1Assistant Professor, P P Savani School of Nursing, P P Savani University, Dhamdod, Kosamba, Surat Nursing. 2Tutor, P P Savani School of Nursing, P P Savani University, Dhamdod, Kosamba, Surat.
*Corresponding Author E-mail: chandrashekhara.shettigara@ppsu.ac.in
ABSTRACT:
Children are innocent victims of HIV infection through vertical transmission. Children who are HIV positive, either through mother-to-child transmission or following sexual abuse, are often not told what could happen to them, and they will certainly be frightened when they experience symptoms.
KEYWORDS: HIV, AIDS, Children.
INTRODUCTION:
Children are innocent victims of HIV infection through vertical transmission. Children who are HIV positive, either through mother-to-child transmission or following sexual abuse, are often not told what could happen to them, and they will certainly be frightened when they experience symptoms. Approximately 90% pediatric HIV infection are acquired from infected mother resulting in vertical transmission for infant. HIV also can pass from mother to child during pregnancy (30-35%), childbirth (60-65%), or breastfeeding (10-15%).
According to UNICEF the estimated 37.9 million [confidence bounds: 32.7-44.0 million] people living with HIV worldwide in 2018, 2.8 million [2.0-3.8 million] were children aged 0-19. Each day in 2018, approximately 980 children became infected with HIV and approximately 320 children died from AIDS related causes, mostly because of inadequate access to HIV prevention, care and treatment services.
The transmission of HIV from a HIV-positive mother to her child during pregnancy, labour, delivery or breastfeeding is transmission rate range from 15% to 45%.
In 2018, around 160,000 [110,000-260, 000] children aged 0-9 were newly infected with HIV, bringing the total number of children aged 0-9 living with HIV to 1.1 million [870,000 - 1.5 million].
India has estimated 145,000 children <15 years of age who are infected by HIV/AIDS, and about 22,000 new infections occur every year. Children account for 7% of all the new HIV infections. According to WHO Globally, 37.9 million people living with HIV in 2018. 23.3 Million People were receiving antiretroviral treatment by end 2018.
A recent maternal infection with HIV may rise the risk of transmission through feeding to twice that women with earlier established infection, receiving probably to high viral and associated recent infection (WHO 2007).
Vertical transmission:
A child can be born with HIV or contract it soon after birth. HIV contracted in utero is also called vertical transmission or perinatal transmission.
During pregnancy (passing from mother to baby through the placenta)
During delivery (through the transfer of blood or other fluids)
While breastfeeding of course, not everyone who has HIV will pass it to their baby, especially when following antiretroviral therapy.
Horizontal transmission, is when HIV is transferred via non-sterile needles (as HIV drug use or tattooing) or via contact with infected semen, vaginal fluid, or blood.
HIV doesn’t spread through insect bites, saliva, sweat, tears, and hugs. You can’t get it from sharing towels or bedding, drinking glasses or eating utensils, and toilet seats or swimming pools.
Children infected with HIV prenatally exposed to HIV may be classified into one or four initially inclusive clinical categories.
Category N:
Not symptomatic, includes children with no signs or symptoms.
Category A:
Mild symptomatic, mild separation because of substantial events of time that can relapse before a child manifest signs and symptoms.
Category B:
Includes all children with signs and symptoms caused by HIV infection but not outlined under A or C
Category C:
Severely symptomatic.
Clinical Stage 1 Asymptomatic PGL
Clinical Stage 2 Hepatosplenomegaly Papular pruritic eruptions Seborrhoeic dermatitis
Extensive human papilloma virus infection Extensive molluscum contagiosum
Fungal nail infections
Recurrent oral ulcerations Lineal gingival erythema (LGE) Angular cheilitis
Parotid enlargement Herpes zoster
Recurrent or chronic RTIs (otitis media, otorrhoea, sinusitis)
Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations:
Moderate unexplained malnutrition not adequately responding to standard therapy.
Unexplained persistent diarrhoea (14 days or more) Unexplained persistent fever (intermittent or constant, for longer than one month)
Oral candidiasis (outside neonatal period) Oral hairy leukoplakia
Acute necrotizing ulcerative gingivitis/periodontitis Pulmonary TB
Severe recurrent presumed bacterial pneumonia
Chronic, HIV, associated, lung, disease, including, brochiectasis,
Lymphoid interstitial pneumonitis (LIP) Unexplained anemia.
Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations:
Unexplained severe wasting or severe malnutrition not adequately responding to standard therapy Pneumocystis pneumonia, Recurrent severe presumed bacterial infections (e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia)
Chronic herpes simplex infection; (orolabial or cutaneous of more than one month’s duration) Extrapulmonary TB Kaposi’s sarcoma Oesophageal candidiasis CNS toxoplasmosis (outside the neonatal period) HIV encephalopathy
CMV infection (CMV retinitis or infection of organs other than liver, spleen or lymph nodes; onset at age one month or more)
Extrapulmonary cryptococcosis including meningitis Any, disseminated, endemic mycosis, (e.g. extrapulmonary, histoplasmosis, coccidiomycosis, penicilliosis)
Cryptosporidiosis Isosporiasis
Disseminated non-tuberculous mycobacteria infection Candida of trachea, bronchi or lungs
Visceral herpes simplex infection Acquired HIV associated rectal fistula Cerebral or B cell non-Hodgkin lymphoma
Progressive multifocal leukoencephalopathy (PML)
HIV-associated, cardiomyopathy, or, HIV-associated nephropathy.
HIV is commonly transmitted via unprotected sexual activity, blood transfusions, hypodermic needles, and from mother to child. Upon acquisition of the virus, the virus replicates inside and kills T helper cells, which are required for almost all adaptive immune responses. There is an initial period of influenza-like illness, and then a latent, asymptomatic phase. When the CD4 lymphocyte count falls below 200cells/ml of blood, the HIV host has progressed to AIDS, a condition characterized by deficiency in cell-mediated immunity and the resulting increased susceptibility to opportunistic infections.
The defined diagnosis of HIV infection in neonates born to HIV infected mothers is difficult due to various reasons. An HIV infected mother transmits the IgG antibodies to the newborn transplacentally. These neonates are usually are positive birth, but only 15 to 30% actually infected.
Maternal antibodies usually undetectable in 9 months but occasionally remain at significant level until 18 months. Hence IgG antibody tests are not reliable indicators of infection status in a child before 18 months of age. Therefore presence of antibody beyond this period is necessary to consider the child infected especially in asymptomatic child.
The definite diagnosis through:
Detection of P24 antigen.
CD4 count is low in HIV infection.
PCR (Polymerase Chain Reaction test) to detect nucleic acid in peripheral blood.
Platelet count above 5,00,000(in serve infection) ELISA or detection of IgG and IgM.
ELISA (Enzyme Linked Immuno Sorbant Assay).
Use of combination of anti-retro viral drugs.
Medication therapy raises from single drug therapy in an asymptomatic HIV exposed newborn to a Highly Active Anti-Retroviral Therapy (HAART)
Medication prescribed based on severity of child’s illness.
One of the goals of the HAART is to prevent or arrest progressive HIV encephalopathy.
Five groups of anti-retroviral drugs. Each attack HIV in a different way.
Table 1: Groups of Antiretroviral Drugs
|
ARV Drug |
Abbreviation |
Action |
|
Nucleosidal Nucleotide Reverse Transcriptase Inhibitors |
NRTIs Nucleotide Analogue Nukes |
NRTIs interferes with the action of HIV protein called reverse transcriptase, which the virus need to make new copy of itself. |
|
Non-Nucleoside Reverse Transcriptase Inhibitors |
NRTIs Non Nucleotide Non Nukes |
NNRTIs also stop from replicating within cells by inhibiting the sense to transcriptase proyien. |
|
Protein Inhibitors |
PIs |
PI inhibits protease which is another protein involved in HIV replication. |
|
Fusion or entry inhibitors |
|
Fusion or entry inhibitors prevent HIV from binding to entering human, immune cells. |
|
Integrase Inhibitors |
|
Integrase Inhibitors interferes with the integrase enzyme, which HIV needs to insert its genetic materials into human cells. |
Most drug combination given to those beginning treatment consist of two NRTIs combined with either a NRTIs or booster protease inhibitor, ritonavir is commonly used as booster.
Example common anti ritroval combination is two NRTIs, Zidovidine and Lamivudine, combined with NNRTI Efavaring.
Table: 2: HIV Antiretroviral Drugs
|
NRTI |
NNRTI |
protease inhibitors |
Fushion Inhibotors |
|
Zidovudine (AZT) Lamivudine (3TC) Emtricitabine (FTC) Stavudine (D4T) Didanosine (DDL) Tenifovir (TDF) Zalcitabine (ABV) Abacavir (DDC) |
Efavirenz (EFV) Nevirapine (NVC) Delavirdine (DLV) |
Ritanovir (RTV) Saquinavir (SQV) Indianavir (IDV) Nelfinavir (NFV) Fosamprenavir (APV) Lopinavir (LPV) Atazanavir (ATV) Duranavir (DRV) |
Enfuvirtide |
Nursing Management:
Review maternal records to identify infants who may be at risk for HIV disease. Infected infants are not easily identifiable by outward appearance.
Review records of at risk or known infected children to determine nutritional status, growth and development, frequency of serious bacterial infections, presence or risk of opportunistic infections, laboratory values and immunization status.
Assess growth, development, lymph nodes, hepatomegaly, splenomegaly, and oropharynx for presence of oral candidiasis and dental caries.
Assess the family’s understanding of child’s condition, care needs, prognosis and medical care plan.
Assess family’s coping mechanisms, comfort with disclosure issues and long-term plans for care including transition plans for the child to an adult care programme.
Assess the health of primary care giver and discuss long- term care plans for respite and permanent alternative caregivers as appropriate.
Assess the child’s understanding and health status and medications.
In children with advanced or end-stage disease, assess the level of pain and discomfort.
Assess the child coping and response to the frequent painful and invasive procedures experienced as part of ongoing diagnosis and management of disease.
Assess for animal contact.
Take through travel history to evaluate risk of co- infections such as TB, malaria or other microbial infections. Also evaluate potential travel plans, particularly to developing countries.
In adolescents, assess increased at risk of behaviours such as substance use, piercing or sexual activity. Also determine method of birth control, as appropriate.
Preventive measures are best attempts to control the global problems of HIV/AIDS.
Four basic approaches to control HIV/AIDS include:
a) Prevention by health education to make lifesaving choices and avoiding blood borne HIV infection.
b) ARVs treatment with combination therapy or post exposure prophylaxis.
c) Specific prophylaxis for HIV manifestations, e.g. isoniazid for tuberculosis.
d) PHC approaches with integrated care in Mother and Child Health and health education.
Daily AZT in antepartum period combination of single dose of NVP at onset of labor and dose of AZT and 3TC during labor followed by combination of AZT and 3TC for 7 days in postpartum period.
Triple ARV drugs starting as early as 14 weeks of gestation until one week after all exposure to breast milk has ended (AZT+3TC+LPV or AZT+3TC+ABC) where ABC is abacavir, LPV lopinavir.
If mother received only AZT during antenatal period.
For breast feeding infants:
Daily NPV from birth until 1 week after all exposure to breast milk has ended. The dose of nevirapine is 10mg/day/oral for infants less than kg or 15mg/day/oral for infants more than 2.5 kg.
For non-breastfeeding infants:
Daily AZT or NVP from birth until 6 weeks age. The dose of AZT is 4mg/kg per oral per dose twice a day.
If mother received triple drug ART during pregnancy and entire breastfeeding daily AZT or NVP from birth until 6 weeks of age irrespective of feeding.
Avoid artificial rupture of membranes (ARMs) unless medically indicated.
Avoid procedure increasing risk of exposure of child to maternal blood and secretions like use of scalp electrodes.
Exclusive breastfeeding has been reported to carry a lower risk of HIV transmission than mixed feeding.
Infected mothers should only give commercial infant formula milk as a replacement feed.
CONCLUSION:
“Hate the disease and not the infected”, nurse has the tremendous role in control and prevention of HIV/AIDS in the pregnant mothers, and children. Nurses have a variety of role to perform in caring AIDS patients which includes assessing, managing, educating and counselling. There is no cure for AIDS as on date, therefore
Prevention is the only way to eliminate this dangerous condition.
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Received on 06.07.2020 Modified on 20.10.2020
Accepted on 11.12.2020 © AandV Publications all right reserved
Int. J. Nur. Edu. and Research. 2021; 9(3):376-380.
DOI: 10.52711/2454-2660.2021.00088