Articles from prior issues of The Advocate

November/December 2000

Advances in Treatment for HIV in Children
by O. Yvonne Holton

Immediately following the session on Advances in Treatment for HIV in Women, Irma Febu, M D., pediatrician, lectured on Advances in Treatment for HIV in Children. Since both subjects are closely linked, much of the information concerning the transmission of HIV infection from birth mothers to children was given in the previous lecture. The ultimate goal in treatment is eradication of the disease in birth mothers but, for children who are born infected, there have been many advances in treatment, according to Dr. Febu.

Per Dr. Febu, the disease is more prevalent in younger women, during the child-bearing stage of life. Careless use of intravenous (IV) drugs and sex with IV drug users are common causes of the disease in adults. From mother to baby, it is spread in utero, at birth and during breast feeding with 95 percent being transmitted perinatally. In HIV infection, the cell in the human body becomes a viral factory for replication. Intervention is possible in utero and at birth and anti-retrovirals have been developed over time which can adequately control the disease. They are often used in combination but therapy varies and requires strict adherence to the protocol designed for the individual.

All HIV infected children are born with a positive Elisa test that can be detected early or late in pregnancy . The earlier the diagnosis is made, the more effective the treatment; therefore, the immediate goal is early detection. All pregnant women should be tested for HIV but, if status of the mother is unknown, the newborn(s) should be tested for HIV within 48 hours after birth to decrease the risk of transmission. Babies should be tested at birth, two weeks, 1-2 months and 3-6 months. By 4-6 months, it is known with some accuracy that the baby is not infected if the disease is not cellular. However, children who are infected should be tested periodically for viral load (VL) counts and the same test should always be used. Every infected child who is less than a year old should be treated regardless of VL count. At age one and above, VL testing precedes treatment and must be provided if the VL count is over 100, 000. If the VL is undetectable, it does not mean the virus has disappeared but that the medications are effectively controlling it.

According to Dr. Febu, in older children and young adults (ages 13-24) , the VL is high early-on but drops to a “set” point. With treatment, the CD4 count rises and stays up. The individual becomes asymptomatic and remains so indefinitely until the immune system stops fighting. The process differs in children; in infants, the VL goes up and stays up longer and it may take about 2 years to get it down to a safe level. In symptomatic HIV, symptoms must also be clinically treated. Signs and symptoms include fungi, oral ulcers in which the children cannot eat and neurological deterioration in which they can not walk and/or talk. Infected children may also develop pneumocystic pneumonia (PCP) in which case, most die very young. However, with proper treatment, many babies with symptomatic HIV can become stabilized for years.

Dr. Febu explained that there is no clinical model for treatment of HIV in children. Medicinally, children are treated as with any other infection but within the guidelines established for use of anti-retroviral agents. However, treatment is more social and behavioral than medicinal for many reasons. Adherence to therapy is very much dependent upon caregivers because compliance requires strict regimentation of as many as 12-16 pills each day, taken with and without food. Toxicity and side effects of medications must also be considered when deciding on a combination of anti-retrovirals. Pharmacology must be age appropriate to correspond with body changes and must also be changed when the disease begins to arrest (CD4 goes up and VL goes down). Additionally, adolescent children desire very much to be like their peers and are very difficult to treat once they become asymptomatic. Caregiving itself may become problematic for HIV infected children who have been orphaned by HIV infected parents. Therefore, adherence must be considered individually before treatment is prescribed.

Other difficulties in rendering treatment to HIV infected children are unstructured lifestyles including homelessness, misinformation and distrust in the medical establishment, unbelief in the effectiveness of medications, lack of insurance and fear, including fear of disclosure because of the stigma surrounding the disease. Two groups of children are being treated: those already born with HIV infection and newly infected babies that continue to be born infected because of the perpetuation of high risk behavior in our society.