6 HIV-associated infections and end-of-life care

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Contents

• Objectives
• HIV-associated infections
• Common infections
• Tuberculosis
• Treating tuberculosis co-infection
• End-of-life care
• Case studies

Objectives

When you have completed this chapter you should be able to:

1. Define an HIV-associated infection.
2. Define an AIDS-defining infection.
3. List the common childhood HIV-associated infections.
4. Diagnose and manage the common HIV-associated infections.
5. Diagnose and manage tuberculosis co-infection.
6. Provide palliative and terminal care.

HIV-associated infections

6-1 What are HIV-associated infections?

HIV-associated infections are infections which are common in HIV-infected people. They may be caused by a wide range of organisms such as bacteria, viruses, fungi or protozoa. These infections occur when the immune system becomes damaged. The first clinical sign to suggest that a child has a weakened immune system is often the appearance of an HIV-associated infection.

HIV-associated infections are common in people with a weakened immune system.

6-2 Which are the common HIV-associated infections in children?

1. Infections which are also seen in children who are not infected with HIV:
   • Skin infections
   • Mild oral candidiasis (thrush)
   • Bacterial pneumonia
   • Otitis media or sinusitis
   • Pulmonary tuberculosis (TB)
   • Diarrhoeal disease
   • Septicaemia
2. Infections which are uncommon in children who are not infected with HIV:
   • Recurrent or chronic oral candidiasis
   • Recurrent bacterial pneumonia
   • Shingles (Herpes zoster)
   • Severe, recurrent mouth ulcers
   • Lymphoid interstitial pneumonitis
   • Extra-pulmonary TB
3. Infections which are rare in children who are not infected with HIV.

6-3 Which infections are common in HIV-infected children but rare in children without HIV infection?

• Oesophageal candidiasis
• Pneumocystis pneumonia
• Cryptococcal meningitis
• Cerebral toxoplasmosis
• Cytomegalovirus (CMV) retinitis

Note

Less common HIV-associated infections include Hepatitis B and C, non-tuberculosis mycobacteria or disseminated fungal infections and chronic diarrhoea due to Isospora or Cryptosporidium. Other HIV-associated infections seen in adults are rare in children.

6-4 Do HIV-associated infections always indicate that the child has advanced disease?

No, as some HIV-associated infections such as pulmonary TB or shingles may also be found in HIV-negative children and children with stage 1 to 3 HIV infection. These infections, however, should always alert one to the fact that the child may be HIV infected. HIV-associated infections are therefore an important indicator for HIV screening.

6-5 What are the AIDS-defining infections?

These are clinical infections which only occur in children who have a severely damaged immune system due to HIV infection. Therefore they are called ‘AIDS-defining infections’. They include conditions which are rare in HIV-negative children, such as oesophageal candidiasis and Pneumocystis pneumonia.

The term ‘AIDS-defining illnesses’ also includes conditions such as unexplained wasting, stunting or severe malnutrition, HIV encephalopathy, non-Hodgkin’s lymphoma, and Kaposi’s sarcoma.

Children with an AIDS-defining illness are classified as having stage 4 HIV infection.

Both infections and malignancies can be AIDS-defining illnesses.

Note

A number of malignancies associated with AIDS have a viral cause, e.g. Kaposi’s sarcoma is caused by the human herpes virus 8.

6-6 What are opportunistic infections?

Opportunistic infections or ‘OIs’ are infections which should not occur in children with a healthy immune system. These organisms ‘take the opportunity’ of infecting and causing illness in children with a weakened immune system. Unfortunately this is a confusing term as some experts use the term opportunistic infections only for AIDS-defining infections while others use the term for all infections seen in HIV-infected children.

6-7 Which children are at high risk for HIV-associated infections?

• All children with HIV infection are at an increased risk for HIV-associated infections.
• The lower the CD4 percentage, the greater the risk for HIV-associated infections. Therefore, children with a CD4 percentage below 15% are at the greatest risk.
• Unlike in HIV-infected adults, where there is a clear relation between the CD4 count and specific HIV-associated infections, in children the relation between CD4 percentage and specific infections is less predictable. For example, HIV-infected adults with a CD4 count below 200 cells/µl are at a high risk for Pneumocystis pneumonia. In HIV-infected children, particularly those less than one year of age, Pneumocystis pneumonia can occur at any CD4 percentage even in those children with a CD4 percentage greater than 25%. Therefore, all HIV-exposed children must be started on cotrimoxazole prophylaxis from the age of 4 to 6 weeks to prevent this life-threatening HIV-associated infection.

The lower the CD4 percentage or count the higher the risk of an HIV-associated infection.

6-8 Can HIV-associated infections be prevented?

The best way of preventing most severe HIV-associated infections is to start antiretroviral treatment in HIV patients. The risk of HIV-associated infections can also be reduced by:

• Primary prophylaxis that prevents the HIV-associated infection from occurring. This is done for Pneumocystis and TB.
• Secondary prophylaxis that prevents recurrences of HIV-associated infections which have already occurred. This is done for cryptococcal meningitis and Pneumocystis pneumonia.

6-9 Which HIV-associated infections are the most important in children?

Severe or repeated bacterial infections as these are very common and can be fatal in HIV-positive children. Important bacterial infections include pneumonia, septicaemia, meningitis, urinary tract infection, osteitis, skin sepsis and otitis media. They often run a complicated course and respond slowly to treatment.

Severe or repeated bacterial infections are common in children with HIV infection.

Common infections

6-10 What skin infections are common in children with HIV infection?

Many common skin infections occur in children who are HIV-infected. However, they are more severe, and often take longer to respond to treatment, than in children who are not immunosuppressed. Common skin infections in children with HIV infection are:

• Severe molluscum contagiosum
• Severe candidiasis nappy rash, which may ulcerate
• Widespread warts
• Severe chicken pox or shingles due to Herpes zoster virus
• Severe scabies, which may involve the whole body
• Severe tinea capitis (ringworm of the scalp)
• Severe impetigo
• Severe seborrhoeic dermatitis

Any of these severe skin conditions, especially shingles, suggests that the child is infected with HIV. Shingles is a very painful vesicular rash which usually only affects one part of the body. Molluscum contagiosum and warts are often extensive and do not recover spontaneously. Severe tinea capitis and impetigo often need systemic therapy and do not respond to local treatment.

6-11 What gastrointestinal problems are common in children with HIV infection?

• Severe, persistent or recurrent oral candidiasis (moniliasis or thrush). Severe oral candidiasis after two months of age is uncommon in children who are not HIV infected.
• Oesophageal candidiasis: Infants who have severe oral candidiasis, pain and difficulty with swallowing and drool saliva, probably have oesophageal candidiasis as well. These children refuse feeds and are very irritable due to hunger and thirst. This rapidly results in dehydration.
• Herpes stomatitis: This is often severe in children with HIV infection, resulting in dehydration. Aphthous ulcers and gum infections (necrotising ulcerative gingivitis) are also common.
• Acute diarrhoea: This is usually due to viruses and bacteria which also cause diarrhoea in children who are not infected with HIV.
• Chronic diarrhoea: This may complicate acute diarrhoea or be due to unusual organism such as Cryptosporidium or Isospora. Lactose intolerance may complicate chronic diarrhoea.

Except for children with mild, acute diarrhoea, most of these children should be referred to hospital for further investigation and management.

Oesophageal candidiasis presents with painful swallowing.

Note

Other conditions which may cause oesophagitis are Herpes simplex, CMV infection or severe gastro-oesophageal reflux. Endoscopy may be needed to confirm the diagnosis.

6-12 How should a child with severe oral or oesophageal candidiasis be managed?

Oral candidiasis (thrush) can usually be successfully treated with mycostatin drops 1 ml or miconazole gel six-hourly after a feed or meal. If the response is poor, oral fluconazole 3 mg/kg daily can be used for seven days.

Oesophageal candidiasis is treated with oral fluconazole 10 to 12 mg/kg daily for 2 to 4 weeks depending on the clinical response. Intravenous treatment may be needed for a few days if the child cannot swallow. Local treatment with topical drugs is not adequate. These patients must be referred to hospital as they may need intravenous rehydration or nasogastric feeding. Analgesia should be given as this condition is painful.

6-13 What is the management of mouth ulcers in children with HIV infection?

• Severe, recurrent aphthous ulcers. These are very painful ulcers that can occur anywhere in the mouth. They may be single or multiple, small or large. Manage with paracetamol (Panado) for pain, and chlorhexidine mouthwashes to prevent secondary bacterial infection. Local (topical) steroids (e.g. Kenalog in Orabase) or spraying a beclomethasone inhaler directly onto the ulcer is helpful in severe cases.
• Herpes infections. These multiple, shallow ulcers often are recurrent or become chronic. Topical gentian violet or 0.1% povidone-iodine (Betadine mouth wash) may be used while oral acyclovir (20 mg/kg/dose four times per day for five days) is indicated for large or extensive ulcers.
• Necrotising ulcerative gingivitis. This causes bleeding and ulceration along the gum margins of the teeth. Mouth washes with 0.2% chlorhexidine gluconate helps while oral metronidazole (Flagyl) is indicated in severe cases. Severe cases should be referred to a dental hygienist.

It is important that children with a sore mouth take adequate amounts of fluids and do not become dehydrated. Intravenous or nasogastric fluids may be required.

Note

Oral hairy leucoplakia with white marks on the sides of the tongue is not painful.

6-14 What are important respiratory infections in children with HIV infection?

• Bacterial ear infections (otitis media), bronchitis and sinusitis are common.
• Severe, recurrent or chronic pneumonia caused by bacteria that also cause pneumonia in children who do not have HIV infection, e.g. Streptococcal pneumonia (Pneumococcus) and Haemophilus influenza type B.
• Viral pneumonias and bronchiolitis.
• Chronic lung disease especially bronchiectasis.
• Pneumocystis pneumonia.
• Lymphoid interstitial pneumonitis (LIP).
• Tuberculosis.

6-15 What is Pneumocystis pneumonia?

Pneumocystis pneumonia is a severe lung infection caused by a fungus called Pneumocystis jiroveci. This fungus does not cause pneumonia in children with a healthy immune system. Therefore, a diagnosis of Pneumocystis pneumonia usually indicates that the child has AIDS. Pneumocystis pneumonia commonly presents in the first year of life with high fever, a cough and marked respiratory distress often with hypoxia. The onset of illness is sudden. It is a fatal infection if not treated.

The risk of Pneumocystis pneumonia can be greatly reduced with cotrimoxazole prophylaxis from four to six weeks in all HIV-exposed infants (i.e. infants born to HIV-positive women).

Chest X-ray shows non-specific changes.

Pneumocystis pneumonia is an important cause of respiratory distress in infants with HIV infection.

Note

Previously Pneumocystis jiroveci was called Pneumocystis carinii, hence PCP or Pneumocystis carinii pneumonia. The diagnosis can be confirmed by finding cysts of Pneumocystis in the sputum using a special stain.

6-16 What is the management of a child with Pneumocystis pneumonia?

Infants with suspected Pneumocystis pneumonia must be urgently referred to hospital for treatment with an intravenous loading dose of cotrimoxazole 20 mg/kg followed by 5 mg/kg intravenously every six hours for 21 days. If intravenous access becomes difficult, change to oral cotrimoxazole 5 mg/kg six-hourly to complete 21 days of treatment. Usually the child is clinically improved after three days of treatment.

If it is not possible to achieve intravenous access, oral cotrimoxazole can be used. A single oral loading dose of 20 mg/kg should be given followed by 5 mg/kg every six hours for 21 days.

All children with cyanosis or a low oxygen saturation must be given oxygen. When hypoxia is present, oral steroids are given routinely (i.e. prednisone 2 mg/kg daily for seven days and then tapered off and discontinued over seven days).

Further episodes of Pneumocystis pneumonia can be prevented with prophylactic oral cotrimoxazole.

6-17 What is lymphoid interstitial pneumonitis?

Lymphoid interstitial pneumonitis (LIP) is a common type of chronic lung disease in children with HIV infection, especially children older than two years. While rare in HIV-infected adults, it occurs in at least 30% of African children with stage 3 or 4 HIV infection. The cause of LIP remains uncertain but it may be caused by a viral infection.

LIP is a slowly progressive condition which usually presents with a chronic cough and shortness of breath (dyspnoea). These children are usually not generally ill other than their respiratory symptoms. They may even have no symptoms at all. However, enlarged parotid glands, lymph nodes, liver and spleen with finger clubbing are common. Advanced LIP causes central cyanosis and severe respiratory distress. It can be fatal. An oxygen saturation of less than 90% confirms hypoxia.

Lymphoid interstitial pneumonitis is an important cause of respiratory distress in older children with HIV infection.

Note

LIP is the only stage 3 condition that is regarded as an AIDS-defining illness.

6-18 How is the clinical diagnosis of lymphoid interstitial pneumonitis confirmed?

By taking an X-ray of the child’s chest. This looks like miliary tuberculosis. It is important to exclude other pulmonary conditions such as bacterial or viral pneumonia, tuberculosis and bronchiectasis.

6-19 How should you manage a child with lymphoid interstitial pneumonitis?

If the condition is symptomatic (respiratory distress or hypoxia) these children should be admitted to hospital. Oxygen should be given for hypoxia if cyanosis is present or the oxygen saturation is low. A course of antibiotics is often given to treat a suspected bacterial infection. LIP does not respond to antibiotics, but improves with antiretroviral treatment. Children with severe respiratory distress improve dramatically with oral steroids. LIP can be prevented by providing early antiretroviral treatment when indicated.

Tuberculosis

6-20 How common is tuberculosis in children with HIV infection?

Tuberculosis is one of the commonest serious bacterial infections seen in children with HIV infection. The clinical pattern of tuberculosis is similar in both HIV-positive and negative children. The risk of tuberculosis is increased even in children with stage 1 and 2 HIV disease.

Tuberculosis is common in children with HIV infection. In one South African study of children under one year of age, the risk of acquiring culture-confirmed tuberculosis was 24-fold higher in HIV-infected infants compared to uninfected children of the same age.

6-21 What forms of tuberculosis are common in children with HIV infection?

Pulmonary TB due to Mycobacterium tuberculosis is the commonest form of TB in both HIV-infected and non-infected children. However, tuberculosis of other organs (extra-pulmonary TB, i.e. lymph node TB, TB meningitis, abdominal TB, TB osteitis, TB arthritis and miliary TB) is more common in children who are infected with HIV.

A combination of HIV and TB infection leads to rapid immunosuppression with progression of both diseases. As a result, TB is more common and more severe in children with HIV infection.

TB in HIV-infected children usually responds well to treatment. However, multi-drug-resistant TB (MDR TB) and extensively drug resistant TB (XDR TB) are becoming a problem with HIV-infected children in South Africa. It is often the result of inadequate or incomplete TB treatment or spread from adults with multi-drug-resistant TB.

Note

Infection with Mycobacterium avium complex (MAC) is rare in children with AIDS.

6-22 How is pulmonary tuberculosis diagnosed in children with HIV infection?

• A high index of suspicion is most important. Usually there is an adult with ‘open’ pulmonary tuberculosis in the home. Tuberculosis is most common in undernourished children from poor, overcrowded communities.
• General symptoms and signs of tuberculosis include poor appetite, weight loss, fatigue and malaise, and fever with night sweats.
• Signs of pulmonary tuberculosis include a persistent cough lasting two weeks or more. The cough may be dry or productive. Shortness of breath, fast breathing and chest pain may also be present. Unlike adults, blood-stained sputum is uncommon in children with pulmonary tuberculosis. Enlarged hilar nodes may press on a bronchus causing wheezing or stridor.
• The Mantoux skin test in HIV-infected children with TB is often negative. It may be negative due to immunodeficiency associated with HIV infection or malnutrition that accompanies TB.
• Chest X-ray will usually show bronchopneumonia, enlarged lymph nodes, a pleural effusion or miliary TB. However, the chest X-ray may appear normal. Other pulmonary infections, such as bacterial and viral pneumonias, may be confused with tuberculosis.
• Sputum or gastric aspirate may be positive on the Xpert MTB/RIF Ultra test. However, in many children with tuberculosis the Xpert MTB/RIF Ultra test may be negative. Induced coughing is the best method of obtaining a sputum sample.
• TB culture of the sputum or gastric aspirate is usually positive with widespread pulmonary TB. However, cultures may be negative.
• The child improves clinically on anti-TB treatment. Sometimes this is the only way of confirming the clinical diagnosis.

Note

A useful method of inducing coughing and sputum collection in a child can be performed before a meal. A puff of inhaled bronchodilator is given using a spacer followed 10 minutes later by 5 ml hypertonic saline (5% saline) also by nebuliser. This is followed by chest physiotherapy to loosen the mucus and promote coughing.

A persistent cough lasting longer than two weeks is an important symptom of pulmonary tuberculosis.

The clinical diagnosis of TB may be difficult in a child with HIV infection. Always consider TB if the clinical signs do not respond to a course of antibiotics.

Treating tuberculosis co-infection

6-23 Can HIV infection and tuberculosis be treated at the same time?

If TB is diagnosed at the time that antiretroviral treatment is being considered the TB treatment should be started as soon as possible and antiretroviral treatment started two to eight weeks later. However, in some children with advanced HIV disease it may be necessary to start antiretroviral treatment soon after starting the TB treatment. It is no longer necessary to wait until the TB treatment is completed before starting antiretroviral treatment. When using TB and antiretroviral treatments together, ALT should be monitored monthly, as drug-induced hepatitis is common.

If possible tuberculosis should be diagnosed and treatment started for 2 to 8 weeks before starting antiretroviral treatment.

6-24 What problems are common when treating tuberculosis and HIV at the same time?

• A large number of different drugs have to be taken which complicates the drug administration. This may confuse care givers, increase the chances of mistakes when giving the medicines and lead to poor adherence.
• The immune reconstitution inflammatory syndrome may occur. This is particularly common if antiretroviral therapy is started during the first two months of TB treatment, especially if the CD4 count is below 15%.
• Drug interactions between antiretroviral and anti-TB drugs are common.
• Drug side effects are more frequent and may be severe as anti-TB drugs and antiretroviral drugs often have similar side effects. This may further affect adherence.

Treatment of HIV is difficult if TB treatment is also being given at the same time. Therefore, children with a co-infection of TB and HIV should be managed by an experienced clinician.

Drugs used in TB therapy and antiretroviral treatment may interact with each other.

6-25 What drugs are usually used to treat pulmonary tuberculosis in children with HIV infection?

Children with HIV and TB co-infection should be treated with 4 drugs, i.e. rifampicin, INH, pyrazinamide and ethambutol for 2 months (intensive phase) followed by rifampicin and INH only for the remaining four months (maintenance phase). Therefore the full course is for six months. However if there has been insufficient improvement on X-ray after six months the two drug maintenance should be continued for a further three months to give a nine month course. The anti-TB drugs are given daily. Compliance is better with daily treatment than only five days a week.

6-26 When should antiretroviral treatment be started in children who have tuberculosis?

• Children with HIV-TB co-infection should be started on antiretroviral treatment two to eight weeks after starting TB treatment
• If the CD4 count is less than 15% or 200 cells/µl or the child very ill (stage 4) antiretroviral treatment should be started earlier. An exception is children with TB meningitis who should ideally be started on TB treatment 4 to 8 weeks before starting antiretroviral treatment.

6-27 What may happen if anti-TB and antiretroviral treatment are started together?

The number of live TB bacilli drops by more than 95% within 48 hours of starting TB treatment. Once antiretroviral treatment is begun the child’s immune system will begin to recover and may start to respond to the remaining dead TB bacilli. This results in the immune reconstitution inflammatory syndrome (IRIS) with worsening of the signs of TB. Children with marked immune suppression are at greatest risk of this complication.

Note

Even the protein remaining in dead TB bacilli may cause the immune reconstitution inflammatory syndrome.

6-28 What should be done if a child on antiretroviral treatment develops tuberculosis?

The antiretroviral treatment must be continued and anti-TB treatment started. However, the antiretroviral regimen may require modification e.g. if the child is on a lopinavir/ritonavir-containing regimen then it should be boosted with additional ritonavir, and if treated with DTG change from daily to twice daily dosing. The child should be carefully monitored for signs of drug interactions and side effects. It is important to exclude TB before starting antiretroviral treatment.

6-29 How do drugs used to treat tuberculosis and HIV interact with each other?

Rifampicin is the usual cause of adverse drug interactions. Rifampicin affects the blood levels of many antiretroviral drugs, especially the ‘non-nucs’ and PIs. Rifampicin stimulates liver enzymes which, as a result, increase the rate of breakdown of these antiretroviral drugs. This leads to low blood levels of these antiretroviral drugs which may prevent them killing HIV. Therefore the choice of antiretroviral drugs and their doses may need to be changed.

The choice and dose of antiretroviral drugs may have to be changed if rifampicin is used to treat tuberculosis.

6-30 What antiretroviral drug changes may be needed if rifampicin is given?

• If NVP is being used, it should be replaced with EFV, which is less affected by rifampicin.
• If lopinavir/ritonavir is being used, it should be boosted with additional ritonavir to maintain adequate blood levels.
• If DTG is used then change from daily dosing to twice daily dosing.

These decisions should be made by an experienced clinician. Not making these changes may lead to drug resistance and failure of antiretroviral treatment.

Table 6-1: Dose of ritonavir for boosting standard dose of lopinavir/ritonavir in children also receiving rifampicin.

Body weight	3-4.9 kg	5-13.9 kg	14-19.9 kg	20-24.9 kg	25-29.9 kg	30 and above kg
Twice daily dose	1 ml	1.5 ml	2 ml	2.5 ml	3 ml	4 ml

6-31 What are the shared side effects of the drugs used to treat tuberculosis and HIV?

Nausea, rash, hepatitis and peripheral neuropathy. As a result these side effects are commoner and may be more serious if the two drug regimens are used together. This may result in a change in the choice of antiretroviral drugs. Careful monitoring is needed for these side effects.

Drug side effects are more frequent and may be severe if anti-tuberculous and antiretroviral treatments are given together.

6-32 How may taking many tablets cause problems?

Adherence may be poor when so many medicines need to be taken. There may also be confusion about the dosing instructions of the many different medicines. Patients should be told they will have to take a large number of medicines and be counselled about these possible problems. A clearly written plan for both anti-TB and antiretroviral treatment is essential. Additional support may be necessary to ensure adherence such as additional counselling and education sessions, more frequent clinic visits, or using a ‘treatment buddy’ or DOTS advocate.

6-33 What is the role of TB prophylaxis?

All HIV-infected children, irrespective of age, who are exposed to TB through a household or close contact should be considered for TB prophylaxis, provided active TB is excluded.

6-34 When are anti-tuberculous drugs given prophylactically to HIV-infected children?

All clinically well HIV infected children irrespective of age who have been in contact with someone who has smear-positive pulmonary TB should be given prophylactic treatment. These young children are at very high risk of developing TB.

Children under five years who are clinically well but have a positive Mantoux skin test (10 mm or more) should also be started on anti-TB treatment.

Currently, prophylaxis consists of INH for six months. The treatment is given daily for seven days a week using the same dose as for short-course treatment. It is important to exclude active TB before starting prophylaxis.

6-35 What neurological infections are common in HIV-positive children?

• The most important neurological complication is HIV encephalopathy. The cause is uncertain but it is probably due to an infection.
• Bacterial and tuberculous meningitis are also common.
• Cerebral toxoplasmosis, cryptococcal meningitis, CMV retinitis and progressive multifocal leukoencephalopathy (PML) are less common in HIV-infected children compared to HIV-infected adults.

6-36 What are the clinical features of HIV encephalopathy?

These children present with delayed milestones and develop neurological signs such as weakness, brisk reflexes, increased tone and gait disturbance. The expected growth in head circumference may slow down. The diagnosis is confirmed by CT brain scan.

Delayed neurological milestones may be a sign of HIV encephalopathy.

End-of-life care

6-37 What is palliative care?

Palliative care is the care of patients who have an incurable disease (such as AIDS). It also addresses the needs of the family. It aims at reducing suffering and improving the quality of life in these patients so that they can still have a good life for as long as possible. Palliative care starts at the time of the diagnosis and addresses all the patient’s physical, emotional, social and spiritual needs. Although HIV infection cannot be cured, most of the HIV-associated conditions can be prevented or adequately treated and controlled. HIV infection has now become a chronic, manageable condition.

Palliative care addresses the physical, emotional, social and spiritual needs of people with an incurable disease.

6-38 What is terminal care?

In contrast, terminal care (or end-of-life care) is the active care of patients whose disease no longer responds to treatment. Terminal care is not the same as no care or poor care. Patients who are dying of AIDS need terminal care. Care should never be withdrawn because there is no longer any hope for cure.

Terminal care is the supportive care of patients who have a serious illness that no longer responds to treatment.

6-39 Do children with advanced HIV infection need terminal care?

Yes. As with adults dying of AIDS, there is an enormous need for terminal care for these children. Terminal care is most needed for children who are likely to die within months or weeks. Their families and carers also need support.

6-40 Where should terminal care be provided?

Home care is the basis of terminal care. If at all possible these children should be cared for in their own home where they are comfortable in their own surroundings and with their family and friends. Only if this is impossible should they be given care in an institution, preferably in a hospice. Hospital admission should be avoided if possible. Community helpers can be trained to provide basic nursing and provide extra help in the home (shopping, cooking, cleaning).

Terminal care should be provided at home if possible.

6-41 What is a hospice?

This is a place where terminally ill patients can be cared for. Management is aimed at compassionate care and support rather than cure. Members of a hospice team also help to care for patients who are at home.

6-42 Who should provide terminal care?

As there are so many aspects to terminal care, it is best provided by a team of people who are trained in this special type of care. A multidisciplinary approach is needed to meet the many different physical, psychosocial and spiritual needs of terminally ill children. Patients, family and friends also have a very important role in terminal care. However, they need professional support to enable them to play their role in helping the child.

6-43 What are the goals of terminal care?

To improve the quality of care of children, and their families, who are facing death. The goal of terminal care is not necessarily to prolong life, but to offer prevention and relief of suffering.

The goal of terminal care is to prevent and relieve suffering.

6-44 What does terminal care involve?

• Controlling unpleasant symptoms, especially pain
• Reducing the side effects of drugs used
• Treating HIV-associated infections
• Supporting the patient, family and friends
• Giving patients and families control over the management

6-45 What physical problems need to be addressed with terminal care?

• Nutrition
• Pain
• Discomfort

6-46 What are the nutritional needs in children with terminal HIV infection?

These children are often wasted and very underweight. They may also have a poor appetite, nausea and difficulty swallowing. As a result it is often difficult for them to eat or drink.

High calorie and protein foods are important. It is important that these children are able to choose whichever foods they prefer. If possible, intravenous fluids or nasogastric feeds should be avoided. Soft or liquid foods are best.

6-47 Is pain a common problem in patients with advanced HIV infection?

Yes, severe pain is very common in children who are dying of AIDS. It is likely to be underdiagnosed and undertreated. Pain significantly reduces the quality of life and results in fear and despair. Pain also causes distress to the family.

Severe pain is a major problem in children who are dying of AIDS.

6-48 What are the principles of pain relief?

• The correct choice and dose of analgesia (pain relief) is important.
• Analgesics (drugs to relieve pain) should be given regularly (‘by the clock’) to both prevent and treat pain.
• Oral analgesia should be used whenever possible.
• Give clear written instructions.
• Assess the amount of pain and review the pain management frequently.
• Manage factors which aggravate pain such as fear.

The aim of pain management is to control pain by giving analgesia regularly so that pain can be prevented.

The aim of pain management is to prevent pain.

6-49 How is pain assessed in children?

Older children can say when they have pain. The assessment of pain in young children is dependent on observing the child’s behaviour and looking at their facial expression. Family and carers are usually good at assessing the degree of pain.

6-50 How is the severity of pain graded?

Into mild, moderate and severe. This is important, as the choice of analgesic is dependent on the severity of the pain.

6-51 What common analgesics are used to control pain?

• For mild pain: Paracetamol (Panado) and ibuprofen (Brufen). The dose of paracetamol is 20 mg/kg stat then 15 mg/kg four to six hourly (maximum: 4 grams per day). Syrup contains 120 mg/5 ml while tablets are 500 mg each. The dose of ibuprofen is 20 mg/kg/day in divided doses. Paracetamol and ibuprofen should be given every four to six hours as required. Aspirin must be avoided.
• For moderate pain: Tilidine HCl (Valoron) 1 mg/kg per dose 6 hourly. Often paracetamol or ibuprofen are used in addition.
• For severe pain: Oral morphine solution starting at 0.3 to 0.4 mg every four - six hours. If necessary morphine may be administered by intravenous infusion.

The choice of analgesics in an individual depends on their degree of pain. As pain increases one moves up the ‘treatment ladder’ from step 1 (non-opioids such as paracetamol and ibuprofen) to step 2 (weak opioids such as tilidine) to step 3 (strong opioids such as morphine).

Note

For the Valoron dose in drops, divide the child’s body weight in kg by 2.5. Each Valoron drop contains 2.5 mg of tilidine HCl.

6-52 How is morphine used?

If possible it should be given orally. A dose must be given every four hours as the action of morphine is short. Give an extra dose equivalent to the four-hourly dose if the pain is not controlled. Giving extra doses for ‘breakthrough’ pain is very important. The starting four-hourly dose is 2.5 to 5 mg for children of one to five years and 5 to 10 mg for older children. Add up the total amount of morphine given in 24 hours (four-hourly dose plus any extra doses) to calculate the four-hourly dose for the next day. There is no maximum dose. The correct dose is the dose which is effective in controlling the pain. Therefore the dose of morphine should be titrated against the degree of pain.

Morphine can also be given intravenously or intramuscularly, but preferably by continuous subcutaneous infusion with a syringe driver.

Frequent doses of oral morphine are the most effective form of pain relief.

6-53 What common problems occur with morphine?

• All patients on morphine develop constipation. Fruit, bran and extra fluids are helpful. Laxatives such as liquid paraffin 5 to 10 ml daily and senna (Senokot) 5 to 20 mg daily should be used. Constipation does not improve with continued use of morphine and is the major side effect. Morphine may be useful in controlling chronic diarrhoea.
• Nausea and drowsiness. This improves with time (tolerance) and responds to a lower dose.

Addiction is not of concern when morphine is used to control pain in terminally ill patients. Do not stop morphine suddenly, however, as this may result in withdrawal symptoms. Respiratory depression is uncommon when morphine is used to control pain.

6-54 What common mistakes are made in treating pain?

• Morphine is used too late.
• The dose of analgesic is too low.
• Medication is not given frequently or regularly enough.
• Medication is only used to treat rather than prevent pain.

6-55 What other forms of discomfort are common in severe HIV infection?

• Anorexia, nausea and vomiting
• Diarrhoea
• Constipation
• Cough and shortness of breath
• Itchy or dry skin
• Fatigue and weakness
• Lack of sleep
• Bed sores
• Incontinence

A syndromic approach is often used in terminal care when the symptoms are managed even if the underlying cause cannot be treated. Help from hospice staff is very useful in preventing and managing most of these problems.

6-56 What can be used to treat nausea?

Nausea is a common problem, especially when treatment with morphine is started. Metoclopramide (Maxolon) 1 to 5 mg (for children of two to 10 years) orally eight-hourly is helpful.

6-57 How can treating HIV-associated infections improve the quality of life in a patient dying of AIDS?

Improving the symptoms caused by HIV-associated infections can greatly improve the quality of the last weeks of life. For example, treating painful mouth ulcers or improving painful swallowing by managing fungal oesophagitis.

Relief of symptoms is often best achieved by treating HIV-associated infections.

6-58 Is it worthwhile treating children who are dying?

This is often a very difficult question to answer. Sometimes it may be realistic not to treat terminally ill children if the treatment will only prolong their suffering. However, pain, discomfort and distress must always be aggressively managed. Both children and their parents should never be allowed to feel abandoned by their health carers.

The question that must always be asked is: ‘Will this make a difference to the quality of the child’s life?’

6-59 What are the psychological aspects of terminal care?

Anxiety and depression are common in terminally ill children and are often not recognised. It is important to manage anxiety and depression as they both aggravate pain. Children need comfort and love and should never feel abandoned or isolated. Physical touch (holding, stroking, cuddling) and emotional closeness are very important.

Anxiety and depression make pain worse.

6-60 Do children understand the concept of dying?

Young children think that dying is like falling asleep and do not understand that dead people do not wake up again. Older children are afraid of being separated from their parents. Children are often more accepting of death than adults and do not understand all that death means. Their questions should be answered simply and honestly.

6-61 How do children manage the death of a parent?

Unfortunately many children are losing parents to AIDS. They may even lose both parents. This is very traumatic and these children need an enormous amount of help and support. This is best provided by family and close friends. Siblings of dying children must not be forgotten as they also need help to talk about and accept the death. Dying parents need help to say farewell to their children.

6-62 What is a memory box?

This is a simple box that parents can store mementos in for their children. Photographs, letters and cards are kept in the box which is given to the children when they are older, to help them remember a parent who has died of AIDS. A memory box is one of the many ways that a parent can prepare themselves before death separates them from their children.

6-63 Do the carers need care themselves?

Yes. This is often forgotten or not realised. Care of the carers (both family and health workers) is a very important part of terminal care. It is physically and emotionally exhausting to care for a terminally ill patient. Signs of depression are often missed.

Case study 1

A three year old child is brought to a primary-care clinic with failure to thrive, dehydration, oral candidiasis and a one-week history of pain and difficulty in swallowing. It is noted that she has extensive severe scabies. A rapid HIV test is positive.

1. Is oral candidiasis common in children with HIV infection?

Yes. It is one of the first presentations in children with HIV infection. It is uncommon to get oral candidiasis (thrush) in children older than two months who have a healthy immune system. Oral candidiasis can usually be successfully treated with mycostatin drops 1 ml or miconazole gel six-hourly after a feed or meal.

2. What is an HIV-associated infection?

This is any infection which is more common in children who have a suppressed immune system due to HIV infection. Therefore, oral candidiasis is an HIV-associated infection.

3. Why do you think this child is having difficulties with swallowing?

She almost certainly has oesophageal candidiasis. These children have pain and difficulty with swallowing and may drool saliva. They are hungry and thirsty but unable to swallow liquids or food. It is very important to look for signs of dehydration.

4. How should oesophageal candidiasis be treated?

This child must be given fluids intravenously or via a nasogastric tube. Usually oesophageal candidiasis is treated with oral fluconazole for 2 to 3 weeks, depending on the clinical response. It may be necessary to give intravenous fluconazole for a few days until the child can swallow the medication. Treating the oral candidiasis alone will not help. Analgesia should be given as the condition is painful.

5. Is oesophageal candidiasis an AIDS-defining infection?

Yes, as it would be graded as stage 4 HIV infection.

6. Why does this child have extensive scabies?

Extensive scabies is common in HIV-infected children because of their weakened immune system. Many other skin infections, such as molluscum, warts, chickenpox, herpes, tinea and impetigo may also be severe and respond poorly to standard treatment.

Case study 2

A nine-month-old child is brought to a local hospital with an acute onset of cough, high fever and shortness of breath. The mother was found to be HIV-positive when screened during pregnancy but was not given prophylactic antiretroviral treatment. On clinical examination the child had clinical signs of pneumonia. There were also many small, painful ulcers on his mouth.

1. What is the likely cause of the pneumonia?

He may have a viral or bacterial pneumonia. However, he is most likely to have Pneumocystis pneumonia which is common in young infants who are HIV infected. TB pneumonia usually does not have an acute onset while lymphoid interstitial pneumonia is usually seen in older children. A chest X-ray will confirm the pneumonia but often does not help to identify the cause.

2. What would be the correct treatment of this child?

Pneumocystis pneumonia is usually treated with intravenous cotrimoxazole for 21 days. If drip access becomes difficult the antibiotic course may be completed with oral cotrimoxazole. Oral treatment can be used from the start if intravenous cotrimoxazole cannot be started. Additional antibiotics may be added to treat bacterial pneumonia (e.g. ampicillin plus gentimicin). The selection of antibiotics is dependent on the suspected organism. Steroids are given for presumed Pneumocystis pneumonia.

3. Which HIV-infected children develop Pneumocystis pneumonia?

Children with stage 4 disease as Pneumocystis pneumonia is an AIDS-defining infection.

4. How can this condition be prevented?

By starting all HIV-exposed children on prophylactic cotrimoxazole from six weeks of life. It should be continued unless the diagnosis of HIV infection is excluded.

5. What is the most likely cause of the mouth ulcers?

Probably Herpes simplex causing severe stomatitis. Severe aphthous ulcers, necrotising ulcerative gingivitis and oral candidiasis can also cause a sore mouth.

6. What is the treatment of Herpes stomatitis?

Topical gentian violet or 0.1% povidone-iodine (Betadine mouth wash) may be used while oral acyclovir is indicated for large ulcers. Paracetamol can be given for pain. It is important to make sure that these children take enough liquids and do not become dehydrated.

Case study 3

While being prepared for antiretroviral treatment, a 5 year old child has a positive Mantoux skin test and signs of TB on his chest X-ray. The sputum is negative for TB on Xpert MTB/RIF Ultra but sputum is sent off for culture. The CD4 count is 20%. His mother asked when antiretroviral treatment will be started.

1. Should this child be started on antiretroviral treatment now?

TB treatment should be started as soon as possible and antiretroviral treatment started 2 to 8 weeks later. In children with advanced HIV infection it may be necessary to start antiretroviral treatment soon after starting TB treatment. It is important to screen all children for TB before starting antiretroviral treatment.

2. Why is it a problem to start TB and HIV treatment at the same time?

Because of the risk of immune reconstruction inflammatory syndrome (IRIS). When the immune system starts to recover with antiretroviral treatment, there may be a severe inflammatory response to TB bacilli. The risk of IRIS is much less after two months of anti-TB treatment.

3. Why is the Xpert MTB/RIF Ultra test negative in this child?

This is not uncommon in children with TB. In children with HIV infection and TB, the Mantoux skin test may also be negative. Even the chest X-ray may appear normal. Therefore, the diagnosis of TB can be difficult in children with HIV infection.

4. Is tuberculosis common in children with HIV infection?

Yes. It is one of the commonest HIV-associated infections. Children with pulmonary TB are classified as stage 3 while extra-pulmonary TB is classified as stage 4.

5. What are the typical presenting symptoms and signs of pulmonary TB?

A persistent cough for more than 2 weeks in a child who is generally unwell. Poor appetite, weight loss and fever are common.

6. When should prophylactic INH be used?

When HIV-infected children, who have no signs of TB, are exposed to an adult with TB in their home. It is also given to children under five years who are clinically well but have a positive Mantoux skin test. It is important to exclude TB before starting prophylaxis.

Case study 4

A 7 year old boy has been on antiretroviral treatment for two months. He develops a cough and a chest X-ray suggests pulmonary TB. A grandfather at home has recently been diagnosed with TB. The medical officer is not sure whether she should stop antiretroviral treatment and start TB treatment.

1. How should this child be treated?

It is important not to stop antiretroviral treatment. Anti-TB treatment should be started. The child must be carefully monitored for signs of adverse effects (side effects) such as hepatitis. It would be best if this child was under the care of a doctor experienced in managing patients with HIV and TB co-infection.

2. What is the TB treatment regimen in children with HIV Infection?

Rifampicin, INH, pyrazinamide and ethambutol are given for two months followed by rifampicin and INH only for a further four months. This treatment course may take longer than that used in children without HIV infection. If the chest X-ray at six months does not show adequate clearing the maintenance treatment should be continued for an additional three months.

3. What adverse drug interactions may occur?

Rifampicin is the usual cause of adverse drug interactions when HIV and TB are treated at the same time. Rifampicin lowers the blood level of many drugs, especially NVP, lopinavir/ritonavir and DTG. Therefore, NVP is usually swapped for EFV, extra ritonavir is added to the lopinavir/ritonavir treatment and DTG dosing frequency is changed to twice daily. Not making these changes may lead to drug resistance and failure of antiretroviral treatment.

4. What shared side effects occur with combined anti-TB treatment and antiretroviral treatment?

Side effects are more common and severe when both treatment regimens are used together. Nausea, rash, hepatitis and peripheral neuropathy may be caused by both anti-TB treatment and antiretroviral treatment. It is important to monitor children for these side effects.

5. Can taking so many different medications cause a problem?

Yes. It increases the chance of poor adherence and making mistakes with taking the medication correctly.

6. Can TB cause neurological complications?

TB is an important cause of meningitis in children with HIV infection.