- Common symptoms of HIV infection in children
- The course of HIV infection in infants and children
- Making a diagnosis of HIV/AIDS when HIV testing is unavailable
- Care for infants and children with HIV-related illness
- Children orphaned by AIDS
The number of children under 15 who have lived or are living with HIV since the start of the epidemic in the late 1970's has reached about 4.8 million - 3.6 million of them have already died. Nearly 600 000 children were infected with HIV in 1999, mostly through their mothers before or during birth or through breast feeding (vertical transmission).
- the unborn child (in utero infection)
- neonates during labour and delivery (intrapartum infection)
- neonates, when exposed to infected maternal birth fluids
- infants, after birth, through breast milk (post partum infection) (30 percent risk of transmission)
- transfusion with HIV-contaminated blood or blood products
- use of non-sterile equipment in health care facilities
- use of non-sterile equipment by traditional healers (surgeries, male and female circumcisions, scarification)
- sexual abuse
- injecting drugs
- sexual initiation practices involving sex workers
- child prostitution
The lives of children who do not have HIV themselves are affected when family members have AIDS. Families face increased poverty and stress because adults have to leave their paid employment, or are too sick to farm their land. Women may be ill themselves, as well as caring for other sick family members and looking after young children.
Girls in particular often become the care providers for sick relatives and their brothers and sisters. Sometimes children have to leave school to look for work or care for other family members. In addition, denial or neglect of girls' human rights results in gender discrimination, giving young women little access to socioeconomic opportunities. These girls (and boys to a lesser extent) often become vulnerable to commercial sex and to the drug trades.
Common symptoms of HIV infection in children
HIV-infected children have an increased frequency of common childhood infections such as ear infections and pneumonia. In developing countries, diseases such as chronic gastroenteritis and tuberculosis are also frequent. In HIV-infected infants, the symptoms common to many treatable conditions, such as recurrent fever, diarrhea and generalized dermatitis, tend to be more persistent and severe. Moreover, HIV-infected infants do not respond as well to treatment and are likely to suffer life-threatening complications. Enlarged lymph nodes and an enlarged liver are common in children infected with HIV. Opportunistic infections occur as the immune system becomes more affected, and most of these children have some type of neurological involvement, such as developmental delay or infection in the brain.
The course of HIV in infants/children
The majority of infected infants develop disease during the first year of life and have a high mortality rate. With recent research and new antiretroviral therapies (ARVs), there has been significant improvement to child mortality in countries where this treatment is available and accessible.
The diagnosis of pediatric AIDS is difficult. In addition, in developing countries, diagnostic procedures might not be available or routinely used. Different countries might show slightly different patterns of the opportunistic infections that are common in HIV-infected children.
- Weight loss
- Chronic diarrhea
- Failure to thrive
- Oral thrush (This often recurs after treatment and can be the first indication of HIV infection.)
Making a diagnosis of AIDS in children when HIV testing is not available
In infected women, the maternal HIV antibody is passively transmitted across the placenta to the fetus during pregnancy. This antibody can persist in the infant for as long as 18 months. Consequently, during this period, the detection of HIV antibody in infants does not necessarily mean that an infant is infected. Therefore, a case definition for AIDS is made in the presence of at least 2 major, and 2 minor signs.
- weight loss or abnormally slow growth
- chronic diarrhea for more than 1 month
- prolonged fever for more than 1 month
- generalized lymph node enlargement
- fungal infections of mouth and/or throat
- recurrent common infections (eg. ear, throat)
- persistent cough
- generalized rash
Please note: Confirmed HIV infection in the mother counts as a minor criterion.
Care for infants and children with HIV-related illness
Most HIV-related illness is caused by common infections which can be prevented or treated at home or in a health centre. However, the illnesses often last longer in HIV infected children, and are slower to respond to standard treatments. The standard treatments are nevertheless the most appropriate treatments. The following general recommendations should be used in the management of HIV infected infants/children and in teaching/counselling mothers and other care-givers.
Maintain good nutritional status in weight loss and failure to thrive
In most countries of the developing world, HIV-infected mothers are still breast-feeding their infants. However, with the knowledge that HIV can be passed through breast milk (approximately 30% risk), this practice might be changing. In some countries, substitutes for breast milk may be recommended for infants of HIV-infected mothers. However there needs to be a safe and adequate supply of affordable breast milk substitutes, access to a clean water supply and adequate means to boil water and to sterilize equipment. In some communities, where supplies and equipment are limited or unavailable, the risk of babies dying if not breastfed will be greater than the risk of passing on HIV. In countries where ARV is available, breast milk substitutes will probably be recommended.
Provide early and vigorous therapy for common pediatric infections as early as possible
All infants with HIV antibodies should be treated vigorously for common pediatric infections such as measles and otitis media. (see Table below) Because the immune systems of children with HIV infection are often impaired, these diseases may be more persistent and severe, and the children may respond poorly to therapy and develop severe complications. Consequently, the mothers of all HIV-positive infants should be encouraged to take their infants for examination and treatment as soon as possible whenever symptoms of common pediatric infections develop.
Oral thrush (Often recurs after treatment and can be the first indication of HIV infection)
Treat with gentian violet application, polyvidone iodine and chlorhexidine mouthwash, and antifungal tablets and lozenges (depending on child's age)
Other skin diseases
Calamine, topical steroids, antibotics orally or topically
Paracetamol; aspirin (in children older than 6 years of age)
Sexually transmitted diseases in the newborn
Antibiotics such as benzylpenicillin, kanamycin, erythromycin and others have been found to be effective for newborn treatment of syphilis, gonorrhea, and chlamydia
Emphasize early diagnosis and treatment of suspected TB for all family
TB is one of the most common and deadly opportunistic infections and the HIV positive child is very susceptible to contracting this disease. Every effort should be made to ensure that TB prevention and treatment is available to family members.
Immunize according to standard schedules
All infants and children should be immunized according to standard schedules. The only exception is that infants with clinical symptoms of HIV infection should not be given tuberculosis vaccine (BCG).
Ensure the child has good quality of life
Most infants of HIV infected mothers are not infected with HIV. In addition, many of those who are infected will have months of asymptomatic life. Some will live for years without developing symptoms. Every effort should be made by members of the child's family and by the health care professional to help the HIV-infected child to lead as normal a life as possible.
Children orphaned by AIDS
Approximately 8.2 million children around the world have been orphaned by the HIV/AIDS epidemic. AIDS orphans, defined as children who have lost their mother or both parents to AIDS before reaching the age of 15, are predicted to number 41 million worldwide by 2010. Nine out of ten (90%) maternal orphans are presently living in sub Saharan Africa. The extended family system, which would traditionally provide support for orphans, is greatly strained in communities most affected by AIDS. This is especially true in populations which migrate.
When children are cared for by other family members, this places an added financial burden on these care givers. After their parent's death, children can lose their rights to the family land or house. Without education, work skills or family support, children may end up living on the streets. These children are especially vulnerable, often becoming sexually active at an early age and at risk from HIV themselves. Poverty is an overwhelming problem. These orphans not only lack money, but basics such as clean water, drugs, food, shelter and medical supplies. They do not have information about how to protect themselves, and have poor access to doctors, nurses, and other health care workers and facilities. Finally, these orphans often lack human rights and dignity. The magnitude of this problem will have to be addressed at international, national, local, and community levels. Government, non-governmental organizations (NGO) and other institutions and organizations will have to combine their efforts to provide effective programs and strategies to care for orphaned children.
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