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Pediatrics & HIV

Every minute there is a child newly infected with HIV somewhere in the world. That’s 1,500 new infections just among children each day or more than 500,000 a year.Right now there are an estimated 2.5 million children worldwide living with the virus. Many will die because they do not have access to treatments, health care, food or clean water. Others will survive: some for a short period of time and others, sadly only the minority, will live longer.

The statistics are startling, yet we know that the use of antiretroviral therapy can not only delay disease progression, but it can prolong life and, importantly, improve quality of life. Initially it was problematic ensuring that countries, especially in the developing world, had supplies of antiretrovirals. Now the issue has changed somewhat, with drugs often making it to these countries, but red tape and internal politics stopping them from being distributed. Stigma can play a major role; there are many countries with treatment centres set up, fully equipped and stocked with antiretrovirals, yet people choose not to go there for fear of being identified as being HIV-positive or worse still, fear for their safety or even their life.
Worldwide the leading cause of HIV among children is mother to child transmission: this is sometimes referred to as vertical transmission. This mode of transmission can occur either during pregnancy, childbirth or as a result of breastfeeding. The risk of vertical transmission can be greatly reduced if the mother receives antiretrovirals during her pregnancy. However, in some countries access to drugs (for what could be a variety of reasons), health care fees or the stigma associated with an HIV diagnosis create barriers to this vital resource.

Right now there are an estimated 2.5 million children worldwide
living with the virus. Many will die because they do not have
access to treatments, health care, food or clean water. Others
will survive: some for a short period of time and others, sadly
only the minority, will live longer.”

Although mother to baby transmission is the leading cause of HIV infection among children, there are other ways they can be infected. All of the HIV transmission routes associated with adults can also affect children. This means any method whereby infected blood or body fluids can enter the body of another person. So this could include sexual transmission, sharing injecting drug equipment or gear used to snort drugs, sharing needles (e.g. for medication, steroids, acupuncture etc), sharing any tools used for piercing or making tattoos and transfusions involving blood or blood products.

As long as sensible precautions are taken, most day-to-day activities are relatively safe. You cannot get HIV through sharing crockery and cutlery, or from eating food prepared by someone with HIV. Hugging and kissing is also safe and you cannot get HIV from a toilet seat.
There are several ways that you can reduce the risk of HIV transmission. As previously stated, mothers who take antiretrovirals during pregnancy will greatly reduce the risk of passing the virus on to their child. Sometimes an elected Caesarean section may be recommended to further reduce the risk, although this is not always necessary, especially if the mother’s viral load is undetectable. On the whole, mothers with HIV are advised not to breastfeed because the virus is present in breast milk and the risk of transmission is further increased if she has cracked or bleeding nipples. However, this advice is most applicable to geographical areas where there is access to suitable replacement milk formulas. Sometimes there is no suitable substitute available.

In some countries, healthy children can be exposed to HIV during ritual ceremonies where group circumcisions (male or female) are carried out: or rituals where tribal markings are carved into a child’s skin. These ceremonies often involve the same equipment being used on several people and there can be blood (possibly infected) present. These rituals are steeped in history and date back many centuries, but sadly they could be putting children at risk.

Sexual transmission of HIV is also a factor for children. Child sex abuse and rape unfortunately occurs around the world, so too does child prostitution and selling children into slavery (often involving sexual favours). These young and vulnerable individuals are often forced into a difficult existence, fighting for their survival and forced to carry out acts that leave them physically and emotionally damaged. But not all sexual acts involving children are against their will. Increasingly it appears that children are engaging in consensual under age sex as highlighted by the ever-growing number of sexually transmitted infections and pregnancies. In fact, the UK has one of the highest rates of teenage pregnancies in Europe and also has one of the highest rates of teenage cases of gonnorhoea and chlamydia.
And it is not just under age sex that children are dabbling in, but drugs too. Although there are no specific statistics for the number of children taking drugs, there is data from the UK’s Home Office showing that almost 10% of people aged between 16 and 24 years of age admitted regularly taking class A drugs, including crack, cocaine and heroin. That figure is for regular use, i.e. at least once a week: the number of children occasionally using drugs is possibly much higher.

While it is important to understand how HIV is transmitted and how you can protect yourself and others, it is equally as important to realise that there are so many other issues to consider. The virus itself is complex and so too is living with it. HIV can have an emotional, physical, psychological and social impact on anyone infected, but children may also have their own additional set of challenges to face.

The only other people that really should know a child’s HIV status are the medical staff directly involved with their health care.”

Children living with HIV, just like most children, have needs both practical and material. Additionally, they may have social, emotional and psychological needs. Emotional care for children with HIV is very important, especially if they contracted the virus as a result of vertical transmission. Throughout various stages of their young life there may be times when they need additional support; this could be when they are first diagnosed, when they start treatment, when faced with stigma or discrimination, or if one or both parents falls ill and they have to deal with end of life issues. Providing a child with a good support network is invaluable, whether it is family, friends, health care workers or agencies set up to deal specifically with these issues. However, children can also be very resilient and should not be underestimated: they also tend to ask lots of questions and expect answers. And yet children can also be incredibly cruel and issues of discrimination can be hard to deal with or overcome. Therefore, it is important to work out who really needs to know about a child’s HIV status and why. A parent or guardian may already know and is possibly also infected. Although in cases of adoption or fostering this may not be the case, but it would still be important for them to know the child’s status. The only other people that really should know a child’s HIV status are the medical staff directly involved with their health care: this includes staff at the HIV clinic, but also extends to a GP. If a social worker or other support staff is assigned to a child, it may be helpful for them to know too. Many infections can start in the mouth, so the dentist should know too. To find out who definitely needs to know and whom you might find it helpful to tell, ask your nurse or clinician.

The list of people you have to disclose to may grow if the child attends playgroup or school. This is not only to ensure that appropriate precautions are taken in the event of an accident, but may also be necessary if the child is on medication. At present there are more than 20 different antiretroviral treatments available for adults, but not all of them are licensed for use in paediatrics. This is because not all of the drugs have been clinically tested and approved for use in paediatrics, while others cannot be dose adjusted and are therefore unsuitable. Ultimately, there is a difference in the way drugs are used to treat paediatric HIV compared with adult HIV. Drugs used to treat paediatric HIV are usually based on the child’s weight or calculated according to body surface area (BSA). As children continue to grow, so their drug dose will continue to change. If a drug cannot be dose adjusted, then it is difficult to use in the treatment of HIV in children. This is one of the reasons why paediatric antiretrovirals are often available as oral solutions, making dose adjustment easy: the other reason is that some children (and adults) have difficulty swallowing pills. However, other antiretrovirals do come in a range of pill sizes, which also makes dose adjusting easy.

While antiretrovirals are available to treat HIV in paediatrics, it is still worth remembering that children are also exposed to a range of childhood diseases. HIV affects the immune system and, left untreated, it weakens it and therefore hampers its ability to fight off infections. Therefore it is not only important to take antiretrovirals to keep the viral load down and therefore preserve the immune system, but also it is important to reduce your risk of acquiring any other infections. Therefore, vaccines, immunisations and good nutrition are important. Most routine vaccines for children are safe to use with those who have HIV. It is mainly the live vaccines, which contain a weak or inert form of a virus to enable the body to build up immunity to it, that are unsafe. Live vaccines include those for measles, mumps, rubella and chickenpox. However, a child with HIV can still receive passive protection (treatment or prophylaxis) for measles and chickenpox and it is recommended.

Hopefully this feature has provided an overview and some insight into HIV in children. And remember, in the time that it has taken you to read this feature, another five or six children have probably been infected with the virus. PN

This article has been sponsored by Abbott Virology UK.

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