Children Living with HIV - Research Paper Example

?HIV Infection in Children Outline I. HIV infection in children: What are the diagnosis, treatment and complications of HIV infection in children? II. HIV is a pandemic disease that has its implications on all aspects of life and affects every strata of the society. HIV infection in children is rapidly progressive with poor prognosis. The most common route of acquisition is perinatal transmission. III. Evidence to support thesis A. Describe HIV infection 1. Transmission routes a.Perinatal tansmission b. Other routes of transmission B. Pathophysiology 1. HIV virus structure 2. Mechanism of entry into the host 3. Disease formation. C. Epidemiology 1. Global statistics 2. Statistics in the US D. Mortality and morbidity E. Clinical presentation 1. Perinatal testing 2. Clinical presentation 3. Complications F. Laboratory diagnosis 1. DNA/RNA PCR 2. HIV culture G. Treatment 1. Definitive: reverse transcriptase inhibitors (RTI), non-nucleoside reverse transcriptase inhibitors (NRTI) and protease inhibitors (PI) 2. Supportive 3. Surgical H. Prognosis: Poor IV. Summary V. References A. Medscape reference B. CDC C. WHO D. Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children. I. Introduction: HIV infection in children HIV is a pandemic disease that has its implications on all aspects of life and affects every strata of the society. It affects all age groups and children develop the infection mainly through transmission from the infected mother during pregnancy, delivery or breast feeding. According to the WHO (2009), based on the 2007 statistics, there are about 2.1 million children suffering from HIV infection. Majority of them are from the sub-Saharan region. One significant aspect of HIV infection in children is that more often than not, even the primary caregivers, especially the mothers also suffer and succumb to acquired immunodeficiency syndrome or AIDS, making HIV infection a miserable disease among children. There are 2 strains of HIV, HIV-1 and HIV-2. More often than not, it is HIV-1 that is identified among patients. Some patients may be positive to both types of viruses. HIV-2 infection is most commonly encountered in the Western part of Africa (Abdelmalek, 2011). HIV infection in children is rapidly progressive with poor prognosis. II. Research statement: HIV is a pandemic disease that has its implications on all aspects of life and affects every strata of the society. HIV infection in children is rapidly progressive with poor prognosis. The most common route of acquisition is perinatal transmission. III. Evidence to support thesis A. Description of HIV infection 1. Transmission Vertical transmission is the most common route of acquisition of childhood HIV infection and without intervention, perinatal acquisition risk is 25- 40 percent (Abdelmalek, 2011). In United States, perinatal acquisition from mother accounts for more than 80 percent cases of childhood HIV infection (CDC, 2009). Perinatal transmission can occur any time, like in utero, in the peripartum period and during breast feeding. The transmissibility of HIV through breast milk is actually very less (WHO, 2007). However, cumulative exposure of the baby to cell-free HIV RNA is the main cause of postnatal transmission of HIV through breast feeding. Other means of transmission like transmission through blood and blood products and injections are very rare in developed countries like United States, but do exist in some developing countries (Abdelmalek, 2011). B. Pathophysiology HIV is a retrovirus that has several proteins, both structural and non-structural, which determine the interaction between the immune system of the host and the virus. The virus mainly attaches to the cells of the host through association of the surface glycoprotein with the CD4 molecule of the cells. It is because of this reason that HIV mainly infects cells with CD4, namely macrophages and lymphocytes. On entry of the virus core into the cytoplasm of the cell of the host, the reverse transcriptase of the virus copies the RNA of the virus to the host's DNA. The DNA of the virus is then transported into the host's nucleus and then incorporated into the cell's DA. Activation of this results in new RNA and proteins of the virus, and further additional cell infection. Since the immune system cells are infected, reduction in the cell mediated immunity ensues and dysfunction of the secondary B-cell occurs resulting in immunocompromise, This leads to opportunistic infections and development of malignancies. There is increased activation-induced cell death in HIV patients because of apoptosis of T cells (Abdelmalek, 2011). C. Epidemiology According to the statistical information from Centers for Disease Control and Prevention (CDC, 2009), the number of newly diagnosed cases of HIV in children is decreasing because of increased public awareness and initiatives taken to prevent vertical transmission of HIV. In the year 2003, 9089 cases of childhood HIV were diagnosed and in 2005 only 3764 cases were diagnosed. The global picture however, is different. The rates of HIV in childhood are raising at an alarming rate and worldwide, it is estimated that there are about 2.1 million cases of HIV among children. 90 percent of these cases are in the sub-Saharan Africa. Among undernourished children, the prevalence of HIV infection is about 25 percent. In the US, the most affected communities are minorities. Infact, more than 50 percent of the affected cases are Blacks and about 25 percent are Hispanic. Most children are identified during infancy itself (CDC, 2009). D. Morbidity and mortality The morbidity and mortality associated with HIV infection is very high. These children die because of Acquired Immunodeficiency Syndrome. The mortality rate in regions like sub-Saharan Africa is very high, as much as 75 percent, because of the orphaned status of the children with HIV. In this region, estimates have shown that HIV infection is the single most common cause of deaths in infancy and childhood (Abdelmalek, 2011). E. Clinical presentation: Signs and symptoms There is no typical clinical presentation of HIV infection. Common presentations in children include unrelenting fever, thrush or diarrhea, recurrent pneumonia or bacterial infections, generalized lymphadenopathy, failure to thrive, developmental delay, chronic parotitis and significant dermatoses. Infact, in many cases of pediatric HIV, the first sign of HIV infection is usually a mucocutaneous eruptions. The presentation depends on the immune status of the child (Abdelmalek, 2011). Under ideal circumstances, HIV diagnosis in a child is done through testing in the perinatal period. In developed and many developing countries, HIV testing is done routinely in all pregnant women. Children who contract HIV through mothers who have not been tested during pregnancy and children who contract HIV infection due to sexual abuse, do not have an early diagnosis of HIV infection and their diagnosis is made after suspicious clinical profile. One of the most common presentations in children with HIV is mucocutaneous disorders. The severity and number of skin manifestations increase with fall in CD4 counts. 57 percent of children infected with HIV due to perinatal transmission develop symptoms during infancy. Dermatological features usually improve with antiretroviral treatment. Oral and mucocutaneous candidiasis is common. Other problems include dysphagia, peridontal disease, retrosternal pain and odynophagia due to esophageal candidiasis, recurrent diaper rash, onychomycosis, chronic paronychia, oral hairy leukoplakia, dermatophytosis, deep fungal infections, recurrent zoster infections, human papillomavirus infection, widespread molluscum contagiosum, recurrent bacterial infections, mycobacterial infections, bacillary angiomatosis, scabies, pneumocystis carini pneumonia, encephalitis, metabolic problems and neoplastic conditions like Kaposi sarcoma and B-cell lymphoproliferative diseases (Abdelmalek, 2011). F. Laboratory diagnosis "The CDC recommends prenatal HIV testing as the standard of care for all pregnant women in the United States" (Abdelmalek, 2011). HIV testing methods are DNA/RNA PCR or HIV culture. Repeat testing is done for confirmation. In perinatal transmission, HIV testing must be done immediately after birth and must be repeated at 1-2 months of age and also at 3-6 months of age. At one month of age, testing with PCR is 96 percent sensitive and 99 percent specific for identification of HIV infection. In children less than 18 years of age, virologic assays are preferred for diagnosis because of transfer of maternal antibodies. The preferred virologic assays are HIV RNA assays and HIV DNA PCR. In uninfected infants HIV antibody-negative status is recommended at 12- 18 months of age. In children above 18 months of age, HIV antibody assays are used for the diagnosis. HIV antigen assay is not recommended for infant diagnosis because of poor specificity and sensitivity during early months of life. It is important to monitor the CD4+ levels in infants every 3-4 months for immune status evaluation and HIV RNA levels every 3-4 months. In case of opportunistic infection, complete blood picture, urinalysis, cultures and specific tests must be done. Other tests which indicate prognosis include CD8+ levels, serum albumin levels and serum immunoglobulin levels. Imaging studies are performed to identify opportunistic infection locus and tumor locations and are done based on clinical suspicion (Abdelmalek, 2011). G. Treatment Interventions in children with HIV are aimed at prevention immune system damage and retardation of potential dissemination of infection. According to the Working Group (2009), goals of treatment in children with HIV infection include reduction in mortality and morbidity related to HIV, restoration and preservation of immune function, suppression of viral replication, minimization of toxicity related to drugs, maintenance of normal physical and mental growth and cause improvement in the quality of life. The commonly used anti-HIV therapies are reverse transcriptase inhibitors (RTI), non-nucleoside reverse transcriptase inhibitors (NRTI) and protease inhibitors (PI). RTI and NRTI inhibit viral reverse transcriptase and suppress viral replication. PI prevent viral replication by interfering with structural protein formation (Working Group, 2009). As of now, there are 17 antiretroviral drugs approved for use in children and treatment is based on the age of the child (Working Group, 2009). In children less than 12 years of age, antiretroviral therapy is initiated irrespective of immune status, viral load and clinical presentation. In those between 1 to 5 years of age, treatment is initiated in those who have HIV-related symptoms or acquired immunodeficiency syndrome, and in those who are asymptomatic or are mildly ill but with CD4+ counts of less than 25 percent, irrespective of the viral load. In those with CD4+ counts of more than 25 percent and who are asymptomatic or mildly symptomatic, antiretroviral therapy must be deferred. Re-evaluation of the deferred patients must be done every 3-4 months. In children above 5 years of age, treatment must be initiated in those with CD4+ counts of less than 350 only, irrespective or viral load, if they have mild symptoms and in case the counts are more than that, treatment must be initiated if viral load is more than 100,000 copies/µL (Working Group, 2009). Surgical interventions like tumor removal, nasogastric tube placement and others may be necessary based on clinical status. Supportive therapy is crucial in advanced stages and much include all aspects of the individual, including medical, emotional, financial and spiritual aspects (Abdelmalek, 2011). H. Prognosis Prognosis in children with HIV infection is poor. The patients succumb to opportunistic infection and malnutrition because of acquired immunodeficiency syndrome (Abdelmalek, 2011). IV. Summary HIV infection in children is a global health challenge and is present in pandemic proportions. More often than not, the infection is contracted through perinatal transmission from the infected mother. Clinical presentation is mainly related to complications like opportunistic infections, dermatological problems and tumors. In many children, HIV is tested after birth because of known maternal HIV status. There is no definitive treatment for HIV in children and prognosis is poor. V. References Abdelmalek, M. (2011). Childhood HIV Disease. Medscape Reference. Retrieved on July 24th, 2011 from http://emedicine.medscape.com/article/1133546-overview Centers for Disease Control and Prevention (2009). HIV/AIDS Surveillance Report: HIV Infection and AIDS in the United States and Dependent Areas. Department of Health and Human Services. World Health Organization (2009). Pediatric HIV and treatment of children living with HIV. Retrieved on July 24th, 2011 from http://www.who.int/hiv/paediatric/en/index.html. World Health Organization (2007). Mother-to-child transmission of HIV. World Health Organization. Retrieved on July 24th, 2011 from http://www.who.int/hiv/topics/mtct/en/index.html Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children. (2008). Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. Developed by Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children. National Institutes of Health. Retrieved on July 24th, 2011 from http://aidsinfo.nih.gov. Read More