2 Childhood HIV
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When you have completed this chapter you should be able to:
- Understand the meaning of HIV and AIDS.
- Explain how children can become infected with HIV.
- Understand how HIV infection is diagnosed.
- List the steps in managing a child with HIV infection.
- Understand the importance of taking HIV medicines (ART) correctly every day.
- Support families with an HIV infected child.
HIV and Aids
2-1 What is HIV?
HIV stands for Human Immunodeficiency Virus. This is a virus (a germ) which attacks and damages the body’s immune system which normally protects the person from severe infections. As the immune system becomes deficient (weak), the person is at high risk of developing a number of serious infections.
2-2 What is AIDS?
AIDS stands for Acquired Immuno-Deficiency Disease. AIDS is a severe, chronic illness caused by HIV infection. It only presents when the immune system is seriously damaged by the HIV infection. Then these children become ill with a wide range of viral, bacterial and fungal infections which can kill them.
The term AIDS is only used for the most severe stage of HIV infection. Therefore the term HIV infection is used for most children who are infected with HIV.
2-3 How does HIV damage the immune system?
HIV kills important cells in the immune system which normally protect the body from serious infections. These protector cells (“soldier cells”) are called CD4 cells. Over time the number of protector cells decreases until there are not enough left to fight off other germs which can infect the child and cause serious illness. Children do not become sick as soon as they are infected with HIV as it takes time for HIV to reduce the number of protector cells.
HIV infection damages the immune system.
2-4 How may children become infected with HIV?
There are 2 important ways that HIV can infect children:
- HIV may cross from the mother to her child during pregnancy, delivery or breast feeding.
- Children or adolescents may become infected with HIV due to sexual transmission.
2-5 Can HIV infection in children and adolescents be prevented?
- By screening all pregnant women for HIV when they book for antenatal care.
- By starting the HIV infected women on HIV medicines (ART) for life.
- By giving HIV exposed newborn infants HIV prophylaxis after delivery.
- By screening all HIV exposed infants for HIV infection.
- By adolescents practicing safe sex.
Most HIV infection in children and adolescents can be prevented.
2-6 Is HIV infection a common cause of death in children?
In South Africa, HIV infection was once a common cause of death in children. However the number of deaths has fallen dramatically due to:
- Reducing HIV transmission from mother to child.
- Early screening of infants to detect those with HIV infection.
- Early lifelong treatment of all HIV infected children.
While HIV infection during pregnancy, delivery and breastfeeding has fallen, the number of adolescents, especially young girls, becoming infected with HIV remains high.
2-7 When do children become sick if they are infected with HIV during pregnancy, delivery or breastfeeding?
Children who are infected during pregnancy may become sick within weeks after birth. However if they are infected during labour or while breastfeeding they usually only become sick a few months or years after they are infected with HIV.
2-8 When do children or adolescence become sick if they are infected by sexual transmission?
They become sick months or even years after the time of infection. The time it takes for a child to become sick after being infected with HIV is longer if they are infected when they are older.
Diagnosing HIV infection
2-9 How is HIV infection diagnosed in children?
With a blood test. The test used depends on the child’s age:
- If the child is under 18 months the HIV PCR test is used.
- If the child is 18 months or older the adult HIV rapid test is used.
A blood test is used to diagnose HIV infection.
2-10 Can you always tell that a child has HIV infection by examining them?
No, as they may appear well for weeks, months or even years after they are infected with HIV. This is because it takes time before HIV damages their immune system. Only when the immune system is damaged do they develop other infections and become ill.
2-11 How do children present with HIV infection?
HIV infection may present in many different ways such as:
- Weight loss or failure to gain weight normally
- Sore mouth due to severe oral thrush (caused by monilia)
- Difficulty swallowing due to thrush spreading to the throat
- A cough for more than 2 weeks
- Fast breathing due to pneumonia
- Chronic loose stools (diarrhoea)
- A severe skin rash
If a child is seriously ill or is sick for longer than 2 weeks, HIV infection may be a probable cause. The mother may be known to be HIV positive.
2-12 How can the severity of the HIV infection be assessed at the clinic?
- By the clinical appearance of the child. If the child is very sick the HIV infection is probably severe.
- By measuring how much HIV is present in the child’s blood. This is called the viral load. A child with severe HIV infection will have a lot of HIV in the blood and therefore will have a high viral load. If no virus is found in the blood (an undetectable viral load) the HIV infection is controlled. The aim of treatment is to get an undetectable viral load.
- By measuring how many protector cells (CD4 cells) are present in the blood. A normal number of protector cells indicates that the immune system is healthy. However a low number of protector cells suggests that the immune system has been weakened by the HIV infection.
A child with severe HIV infection will look sick, have a lot of HIV in their blood (a high viral load) and few protector cells (a low CD4 count). Once treatment is started the child should look better, the virus should disappear from the blood and the number of protector cells increase and return to normal.
2-13 Is TB common in children with HIV infection?
Yes. TB (tuberculosis) is one of the serious infections which is common in children who have a damaged immune system caused by HIV infection. Children with HIV infection are at high risk of getting TB if there is an older member of the family in the home who is coughing due to untreated TB.
TB is common in children with HIV infection.
2-14 What should you do if you think a child may have HIV infection?
Refer the child urgently to the nearest clinic so the child can be examined and screened with a blood test for HIV.
2-15 Is consent needed before a child has an HIV test?
Yes. Usually a parent or guardian will give consent. In South Africa adolescents of 12 years or more can give their own consent without needing the consent of a parent or guardian. However it is preferred that a parent or guardian can give consent (depending on circumstances).
2-16 Should counselling be given before getting consent for HIV testing?
The person giving consent should be fully informed about HIV infection so that they understand why the HIV test is needed and what it means to be a child with HIV infection. Well-trained Community Health Workers may help clinic staff with counselling parents and older children.
Managing a child with HIV infection
2-17 How is a child with HIV infection managed?
There are a number of important steps when a clinic starts to treat a child with HIV infection:
- Always confirm the clinical diagnosis with a blood test.
- Start antiretroviral treatment (ART).
- Treat any other problems (complications).
- Improve nutrition.
- Support the family.
A Community Health Worker can help the nurses and family in each of these steps.
2-18 Should all children with HIV infection be given treatment?
Yes. All HIV infected children must be given antiretroviral treatment even if they appear perfectly well.
All children with HIV infection should be treated for life.
2-19 What is antiretroviral treatment?
Antiretroviral treatment is usually called ART because HIV is classified by scientists as a retrovirus. ART uses a number of medicines together to control the HIV and allow the immune system to slowly recover. These HIV medicines (ART) have changed the lives of children infected with HIV.
There is no evidence that traditional medicines can cure HIV infection.
2-20 Can HIV infection be cured?
Unfortunately it cannot. However treatment can control HIV with an undetectable viral load and allow the child to remain well for many years. In future new medicines may be discovered which will be able to cure HIV infection. At present children with HIV infection, who take their medicine correctly, can be expected to remain well and live into adulthood. There is no evidence that traditional medicines can cure HIV infection.
2-21 What medicines are used to treat HIV?
Usually 3 medicines are used together to treat HIV infection by lowering the viral load. Using 3 medicines makes the treatment more effective than using only 1 medicine. It also helps to prevent HIV becoming resistant to the treatment. With resistance the medicines are no longer effective.
The choice of the best 3 medicines depends on the child’s age and weight. The 3 medicine combination changes when the child reaches 3 years of age and weighs more than 10 kg.
As children grow and gain weight the dose of HIV medicines (ART) needs to be increased.
2-22 How are the HIV medicines given?
They are all given together every day. Some medications are taken once a day usually in the morning after breakfast while others are taken twice a day. It is very important that the medicines are taken correctly in the right dose, at the right time every day.
It is important to keep HIV medicines (ART) away and out of reach of small children to avoid accidental poisoning with an overdose.
2-23 What is good adherence?
Good adherence means that the child takes their medicine correctly every day for the rest of their life. Good adherence is very important as it is needed to control the HIV infection. Poor adherence is the commonest cause of drug resistance and treatment failure. Missing more than one daily dose a week can lead to treatment failure. With drug resistance the ART no longer controls HIV. This is an important cause of death. It must be prevented by taking HIV medicine (ART) correctly.
Good adherence to HIV medicines (ART) is very important.
2-24 How can parents be helped to remember to give the medicines every day?
Community Health Workers should play an important role in making sure that children are given their HIV medicine (ART) correctly:
- Parents and older children should understand how important it is to give the medicine every day.
- They should have a list (home record card), calendar or diary where they can record when the medicine has been given.
- For older children taking tablets they can use a pill box where the daily tablets are counted out beforehand at the start of the week.
- Cellphones can be used to remind parents.
- A Community Health Worker or responsible neighbour or family member can remind them each morning or even take responsibility of giving the medicine themselves.
2-25 Do HIV medicines cause adverse effects?
Most children do not have adverse effects (side effects) to HIV medicines (ART). However it is important that parents know what adverse effects to be aware of. Uncommon but serious adverse effects include a rash, abdominal pain and vomiting. If a child develops adverse effects they should be taken to the clinic for urgent assessment.
2-26 When should children on HIV medicines attend their local clinic?
There are 3 reasons for these children to go to the clinic:
- For routine follow up visits.
- To collect HIV medicines (ART).
- If there is a problem such as an adverse effect.
2-27 What are routine follow up visits?
All children on HIV medicines (ART) need to visit the clinic according to a schedule of follow-up visits. At these visits the child’s general health, growth and development are assessed. The medication dosage is adjusted according to the weight of the child. A number of blood tests are done to make sure that HIV is under control and to check for adverse effects of the treatment. It is very important that these children attend all their scheduled visits.
Community Health Workers should make sure that these appointments are kept.
2-28 When should medicines be collected?
Usually once a month. It is very important that the child does not run out of HIV medicines (ART). Stopping and starting HIV medicines (ART) leads to drug resistance and then the medicine no longer controls the HIV.
2-29 What other treatment is needed for HIV infected children?
They may need medicine to prevent or treat other infections which can be a complication of HIV infection. For example they may need treatment for TB or oral thrush. These medicines must be given correctly.
2-30 Should HIV infected children be immunised?
Yes. They should receive all the standard immunisations at the time stated by the national immunisation programme. They should also receive the scheduled vitamin A and deworming.
HIV infected children should be fully immunised.
2-31 How should the children’s growth be monitored?
At every clinic visit the child should be weighed and the weight plotted on the growth chart in the Road to Health booklet. Children on HIV medicines (ART)should grow normally. If the weight gain is poor a cause must be looked for and treated. HIV infected children from poor homes may need food parcels or a social grant. Good nutrition is very important as it helps to strengthen the immune system.
2-32 What is family-centred care?
With family-centred care the whole family must be considered and managed, and not only the child. The family must be fully informed as the child depends on them to give the medicines correctly and look out for adverse effects.
All family members must be encouraged to know their HIV status.
The Community Health Worker should not share confidential information about the family except with other members of the health care team.
2-33 When should children be responsible for taking their own medication?
As children get older they should start shared responsibility for taking their medicine correctly. Adolescents want to be independent and should be encouraged and supported to take control of their medicines.
2-34 At what age should children be told they have HIV infection?
HIV infected children soon realise that they are different from other children as they need to take medicine every day. Once they start asking why they need medicine the parents can slowly start giving them information at a level that they can understand.
Giving a child information about their HIV infection should be done step by step as with giving a child sex education or telling a child that they are adopted. A Community Health Worker can help if parents find this difficult.
2-35 How can HIV infection in adolescents be prevented?
- Good sex education for all children.
- Keep children in school.
- Delay the time of first sex (sexual debut).
- Always practice safe sex with condoms.
- Learn how to negotiate safe sex.
- Form adolescent support groups.
- Create an environment where adolescents are not exposed to harmful relationships especially with adults.
Community Health Workers can help with providing information and counselling to parents and adolescents.
2-36 What role can community health workers play in managing a child with HIV infection?
A Community Health Worker can play an important role managing a child with HIV infection. They can:
- Help the family understand HIV infection and explain the importance of taking medicine correctly.
- Help promote excellent adherence.
- Make sure that the child is taken for all routine clinic visits.
- Provide routine immunisations, vitamin A and deworming.
- Monitor growth and development.
- Inform the family about adverse effects of the HIV medicines (ART).
- Encourage all family members to know their HIV status.
- Counsel and support the parents of a child with HIV infection.
Community health workers can play a very important role in managing a child with HIV infection.
Case study 1
A mother takes her 4-year-old child to a clinic because he has been losing weight and coughing for the past month. TB is diagnosed. An HIV test is done and the result is positive. The child also has a sore mouth. The mother asks the nurse a number of questions.
1. Is HIV the cause of her child’s TB?
HIV does not cause TB but many children with HIV infection commonly develop TB.
2. Why do many children with HIV infection get TB?
Because HIV infection weakens the immune system by decreasing the number of protector cells (CD4 cells) which are needed to fight infections. As a result children with HIV infection are at a great risk of getting TB.
3. What may be the cause of the sore mouth?
Oral thrush. This is one of the infections commonly seen in HIV infected children.
4. How do you think this child became infected with HIV?
He was probably infected via his mother’s breast milk. These children only become sick a few months or years after they became infected with HIV.
5. Could the HIV infection in the child have been prevented?
Yes. The mother should have been screened for HIV when she started antenatal care so that she could have been started on lifelong HIV medicines (ART). The child should also have had HIV prophylaxis after birth. This will prevent the HIV crossing to the child.
Case study 2
A 6-month-old child is diagnosed with HIV infection. After counselling the parents at the clinic the child is started on HIV medicines (ART). The parents are told that it is very important to give the HIV medicines (ART) every day.
1. How many medicines are usually used to treat HIV?
Three HIV medicines (ART) are used together. Treatment with 3 medicines is much more successful than only 1 or 2 medicines.
2. When should the treatment be given?
They must all be given together by mouth every day, usually after breakfast. Giving the treatment correctly every day is called good adherence.
3. What role can a community health worker play in getting good adherence?
The community health worker must explain to the parents why giving the medicine correctly every day is very important. With good adherence and adequate nutrition the child will grow and develop normally. Parents can use a treatment diary or pill box to help them remember and record correct treatment.
4. Why should this child be followed up at the clinic?
- To collect medicine monthly.
- To increase the dose of medicine as the child gains weight.
- To make sure that the medicine is being given correctly.
- To monitor growth and development.
- For routine blood tests.
- To look for adverse effects.
- To support the parents.
5. Are adverse effects common in children on HIV medicines?
No. Adverse effects are less common in children than adults. If the child develops a rash, abdominal pain or vomiting they should be taken urgently to the clinic.
Case study 3
A grade 8 teacher asks a community health worker to help her set up a discussion group of pupils to help them learn about HIV infection and how to prevent getting infected.
1. How may older children and adolescents become infected with HIV?
Through sexual abuse or by engaging in unprotected sexual intercourse.
2. Are these common causes of HIV infection in South Africa?
3. What other chronic infection commonly complicates infection with HIV?
4. Who should be responsible for a teenager taking their medicine correctly?
They should be fully informed about HIV and encouraged to take responsibility for taking their medicine correctly every day. This will be needed for the rest of their lives.
5. What is the danger of not taking HIV medicines correctly?
Resistance to the medicines and treatment failure. This may result in death due to the uncontrolled viral load.