Common clinical conditions associated with HIV

• Infants have immature immune systems, making them prone to bacterial infections.

• HIV further weakens the immune system, increasing the risk of severe bacterial infections in HIV-positive infants.

• Common childhood infections are more frequent and severe in HIV-infected children, with higher fatality rates compared to uninfected children.

• These include:

  • Diarrhea

  • Acute suppurative otitis media (sudden ear infection with pus)

  • Sinusitis (sinus inflammation)

  • Failure to thrive

• Immunization and cotrimoxazole prophylaxis significantly reduce severe bacterial infections in HIV-infected children.

• Preventative measures are critical in managing these risks.

Common Opportunistic Infections

• Cytomegalovirus (CMV):

  • A common virus that can cause serious illness in immunocompromised individuals.

  • Presents as encephalitis (brain inflammation) with retinitis (retina inflammation) or neuritis (optic nerve inflammation).

• Cryptococcus:

  • A type of fungus.

  • Symptoms: fever, headache, seizures, altered mental status. Focal neurological signs are less common.

• Toxoplasmosis:

  • Infection by a parasite.

  • Common signs: encephalitis, mental changes, fever, headache, confusion.

• Herpes simplex virus (HSV):

  • A common virus.

  • Associated with fever, altered consciousness, personality changes, convulsions.

• Kaposi’s sarcoma:

  • A type of cancer.

  • Can appear very early in life (first month). Linked to human herpes virus.

  • Presents with generalized lymphadenopathy and dark lesions on skin, eyes, mouth.

• Bacterial pneumonia:

  • Lung infection caused by bacteria.

  • Leading cause of hospitalization and death in HIV-infected children.

  • Streptococcus pneumoniae is the most common bacteria. Other possible bacteria include H. influenzae, Staphylococcus aureus, Klebsiella.

• Pneumocystis pneumonia (PCP):

  • Caused by the fungus Pneumocystis jiroveci.

  • Major cause of severe pneumonia and death in HIV-infected infants.

• Tuberculosis (TB):

  • Bacterial infection.

  • HIV pandemic has led to TB resurgence.

  • Children with HIV are at higher risk for primary progressive TB due to weakened immunity.

  • High fatality rate in children with HIV and TB co-infection.

• Lymphoid interstitial pneumonia (LIP):

  • Inflammation of lung tissue.

  • Common in children with perinatal HIV (around 40%).

  • Usually occurs in children older than 2 years.

• Viral pneumonitis:

  • Lung inflammation caused by viruses.

  • Caused by viruses like respiratory syncytial virus (RSV), para-influenza virus, influenza virus, adenovirus, varicella, measles, and Cytomegalovirus (CMV).

Examples of Opportunistic infections

• Bacterial OIs

  • Pneumococcal pneumonia (Streptococcus pneumoniae pneumonia)

  • Pulmonary tuberculosis (TB in the lungs)

  • Salmonellosis (Salmonella infection)

  • Extra-pulmonary tuberculosis (TB outside the lungs)

• Viral OIs

  • Herpes zoster (shingles)

  • Recurrent/disseminated viral herpes simplex (returning or widespread herpes infection)

• Parasitic OIs

  • Pneumocystis pneumonia (Pneumocystis jiroveci pneumonia)

  • Toxoplasmosis (Toxoplasma parasite infection)

• Fungal OIs

  • Cryptosporidium (Cryptosporidium parasite infection)

  • Oro-pharyngeal candida (fungal infection in mouth and throat)

  • Candida Esophagitis (fungal infection in esophagus)

  • Histoplasmosis (Histoplasma fungus infection)

  • Coccidioidomycosis (Coccidioides fungus infection)

  • Cryptococcal meningitis (fungal infection of brain/spinal cord membranes)

• Opportunistic cancers

  • Invasive cervical cancer (caused by human papilloma virus/HPV)

  • Kaposi sarcoma (caused by human herpes virus 8/HHV-8)

  • Non-Hodgkin lymphoma (lymphatic system cancer)

Causes of opportunistic infections in HIV/AIDS children

• Poor adherence to treatment (not taking medications as prescribed)

• Presence of other diseases (e.g., juvenile diabetes mellitus)

• Delayed infection identification

• High viral load (large amount of HIV in the body)

• Poor nutrition

• Exposure to opportunistic infectious agents

• Ingestion of contaminated substances

• Missed immunization programs

• Poor child hygiene

• Poor sanitation

• Poor ventilation

Prevention of opportunistic infections

• Avoid contact with disease agents

• Proper management of underlying diseases

• Adherence to HIV drug treatment

• Immunization against preventable diseases

• Safe food and water consumption (well-cooked food and boiled water)

• Early detection and treatment of opportunistic diseases

• Health education for family and child about opportunistic infections

General management of opportunistic infections

• Assessment of the child

  • History taking: From mother/caregiver and child (if verbal).

  • Physical examination:

    • Vital signs (temperature, heart rate, breathing rate)

    • Head-to-toe examination

  • Investigations: e.g., blood microscopy.

• Provision of treatment

  • Fungal infections: Anti-fungals

  • Bacterial infections: Anti-bacterials

  • Viral infections: Anti-virals

  • Parasitic infections: Anti-protozoals

  • Cancers: Cytotoxic drugs

WHO CLINICAL STAGING OF HIV

Staging HIV infection and disease in children

• Staging is a standard method to assess disease progression and guide treatment decisions.

• Uses clinical signs and laboratory parameters to determine HIV disease stage.

WHO staging for HIV infection and disease in children above 10 years

• Clinical Stage I:

  1. Asymptomatic (no symptoms)

  2. Persistent generalized lymphadenopathy (ongoing lymph node swelling)

• Clinical Stage II:

  1. Moderate weight loss (less than 10% of body weight)

  2. Minor muco-cutaneous manifestations (skin and mucous membrane issues): seborrheic dermatitis, prurigo, fungal nail infections, recurrent oral ulcers, angular stomatitis.

  3. Herpes zoster within the last five years (shingles history).

  4. Recurrent upper respiratory tract infections (URTIs): bacterial sinusitis, tonsillitis, otitis media, pharyngitis.

• Clinical Stage III:

  1. Severe weight loss (more than 10% of body weight)

  2. Unexplained chronic diarrhea (over one month)

  3. Unexplained prolonged fever (over one month, intermittent or constant)

  4. Oral candidiasis (thrush)

  5. Oral hairy leukoplakia (white tongue patches)

  6. Pulmonary tuberculosis (current active TB)

  7. Severe bacterial infections: pneumonia, pyomyositis, empyema, bacteremia, meningitis.

  8. Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis (severe mouth/gum inflammation)

  9. Unexplained anemia (<8gm/dl), neutropenia (<0.5× 10^9/L), or chronic thrombocytopenia (<50× 10^9/L).

  10. Performance Scale 3: Bed-ridden less than 50% of the day in the last month.

• Clinical Stage IV:

  1. HIV wasting syndrome (weight loss >10% + chronic diarrhea/weakness/prolonged fever)

  2. Pneumocystis pneumonia (PCP)

  3. Recurrent severe bacterial pneumonia

  4. Toxoplasmosis of the brain

  5. Cryptosporidiosis with diarrhea (over one month)

  6. Chronic isosporiasis

  7. Extra-pulmonary cryptococcosis (including meningitis)

  8. Cytomegalovirus (CMV) infection (retinitis or other organs)

  9. Herpes simplex virus (HSV) infection (mucocutaneous >1 month or visceral)

  10. Progressive multifocal leukoencephalopathy (PML)

  11. Disseminated endemic mycosis (histoplasmosis, coccidioidomycosis)

  12. Candidiasis of esophagus, trachea, bronchi, lungs

  13. Atypical mycobacteriosis, disseminated

  14. Recurrent non-typhoid salmonella septicemia

  15. Extra-pulmonary tuberculosis

  16. Lymphoma

  17. Invasive cancer of cervix

  18. Kaposi’s sarcoma

  19. HIV encephalopathy (cognitive/motor dysfunction interfering with daily life)

  20. Atypical disseminated leishmaniasis

  21. Symptomatic HIV-associated nephropathy or cardiomyopathy

  22. Performance Scale 4: Bed-ridden more than 50% of the day in the last month.

WHO staging for HIV infection and disease in infants and children

• Clinical Stage I:

  1. Asymptomatic

  2. Persistent generalized lymphadenopathy

• Clinical Stage II:

  1. Unexplained persistent hepatosplenomegaly (liver/spleen enlargement)

  2. Papular pruritic eruptions (itchy bump rash)

  3. Extensive wart virus infection

  4. Extensive molluscum contagiosum

  5. Recurrent oral ulcerations (mouth sores)

  6. Unexplained persistent parotid enlargement (parotid gland swelling)

  7. Linear gingival erythema (red gum line)

  8. Herpes zoster (shingles)

  9. Recurrent or chronic upper respiratory tract infections (URTIs): otitis media, otorrhoea, sinusitis, tonsillitis.

  10. Fungal nail infections

• Clinical Stage III:

  1. Unexplained moderate malnutrition (not responding to standard therapy)

  2. Unexplained persistent diarrhea (14+ days)

  3. Unexplained persistent fever (>37.5 ºC, >1 month)

  4. Persistent oral candidiasis (after 6 weeks of life)

  5. Oral hairy leukoplakia

  6. Acute necrotizing ulcerative gingivitis/periodontitis

  7. Lymph node Tuberculosis

  8. Pulmonary Tuberculosis

  9. Severe recurrent bacterial pneumonia

  10. Symptomatic lymphoid interstitial pneumonitis (LIP)

  11. Chronic HIV-associated lung disease including bronchiectasis

  12. Unexplained anemia (<8.0 g/dl), neutropenia (<0.5 x 10^9/L), or chronic thrombocytopenia (<50 x 10^9/ L3).

• Clinical Stage IV:

  1. Unexplained severe wasting, stunting or severe malnutrition (not responding to standard therapy)

  2. Pneumocystis pneumonia (PCP)

  3. Severe recurrent bacterial infections (empyema, pyomyositis, bone/joint infection, meningitis, excluding pneumonia)

  4. Chronic herpes simplex infection (oro-labial/cutaneous >1 month or visceral)

  5. Extra-pulmonary Tuberculosis

  6. Kaposi’s sarcoma

  7. Oesophageal candidiasis (or Candida of trachea, bronchi, lungs)

  8. Toxoplasmosis of the brain (after neonatal period)

  9. HIV encephalopathy

  10. Cytomegalovirus (CMV) infection (retinitis or other organs, onset >1 month age)

  11. Extra-pulmonary cryptococcosis (including meningitis)

  12. Disseminated endemic mycosis (extra-pulmonary histoplasmosis, coccidiomycosis)

  13. Chronic cryptosporidiosis (with diarrhea)

  14. Chronic isosporiasis

  15. Disseminated non-tuberculous mycobacteria infection

  16. Cerebral or B-cell non-Hodgkin lymphoma

  17. Progressive multifocal leukoencephalopathy

  18. HIV-associated cardiomyopathy or nephropathy