Prevention of HIV infection in children

The threshold of a new century is an opportune time to review advances in the prevention of HIV infection in children. In the United States, progress in the ability to virtually eliminate perinatal HIV transmission that was unthinkable just a few years ago has been achieved. Clinicians providing care to pregnant women should educate and counsel women about HIV and strongly recommend that they be tested. They should also counsel HIV-infected women about the means available to substantially decrease the risk for HIV transmission to their infants (e.g., antiretroviral drug use, avoidance of breast-feeding, elective C-section, encouraging pregnant women to use barrier methods during sexual intercourse, and to discontinue injection drug use). This article has highlighted some of the remaining challenges that constitute barriers to achieving maximal decrease of HIV infection in children. Studies conducted in resource-poor countries have added greatly to the understanding of vertical transmission of HIV, and they are now leading to practical and affordable approaches to reduce vertical HIV transmission world-wide. The results of this research must lead to coordinated public health action and a global political commitment to extend the benefits of antiretroviral drug prophylaxis that now exist widely in the United States to more resource-poor countries.     

Nutrition and HIV infection in children

HIV infection has profound effects on a patient’s nutritional status because it can modulate appetite, nutrient absorption and basal metabolic rate. In addition, HIV infection can lead to the depletion of a variety of vitamins and micronutrients including vitamins A, D, B₂, B₆, B₁₂, L-carnitine, iron, zinc and selenium. This review article summarizes existing data regarding nutritional defects in HIV-infected patients and the results of clinical studies addressing the effects of nutritional supplementation in infected patients.     

Antiretroviral therapy of HIV infection in children

Much progress has been made in the therapy of pediatric HIV infection, which has been transformed from a usually fatal disease into that of a chronic disease model. Early, aggressive therapy with the goal of complete suppression of viral replication (undetectable plasma virus) should be the therapeutic goal, but this new, more hopeful environment has been created at the cost of complexity and compromises in quality of life. The rapid pace of new developments and therapeutic complexities argue strongly for care in specialized centers or, at least, frequent consultation. Efforts are ongoing to develop simpler, more effective therapeutic regimens that suppress and ultimately eradicate infection and that stimulate immune reconstitution.     

Secrecy in children with HIV infection]

The secrecy surrounding the disease of parents and children infected with HIV leads to psychic and affective isolation and difficulties of communication within the family. Psychological management may possibly help to resolve the problem of secrecy between parents and children. We analyzed the organization and dynamics of the secret surrounding children contaminated by their mothers. The analysis was prospective and was based on semi-directive interviews and drawings. We followed up, over a period of two years, ten children (mean age: 4 years, range: 4 months to 12 years) with different ethnic and socio economic backgrounds. In each family, the child was the target of the secret, the pediatrician the guardian, and the mother (or her substitute) the keeper. The organization of the secret around the other potential guardians varied from one family to another. Two modes of intra-family communication were observed: the secret (reserved for the youngest children) and the tacit. One child suffered from a disorder related to the secret, the others had depressive and reactional symptoms. At the end of the study, the manner of approaching, and especially dealing with, the question of the secret had changed appreciably in each family: disclosure to the family circle (three cases), passage of the child from the secret to the tacit (two cases), and easier questioning of the pediatrician in all of the cases. Nonetheless, in no case had the secret been completely lifted for the child. Four children asked to continue psychological management. The changes in the dynamics of the secret and the appeasement observed in the families suggest that psychotherapeutic aid should be offered to families where a child has been contaminated with HIV by the mother.     

Epidemiology of HIV infection in children in Italy

As of April 1992, 2337 children born to HIV-1-positive mothers were recorded by our multicentre study. Another 131 children were infected by contaminated blood products, while in 5 cases the risk factor remained unknown, as their personal history was lacking. The number of perinatally exposed children increased exponentially from 1981 to 1986, then stabilized. Of these, at last visit 624 were infected (531 P-2, 93 P-1), 463 were P-O and 1195 had seroreverted. Drug addiction continues to be the most frequent maternal risk factor, although infection acquired through sexual contact gradually increased up to 26.5% in 1991. Of the 762 first children identified at birth and older than 15 months of age, 132 (17.3%) acquired infection and seroconverted to HIV. A similar transmission rate was observed in 43 second-born children.     

Epidemiology of HIV infection in children in Europe

In Europe the Human Immunodeficiency Virus (HIV) epidemic in children is an important public health problem. Reliable epidemiological information varies widely among countries, and there is no standard method to document the pandemia. By September 1992, a total of 81,849 AIDS cases were identified. France had 21,487, Spain 15,678 and Italy 14,784 (63% of all cases). The highest rate per 100,000 inhabitants occurred in Spain (88.9), France had 70.6 and Italy 63.5. The numbers of HIV⁺ newborns (NB) in Spain were 4673, in Italy 2,693, in Belgium 368, in Scotland 79 and in Holland 11. The highest rate of HIV⁺ NBs per 100,000 inhabitants occurred in Spain (120.1), the lowest in Holland (0.73). In Western Europe, 82% of all cases were due to vertical transmission. Mothers'venous drug use was the most common form of HIV transmission.     

Blood product acquired HIV infection in children

The medical community needs to ensure safety of blood and blood products. Blood bankers have instituted rigid criteria for exclusion of potential donors in high risk categories. Institution of HIV testing would appear to make blood products safer although the complete elimination of HIV contaminated blood and blood products may not be possible. The ELISA test is excellent for screening but misses approximately 1 in 200 (0.5%) HIV infected donors. Donor-screened, heat-treated factor VIII products appear to be quite effective in protecting the hemophilia population. However, we must continue to search for methodologies and techniques which will further guarantee blood product safety. The following methodologies have been suggested and warrant strong consideration: Vigilance in exclusion of potential high risk donors. Newer methodologies for retrovirus screening including the use of other surrogate markers. Institution of screening for HTLV-I and other retroviruses with attention to population surveillance for newer agents. Institution of cleaner methods of extracting specific blood components by monoclonal antibody techniques and DNA methodologies. For hemophiliacs, development of recombinant DNA products which by-pass the need for plasma derived clotting factors. It is predicted that such products should become available for use in about two years. In the interim, all clotting factors used should be donor-screened and virus-inactivated (by heat treatment, detergent washing and/or other newer methodologies). For the blood recipient, programs allowing for self donation prior to elective surgery and designated donors should be implemented. Although such programs may be logistically difficult, they should be given high priority.(ABSTRACT TRUNCATED AT 250 WORDS)     

Neurologic complications of HIV infection in children.

Neurologic abnormalities occur frequently in children with symptomatic HIV-1 infection (class P2) and include cognitive, language and motor deficits, as well as acquired microcephaly. Neurologic abnormalities can be seen as early as the first 3 months of age and can precede signs of immune deficiency and systemic illness. Hypotonia, delayed or poor head control and decreased vocalizations are some of the early neurologic manifestations of HIV-1 infection. In the majority of cases CNS impairment appears to be related to HIV-1 brain infection although at this time the exact timing of CNS invasion by the virus and the pathogenesis of CNS dysfunction are unknown. Treatment with antiretroviral agents can at least temporarily improve neurologic functioning in some children with HIV-1-related encephalopathy.     

Disclosure of the HIV infection status in children

Objective  

To determine the perception of caregivers about the disclosure of the diagnosis of HIV infection in children.     

Clinical practice treatment of HIV infection in children

Perinatal transmission remains the main cause of HIV infection in the pediatric population. Treatment of HIV-infected children has become less of a problem in resource-rich countries with a remarkable decrease of perinatal infections, resulting in an effective prevention of mother-to-child transmission and antiretroviral treatment of HIV infection in pediatrics because of differences in drug pharmacokinetics, the lack of available licensed drugs, the use of different immunologic markers and age-related adherence issues. This review, for the general pediatrician, summarizes the most recent pediatric data and guidelines for treatment of HIV. Recommendations for when to initiate therapy are more aggressive in children than in adults, particularly in infants because disease progression in children is more rapid. The indications to start therapy differ by age and are based on international immunologic and clinical classification system for HIV infection. At present, combination regimens of at least three drugs are recommended. Moreover, therapies must also consider the potential complications in these children currently treated for a long time.