Diagnosis…

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 Mycobacterium tuberculosis
Treatment
 Treatment principles similar in HIV-positive and HIV-
negative children
 Initiate treatment as soon as possible in children <4
years old with suspected TB
 Begin TB treatment 4-8 weeks before ARVs
 If already on ARV, review drug interactions
 Use of DOT increases adherence, decreases
resistance, treatment failure, and relapse

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 Mycobacterium tuberculosis
Treatment…
Initial treatment (induction phase)
 4 drugs: isoniazid, rifampin, pyrazinamide, plus
either ethambutol or streptomycin
 Use ethionamide as alternative to ethambutol for
CNS disease

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 Mycobacterium tuberculosis
Treatment…
 If clinical response occurs and organism is
susceptible to isoniazid, discontinue ethambutol
after 2 months
 If severe disease, treat for 9-12 months
 If multidrug resistance is found, treat with expert
consultation

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 Mycobacterium tuberculosis
Treatment…

Isoniazid
 Dosage: 10-15 mg/kg orally once daily (maximum 300
mg daily)
 Hepatic toxicity increases with rifampin
 Peripheral neuritis, mild CNS toxicity, gastric upset

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 Mycobacterium tuberculosis
Treatment…
Rifampin
 Dosage: 10-20 mg/kg orally once daily
(maximum 600 mg daily)
 Side effects include rash; hepatitis; jaundice; GI
upset; orange coloring of urine, tears, sweat
 Rifampin can accelerate clearance of protease
inhibitors and NNRTIs

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 Mycobacterium tuberculosis
Treatment…
Rifabutin
 Dosage: 10-20 mg/kg orally once daily
 Limited data in children
 Peripheral leukopenia, elevated liver enzymes,
pseudo jaundice, GI upsets

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 Mycobacterium tuberculosis
Treatment…
Pyrazinamide
 Dosage: 10-15 mg/kg orally once daily (maximum
2 g daily)
 Hepatic toxicity, rash, arthralgia, GI upset
Ethambutol
 Dosage: 15-25 mg/kg orally daily (maximum 1 g
daily)
 Toxicity includes optic neuritis, rash, nausea

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 Mycobacterium tuberculosis
Treatment…
Secondary drugs
 Ethionamide: 15-20 mg/kg orally divided into 2 or 3
doses daily
 Streptomycin: 20-40 mg/kg daily intramuscularly
(maximum dosage 1 g daily)
 Alternatives: kanamycin, amikacin, capreomycin,
quinolones, cycloserine, paraaminosalicylic acid
 Steroids may be indicated for TB meningitis

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 PREVENTION

 There is clear evidence that Bacille Calmette-Guérin

(BCG) vaccination reduces the incidence of severe
TB in children.

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Opportunistic infection
among HIV-infected
children

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 Introduction
• Children living with HIV are at a high risk of acquiring
OIs due to their immature and compromised immune
systems.
• Routine care of these children should include
prevention and treatment of OIs, as the risk of
developing OIs is directly related to the degree of
immunosuppression.

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 Introduction cont’d
• MTCT of OI is an important mode of acquisition
• HIV-infected women coinfected with OI and are more
likely to transmit (e.g. CMV, HCV)
• HIV-infected women or HIV-infected family members
are sources of horizontal transmission (eg,
tuberculosis)

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Common opportunistic infections in
children
 Serious and recurrent bacterial infections
 Mycobacterium tuberculosis
 Toxoplasmosis
 Cytomegalovirus (CMV) infections
 Pneumocystis jiroveci
 Candidiasis
 Pneumonia

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 Serious Recurrent Bacterial
Infections…
• Isolated bacteria include:
Streptococcus pneumoniae
Haemophilus influenzae type B
Staphylococcus aureus
Escherichia coli
Pseudomonas aeruginosa
Non typhoid Salmonella
• Incidence of S.pneumoniae and H influenzae
may be lower in regions where vaccines are
administered

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 Serious Recurrent Bacterial Infections
Treatment
 Response of mildly immunodeficient children is similar to
that of HIV-uninfected children
 Treat HIV-infected children outside the neonatal period with
empiric therapy until cultures are available
Ceftriaxone: 80-100 mg/kg in 1 or 2 divided doses, or
Cefotaxime:150-200 mg/kg divided into 3 or 4 doses, or
Cefuroxime: 100-150 mg/kg divided into 3 doses

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 Pneumocystis jiroveci (carinii)
Epidemiology

 Most common AIDS indicator disease in children

 Incidence highest in first year of life, peaking at 3-6 months
Clinical Manifestations:
 Fever, tachypnea , cough, dyspnea , poor feeding, weight
loss
 Abrupt or insidious onset
 Bibasilar rales with evidence of hypoxia and respiratory
distress
 Extrapulmonary locations – spleen, liver,colon, pancreas,
ear, eye, GI tract, bone marrow, heart, kidney, lymph
nodes, CNS
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 Pneumocystis jiroveci (carinii)
Diagnosis
 Hypoxia with low arterial oxygen pressure (alveolar-
arterial oxygen gradient >30 mm/Hg)
 Definitive diagnosis requires demonstrating organism
 Induced sputum (difficult <2 years)
 Open lung biopsy most sensitive
 Bronchoscopy with bronchoalevolar lavage
 Fiber optic bronchoscopy with biopsy – generally not
recommended
 Requires thorachotomy, chest tube drainage

53
 Pneumocystis jiroveci (carinii)
Treatment
 Trimethoprim / sulfamethoxazole (TMP/SMX)
• >2 months 15-20 mg/kg/day of TMP component
intravenously in 3-4 divided doses
• Can be given orally in children with mild to moderate
disease
Lifelong prophylaxis indicated
Pentamidine isothionate
• Recommended for patients intolerant of TMP/SMX or
clinical failure with TMP/SMX (A I); do not combine
use
• 4 mg/kg/day intravenously once daily over 60-90
minutes

54
 Treatment Alternatives

Atovaquone
• 30-40 mg/kg/day divided into 2 doses, given with
fatty foods
• Infants 3-24 months may require 45 mg/kg/day
divided into 2 doses, given with fatty foods.
Adverse reactions include rash, nausea, diarrhea,
increased liver enzymes
Primaquine contraindicated in G6PD deficiency
Trimetrexate glucuronate plus leucovorin (folinic
acid)
• Trimetrexate – 45 mg/m2 for 21 days
• Leucovorin – 20 mg/m2 every 6 hours for 24 days

55
 Treatment Alternatives…

Dapsone /trimethoprim:
• Use for mild to moderate PCP in adults – no data in
children
• Dapsone dose <13 years 2 mg/kg/day orally once
daily for 21 days
Adverse reactions include rash, anemia,
thrombocytopenia, increased liver
enzymesCorticosteroids
• Use within 72 hours of diagnosis
• Results in reduced respiratory failure, decreased
ventilation requirements, and decreased mortality

56
 Candida Infections
Epidemiology
• Most common fungal infections in HIV-infected
children
• Thrush and diaper dermatitis occur in 50-85% of
HIV-infected children
• Disseminated candidacies rare in children except
those with CMV, HSV co-infection or with central
venous catheter

57
 Candida Infections
Epidemiology…
• A substantial percentage of children with fungemia
receive oral systemically absorbable azole
antifungals, e.g., ketoconazol
• Complications include disseminated infection of
bone, liver, and kidney.
• Mortality >90% from disseminated candidiasis in
children with fever and symptoms >14 days

58
 Candida Infections
Clinical Manifestations
• Thrush and erythematous, hyperplasic, and angular
cheilitis
• Esophageal candidiasis may present with
odynophagia, dysphagia, or retrosternal pain
• Children may develop nausea, vomiting, or weight
loss and dehydration
• New onset of fever in individuals with central
venous catheters

59
 Candida Infections
Diagnosis
• Biopsy
• Blood culture
• “Cobblestone” appearance on barium swallow
• Perform endoscopy in refractory cases to look for
CMV, HSV, MAC co-infections

60
 Candida Infections
Treatment
Treat early uncomplicated oropharyngeal candidiasis
(OPC) with topical therapy
• Cotrimoxazole: 10 mg troches 4-5 times/day for 2
weeks (B II)
• Nystatin suspension: 4-6 mL (400,000-600,000
units/mL) 4 times/day
• Amphotericin B suspension: (100 mg/mL) 1 mL 4
times/day

61
 Candida Infections
Treatment
Oral systemic therapy for OPC
• Fluconazole: 3-6 mg/kg orally once daily for 7-14
days (A I)
• Itraconazole: 2.5 mg/kg orally twice daily for 7-14
days (A I)
• Ketoconazole: 5-10 mg/kg/day orally divided into 2
doses given for 14 days (D II)
• Amphotericin oral suspension or IV for OPC refractory
to other treatment

62
DIARRHEAL DISEASE IN HIV
POSITIVE CHILDREN

63
 Introduction
 Diarrhea remains the second leading cause of death
among children under five globally.
 Nearly one in five child deaths (about 1.5 million each
year) is due to diarrhea.
 Of all child deaths from diarrhea, 78% occur in the
African and South-East Asian regions, which are also
disproportionately burdened with infant and childhood
HIV infections Administration of ART and restoring
immune function are critical for the prevention and
treatment of diarrhea in children with HIV infection.

64
Definition: Persistent Diarrhoea

 Liquid stools
 3 or more times per day
 Continuous or intermittent
 At least 2 weeks duration
 HIV positive

65
 Etiological agents

 Severity is influenced by many factors, including the

agent and its pathogenicity and host characteristics,
such as immunodeficiency and age.

66
Common etiological agents of persistent
and bloody diarrhoea
 Persistent diarrhoea  Bloody diarrhoea
 Enteropathogenic E. coli  Shigella= mostly
 Enter aggregative E. coli  Nontyphoidal Salmonella

 Nontyphoidal Salmonella  Campylobacter

 Cryptosporidium  Enteroaggregative E. coli
 Enteroinvasive E. coli
 Microsporidia  Shiga toxin-producing E.
 Giardia lamblia coli
 Entamoeba histolytica
 Ascaris lumbricoides
 Cytomegalovirus
 Other viruses

67
 Foams of diarrhoea

 Acute watery diarrhoea :

 It includes cholera and isassociated with
significant fluid loss and rapid dehydration in an
infected individual.
 It usually lasts for several hours or days.

68
 Foams of diarrhoea…cont’d

Bloody diarrhea:
 It is often referred to as dysentery
 It is marked by visible blood in the stools.
 It is associated with intestinal damage and nutrient
losses in an infected individual.
The most common cause of bloody diarrhea is Shigella
Persistent diarrhea:
 it is an episode of diarrhea, with or without blood, that
lasts at least 14 days.
 Undernourished children and those with other illnesses,
such as AIDS, are more likely to develop persistent
diarrhea
69
TREATEMENT
AND
PREVENTION

70
 Assessment for Dehydration

Moderate/
Clinical Feature Severe
some
General Irritable Cold, Sweaty
Pulse Rapid Rapid, Feeble
Respiration Deep Deep, Rapid
Skin Elasticity Poor Very Poor
Eyes Sunken Deeply Sunken
Mucous
Dry Very Dry
Membranes
Urine
.
Flow Reduced None > 6 hours
71
 Rehydration in Primary Care
Setting
 Mild or moderate dehydration – Oral rehydration
 Oral Rehydration Solution (ORS) packets preferred
 ‘Home’ recipe
• ½ tsp salt with
• 8 tsp sugar in
• 1 liter boiled water
 Severe dehydration
– initial IV rehydration preferred
 If unable to correct, refer to level 2

72
Potassium Replacement

 Oral rehydration solution (ORS)

 Fruits – like bananas, oranges, etc.
 Vegetables including potatoes and leafy
greens like spinach
 Breast feeding

73
Parasites and Their Treatment
Etiology Treatment
Giardia Metronidazole 400 mg tds x
lamblia 5d
Metronidazole 400 mg tds x
E. histolytica
10d
Strongyloides Albendazole 400 mg bd X 2-
stercoralis 7d
Ascaris, Albendazole 400 mg once
hookworm
Cotrimoxazole (80/400) 2 tab
Isospora belli
bd or qds x 7-21 d
Cryptosporidiu Immune Restoration with
m ARVs
74
Bacteria and Their Treatment
Etiology Treatment
Chloramphenicol 250-500 mg qid x
7-14 d
Salmonella
OR
Nalidixic Acid 1g qid x 5d
Shigella Nalidixic Acid 1g qid x 5d
Campylobacte Erythromycin 500mg qid x 7d
r
Clostridium Stop other antibiotics
difficile Metronidazole 400mg tds x 10d
E. coli Nalidixic Acid 1g qid x 5d
75
Treatments

 Nitazoxanide for Cryptosporidium diarrhoea is

used for treatment of HIV-infected children has
proved particularly difficult because of low drug
efficacy.
 Ciprofloxacin for bloody diarrhoea is
recommended for 3 days at an oral dose of 15
mg/kg for treating bloody diarrhoea

76
Preventive interventions
Vitamin A supplementation :
 Vitamin A supplementation is recommended for all
HIV-infected and -exposed infants and children
aged 6 months to 5 years
 1,00,000 IU for infants aged 6–12 months
 2,00,000 IU for children > 12 months

77
Preventive interventions…
Zinc supplementation:
 Elemental zinc supplementation is recommended for
10–14 days, with increased fluids and continued
feeding, for all HIV-infected and -exposed children
with diarrhoea
 10 mg per day for infants under 6 months of age
 20 mg per day for infants and children over 6 months
 Proper disposal of feces in a toilet or latrine or, at a
minimum, by burial in the ground is recommended
for people with HIV and their households

78
 Preventive interventions…
Co-trimoxazole prophylaxis:
 co-trimoxazole prophylaxis an important intervention for
preventing mortality in HIV-infected and -exposed infants
and children
 All HIV-exposed and -infected infants and children should
receive daily co-trimoxazole prophylaxis in accordance with
existing WHO guidelines
Promotion of hand-washing with soap after defecation and
after handling human or animal feces and before food
preparation and eating and the provision of soap are
recommended for people with HIV and their households.
Immunization
Brest feeding and adequate nutrition
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Preventive interventions…

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ART ADHERENCE IN
CHILDREN

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 Definition
A persons behavior in relation to prescribed medical
regimen which may include:
 Keeping appointments
 Taking medications
 Following prescribed diet
 Executing other life style changes.

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 Importance of adharance

1) Prognosis
• Preserve and restore immune function
• Supress viral load
– Decrease morbidity
– Prevent death
2) Improve quality of life

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 Adherence Versus Compliance

 Compliance implies the patient does what he or she

has been told to do by the health care provider.
 Adherence implies an informed choice. It involves a
relationship of trust between the child, family, or
caregiver.

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 Children in relation to adherence

 Children have unique needs; they are not just small

adults
 They are physically, developmentally and
psychologically different
 They should be managed and treated differently
 Children are constantly growing and developing; new
issues emerge

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 Factors Affecting Adherence

Child factors;
 Age (developmental not chronological)
 Previous history with medication
 Ability to swallow pills
 Refusal
 Fear
 Emotional and behavioral

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 Factors Affecting Adherence
Medication factors;
 Taste of medication: bitter
 Formulation: Pill/liquid volume
 Frequency of dosing
 Side effects: feeling unwell, toxicity
 Food requirements: with/without
 Drug interactions

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 Factors Affecting Adherence
Parent/guardian factors;
 Knowledge about HIV
 Lack of understanding
 Literacy level
 Illness/physical health
 Stigma/disclosure issues
 Mental health status
 Cultural beliefs
 Past experiences with health care system

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 Factors Affecting Adherence
Provider factors;
 Availability/how often does a family see the same
health care provider?
 Assessment skills
 Cultural sensitivity
 Non-judgmental approach
 Resources
 Provider stress/burnout

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 Factors Affecting Adherence

Provider-patient relationship factors,

 Communication skills
 Flexibility
 Willingness to form a partnership
 Trust

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Consequences of Poor ART Adherence in Children

 Drug resistance
 Limited options for future therapy
 Treatment failure
 Susceptibility to potentially fatal opportunistic
infections
 High viral load increases the probability of
transmission
 Unnecessary healthcare costs

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Common Reasons Given for Non-Adherence
in Children

Away from home Forgot/play Side effects/ Spillage

Felt better Reasons for Pills do not help

missing doses

Did not want Instructions not

Fear of side effects others to see understood

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 General Rules for Giving Medication to
Children
 Begin by telling the truth
 Involve children in their care; even small
children can be involved in their care through
play therapy.
 Tell the child that s/he is going to learn a new
skill. Remind him/her that other skills have been
learned in the past , like skipping, dressing and
eating.

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 General Rules for Giving Medication to
Children
 Do not bargain or bribe the child to take
medication. Bargains or bribes will likely cause
the child to take medication to earn a reward
rather than because it is a habit, an expected part
of growing up, and good for their health.
 Do not mix with food or otherwise try to “trick”
the child
 Do not threaten or punish

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Strategies for Giving Medicines to Babies
and Toddlers 0-2 Years
 Use a syringe or small soft dropper; ensure that it is
clearly marked with date, time, and dosage of
medication
 Sit the baby on your lap; keep the head slightly tilted
but firmly towards your body so that it does not move
 Gently close the child’s mouth with your hand on the
chin, until the child has swallowed.
 Speak softly to the child throughout
 Offer some water/juice

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 Strategies for Giving Medicines to Children
above 2 Years
 Do not ask children if they want to take the
medication
 Do not mix with food, especially favorite food.
 Speak softly to the child
 Never show anger toward the child for refusing to
take the medicine.
 Reassure the child after giving the medication.
 Let the child choose some water/juice afterward.

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