Pediatric HIV/AIDS

How Pediatric HIV/AIDS differs from adult

HIV/AIDS?

• More than 90% children infected through Mother-to-

Child transmission

• Children become symptomatic early in life

Differences in the Manifestations of
HIV Infection in Children & those in
Adults
• Features More Common in HIV Infected Children:
v Early Onset of Symptoms
v Lymphocytic Interstitial Pneumonia
v Chronic parotid swelling
v HIV encephalopathy and
v Pneumocystic Pneumonia and
v Recurrent bacterial infections
• Features More Common in HIV Infected Adults:
v MAC
v Histoplasma infection
v Cryptococcal infections
v Kaposi’s sarcoma
 Estimates for Children – 2006
• Children represented 2.3 million (5.8%) of 39.5 million
people infected with HIV/AIDS Globally (2006)

• Accounted for 3,80,000 (13%) of the 2.9 million AIDS deaths

in globally (2006)

• Accounts for 1500 (13.6% ) of 11000 all New HIV Infections

per day in globally (2006)

• Only 40,000 or 4% of the one million people now on ART

are children
 Burden of Exposure
• Total annual pregnancies 27 million

• With 0.7% prevalence rate of HIV among

pregnant women, about 189,000 HIV infected
women deliver every year in India
• 30% – Transmission rate: 56700 babies HIV
infected annually

• HIV status of 90% antenatal women is unknown

• Even if HIV status is known , only 6% (3402) of
exposed infants followed up at 8 wks of life
 Estimated risk of Mother to Child
Transmission
During pregnancy 05 to 10 %
During labour and delivery 10 to 15 %
During breastfeeding 05 to 20 %

Overall risk without Intervention 20 to 45%

 I :NO PPTCT INTERVENTION (100 HIV
positive pregnant women)
• Transmission rates before delivery: 7
• During labour and delivery : 16
• After Delivery: Breast feeding continued:
breast feed for 6 months: 6 cases
breast feeding for 12 months: 2 more
cases
• TOTAL CASES: 31/100

HIV & Nephrology 23-08-07

CARE OF HIV EXPOSED BABY
 Interventions to reduce PTCT

1. National PPTCT programme Guidelines:

A single dose of NVP : to the mother at the onset of
labour AND to the bay within 72 hrs of birth (WHO
Recommendation)
DOSE : Mother:200 mg single dose
Baby: 6 mg/Kg B.Wt. single dose
(Oral suspension: 10 mg/ml)
2. Reduction of Maternal viral load by ART
3. Reducing exposure of fetus by C. section, avoiding invasive
practices as forceps ,episiotomy, fetal blood sampling from
scalp
4. Safe infant feeding practices : Exclusive formula feeding or
exclusive breast feeding for 6 months. No Mix feeding
Chart II: Only Nevirapine Prophylaxis (No intevention
for infant feeding )
100 HIV positive pregnant women

• Transmission rates before delivery: 7/100

• Proper NVP prophylaxis: 6 more cases
(instead of 16 without NVP)
• After delivery: Continued breast feeding:
--------------------for 6 months: 6 more cases
--------------------for 12 months: 2 more cases

TOTAL CASES: 21 CASES

Chart III: NVP prophylaxis + Exclusive Formula
Feeding (100 HIV positive pregnant women )

• Transmission rates before delivery: 7/100

• Proper NVP administration: 6/100
• After delivery only top feeding: Nil

TOTAL: 13/100
 ANC HIV SCREENING
• ALL PREGANANT WOMEN SHOULD BE
COUNSELED & HIV TESTED AT ICTC CENTRES
AFTER INFORMED CONSENT
• THOSE FOUND HIV POSITIVE SHOULD BE SENT TO
ART CENTRE -KALAWATI SARAN HOSPITAL FOR CD
4 COUNT, IF CD 4 COUNT < 350/CUMM ART TO BE
STARTED IN ORDER TO DECREASE MATERNAL
VIRAL LOAD WHICH DECREASES MTCT.
• ALL SUCH MOTHER BABY(0-18 MTHS) PAIRS TO BE
REGISTERED & FOLLOWED UP AT ART CENTRE
KALAWATI SARAN CHIDREN HOSPITAL
 Immediate Care after birth
• Wipe baby’s mouth and nostrils with gauze as soon as the head
is delivered

• Handle the infant with gloves & do early baby bathing

• Clamp cord immediately after birth, avoid milking the cord &
cover the cord with gloved hand or gauze before cutting to
avoid splattering of blood

• Wipe the baby dry with a towel

• Use suction only when meconium-stained liquor is present

Infant Feeding : HIV-Infected Mothers
WHO Recommendations
• Avoid all breastfeeding if replacement feeding is AFASS
• Acceptable
• Feasible
• Affordable
• Sustainable &
• Safe
Options for Replacement Feeding : Home-Prepared Modified
Animal Milk or Commercial Infant Formula
• Otherwise, exclusive breastfeeding during the first 6
months of life
Expressed Heat-treated Breast Milk

Steps :

• Clean the containers with soap and water

• Heat EBM sufficient for one feed until boiling

followed by cooling &

• Use within one hour

 Follow up of HIV Exposed babies

• As per UIP Schedule start at 6 weeks of age

• Road to Health card for them to include information on
maternal HIV status, CTX prophylaxis, Infant HIV
diagnosis, and feeding information
• At each visit: Give to mother or care provider
(i) information on potential common HIV related features
(ii)reinforce need of CTX prophylaxis,
(iii) Infant feeding & adherence to ART if started
• Growth Monitoring: If growth curve flattening, assess for
HIV related features & treatable causes like respiratory,
U.T.I., & G.I. infections
• Review for TB at each visit
 COTRIMOXAZOLE
PROPHYLAXIS
• Started from 4-6 weeks of age to all HIV exposed
infants until HIV infection has been ruled out &
mother not breast feeding

• Dose 5 mg/kg/day as a single dose

• It protects infant from Opportunistic Infections-

PCP, Toxoplasmosis, bacterial infections, isospora
& cyclospra infections.
• Alternative: Dapsone 2mg/kg once a day
 Important maternal HIV associated
infections and the baby

• Mother Open case (sputum positive) TB

– INH (5 mg/kg/day for 6 months)
chemoprophylaxis to baby
• Maternal Herpes simplex Type II infection
(Recurrent herpes genitalis)
– Merits attention from OB/GYN during delivery &
early detection by Pediatrician
• CMV infection
 Patterns of Manifestations In
Paediatric HIV Infection
The mean age of presentation in perinatally infected children
is 17 mths;
On the basis of age of presentation, three patterns have been
described:
a. Rapid Progressor: Manifestations in the form of opportunistic
infections and neurological manifestations are apparent within
the first few months of life.
b. Moderate Progressor: These children tend to develop
manifestations after the age of 1 year and they usually
present with failure to thrive, recurrent bacterial infections and
LIP.
c. Slow Progressor: It comprises of children who manifest later
in childhood with minor manifestations and behave as “adult
equivalents”
 Manifestations That Suggests Underlying
HIV Infection in HIV Exposed Infants
• Impairment of Growth/failure to thrive
• Diarrhoea
• Lymphadenopathy
• Hepatomegaly
Development of hepatomegaly by 3 months of age
indicates a poor prognosis
• Splenomegaly
• Parotid Swelling
The painless parotid swelling develops gradually
• Lymphocytic Interstitial Pneumonia (LIP)
• Skin lesions
 Manifestations That Suggests Underlying HIV
Infection in HIV Exposed Infants (Contd.)
Lymphocytic Interstitial Pneumonia
LIP is found in 22-75% of paediatric patients with HIV who have pulmonary
disease.
In contrast, among adult patients with HIV, LIP accounts for only 3% of HIV-
related pulmonary pathology.
Ø Has an insidious onset.
Ø EARLY S/S: Cough and tachypnea.
with swollen glands, enlarged liver and spleen (hepato-splenomegaly), and
eye inflammation (uveitis)
Ø LATE S/S: Dyspnoea and clubbing
• X-ray Chest: bilateral reticulo-nodular interstitial infiltrates
Ø A presumptive diagnosis is made on the basis of clinical and radiological
findings.
Ø Elevated LDH) may be elevated to 300-500 IU/L
Ø A bronchoscopy may be needed to confirm the diagnosis of LIP, to
differentiate from PCP or bacterial.
Ø Treatment: Steroids + HAART
.

Chest radiograph showing bilateral reticulo-nodular interstitial

infiltrates in a 2-year-old boy with HIV infection and lymphocytic
interstitial pneumonitis/pulmonary lymphocytic hyperplasia
(LIP/PLH).
Presumptive diagnosis of LIP/PLH is based on persistence for 2
months or more of characteristic radiographic features
 Manifestations That Suggests Underlying
HIV Infection in HIV Exposed Infants
• Several skin diseases and manifestations are
seen in children infected with HIV such as:
ü Seborrheic dermatitis
ü Atopic and generalized dermatitis,
ü Lesions due to nutritional deficiency,
ü Eczema,
ü Psoriasis,
ü Drug eruptions and alopecia
• Anaemia and thrombocytopenia
 FU Algorithm in HIV-exposed infants in
Resource-Limited Settings

• Ask • Look and feel

– If child has pneumonia – Poor weight gain or fall
– Has or had diarrhea in - as seen in road to health
card
last 3 mo for >14 d
– Enlarged LN in neck,
– Has now or had ear
axilla or groin
discharge in past
– Oral thrush
– Parotid swelling
Suspect HIV Infection
Detailed general & systemic examination
• Herpes zoster
• Papular pruritic eruptions (PPE)
• Diffuse skin dryness
• Warts, molluscum, etc.
• Angular cheilitis
• Parotitis, ENT exam etc.
• Lymphadenopathy
• Oropharyngeal mucosa candidiasis, oral hairy leucoplakia (OHL)
etc.
• Exclude active tuberculosis: respiratory system, abdominal
lymphadenopathy, etc.
• Hepatosplenomegaly
• Examination of eye and optic fundus
Examination of genito-urinary tract
Immunization Schedule for HIV-exposed and/or
infected infant

Age Vaccine Vaccine Vaccine

Birth BCG OPV-0 Hep B-1

6 weeks DPT+HiB-1 OPV-1 HepB-2

10 weeks DPT+HiB-2 OPV-2 Hep B-3

14 weeks DPT +HiB-3 OPV-3

9 mo Measles - Vitamin A
dose
15 mo MMR

18 mo Booster -1 Booster-1

5 yrs Booster – 2 Booster – 2

DT OPV
 Additional Vaccines in
HIV Infected Children
§ Pneumococcal vaccine
v Single dose > 2yrs
v Booster after 5 yrs
§ Varicella vaccine
v Recommended in asymptomatic /mildly symptomatic children
v 2 doses at 3 monthly interval
v Strongly recommended for HIV negative siblings and children in house
hold
v Contraindicated in moderate and severe immuno-compromised
children
§ Other vaccines
v Influenza virus vaccine annually, specific strain only
v Hepatitis A if indicated
§ Typhoid oral vaccine - contraindicated
Tests for diagnosis of HIV infection

• HIV antibody test

• HIV viral culture

• HIV immune complex dissociated (ICD)

p24 antigen test

• HIV DNA PCR

Tests of choice for infants & children
under 18 months of age
Test Recommended Reason
/ Not
HIV Elisa No False +ve due to
persistent maternal
antibodies
HIV viral culture Yes, but Costly, result takes
2-4 wks, not readily
available
HIV ICD p24 Yes, but Lower sensitivity
antigen than PCR
(27% at 6 weeks)
HIV DNA PCR Yes 98% sensitive from
4 weeks of age
 HIV diagnosis under 18 months
Non-breast feeding Breast-feeding
infant infant

IST HIV DNA PCR IST HIV DNA PCR

at 6 weeks of age at 6atweeks
6 weeks
of age

Retest 6-8 wks

+ve test -ve test +ve test -ve test after stopping
Breast-feeding
Repeat Again IIND PCR Repeat Again
If +ve test +ve test +ve test -ve test
At 6 months

REPORT HIV REPORT HIV

POSITIVE POSITIVE Report HIV
Uninfected
Repeat virological test if infant becomes symptomatic
 What about mother/infant on ART
prophylaxis for PPTCT?

• DNA PCR is a sensitive technique used to

detect specific HIV proviral sequences in
DNA of patients’ peripheral blood
mononuclear cells (PBMC).
• HIV DNA remains in infants’ peripheral blood
mononuclear cells, so DNA PCR testing may
be used to confirm or rule out diagnosis of
HIV infection in infants of mothers who have
received ART.
 AVAILABILITY OF DNA - PCR
TEST
1. KALAWATI SARAN CHILDREN
HOSPITAL (Centre Of Excellence)
2. A.I.I.M.S (CHARGING RS. 400/-)
3. N.I.C.D
4. PVT. RANBAXY LABORATORIES (RS.
3000-4000/-)
 HIV diagnosis over 18 months
Non-breast feeding Breast-feeding
child child

1st HIV antibody test 1st HIV antibody test

Retest 6-8 wks

2nd 2nd -ve
2nd +ve test 2nd -ve test after stopping
+ve test test breast-feeding
Not HIV
Infected
Clinical Signs +ve test
of HIV -ve test
Clinical Clinically
Signs of HIV Normal +ve
Clinically Not HIV
Report HIV Infected
3rd HIV Normal
Report HIV +ve Infected
antibody
Infected Test
-ve
-ve Indeterminate 3rd HIV Test
 CD4 counts / % in
Pediatric HIV infection
• Used to assess immunological status of the HIV-infected
child

• CD4 % varies less than CD4 counts, hence considered

more valuable in children < 5 years of age.
Absolute CD4 T-Lymphocyte count
• CD4%= ------------------------------------------------ X 100
Total Lymphocyte Count
• Total Lymphocyte Count= Total no. of Lymphocytes X
TLC/100
 NORMAL CD4 COUNT &
CD4%
AGE CD4
CD4%

Ø< 12 MONTHS : >1500/cu.mm

>=25%

Ø < 1- 5 YEARS: >1000/cu.mm

>=25%
 WHO cutoffs for initiating ART

Immunological </= 12-35 36-59 >/=

marker 11 mo mo mo 5 years

CD4% </= </= </= </=

25% 20% 15% 15%

CD4 count </= </= </= </=

cells/mm3 1500 750 350 200
 WHO Revised Clinical Staging
Principles of Staging
Classification of HIV- WHO Clinical Stage
associated clinical disease
Asymptomatic 1

Mild 2

Advanced 3

Severe 4
Primary HIV infection
Asymptomatic
Acute retroviral syndrome
Clinical Stage 1
Asymptomatic
Persistent generalized lymphadenopathy

It should be emphasized that WHO clinical staging of HIV

disease can only be applied where HIV infection has been
established
Clinical Stage 2

§ Unexplained persistent hepatosplenomegaly

§ Papular pruritic eruptions
§ Extensive wart virus infection
§ Extensive molluscum contagiosum
§ Recurrent oral ulcerations
§ Unexplained persistent parotid enlargement
§ Lineal gingival erythema
§ Herpes zoster
§ Recurrent or chronic respiratory tract infections (otitis
media, otorrhoea, sinusitis, tonsillitis )
§ Fungal nail infections
unexplained hepato-splenomegaly
Parotid Swelling, molluscum contagiosum
Herpes simplex and extensive
warts
Clinical Stage 3
1. 1. Moderate unexplained malnutrition not responding
2. 2. Unexplained persistent diarrhoea (14 days or more )
3. 3. Unexplained persistent fever > 1mth (intermittent or constant)
4. 4. Persistent oral Candida (outside first 6- 8 weeks of life)
5. 5. Oral hairy Leukoplakia
6. 6. Acute necrotizing ulcerative gingivitis/periodontitis
7. 7. TB lymphadenitis
8. 8. Pulmonary tuberculosis
9. 9. Severe recurrent presumed bacterial pneumonia
§ Symptomatic lymphoid interstitial pneumonitis
§ Chronic HIV-associated lung disease including bronchiectasis
10.Unexplained anaemia (<8g/dl ), neutropenia (<500/mm3) or
chronic thrombocytopenia (<50 000/ mm 3)
11. HIV-associated cardiomyopathy or
12. HIV-associated nephropathy
Unexplained malnutrition and recurrent
sever oral thrush can bee seen tin the child
Tubercular
lymphadenopathy
Clinical Stage 4
§ Unexplained severe wasting, stunting or severe
malnutrition not 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 or visceral at any site)
§ Extrapulmonary tuberculosis
§ Kaposi sarcoma
§ Oesophageal candidiasis (or candida of trachea, bronchi
or lungs)
§ Central nervous system toxoplasmosis (outside the
neonatal period)
Clinical Stage 4 (Contd.)

§ HIV encephalopathy
§ Cytomegalovirus (CMV) infection; retinitis or CMV
infection affecting another organ, with onset at age over 1
month .
§ Extrapulmonary cryptococcosis including meningitis
§ Disseminated endemic mycosis (extrapulmonary
histoplasmosis, coccidiomycosis, penicilliosis)
§ Chronic Cryptosporidiosis
§ Chronic Isosporiasis
§ Disseminated non-tuberculous mycobacteria infection
§ Acquired HIV-associated rectal fistula
§ Cerebral or B cell non-Hodgkin lymphoma
§ Progressive multifocal leukoencephalopathy
sever malnutrition and PCP
pneumonia
Herpes and TBM-extra pulmonary
tuberculosis and sever cachaxis state
Clinical criteria for presumptive diagnosis of severe HIV disease
in infants and children < 18 months of age
• A presumptive diagnosis of severe HIV disease should be made if
§ The infant is confirmed HIV antibody positive
and
§ Diagnosis of any AIDS-indicator condition(s) can be made
or
§ The infant is symptomatic with two or more of the following
o Oral thrush
o Severe pneumonia
o Severe sepsis

• Other factors that support the diagnosis of severe HIV disease in an

HIV sero-positive infant include
§ Recent HIV-related maternal death or advanced HIV disease in the mother
§ CD4 < 20%

– Confirmation of the diagnosis of HIV infection should be sought as soon as

possible
AIDS Indicator(s) Illnesses in Children

Some clinical conditions are very unusual

without HIV infection
– Pneumocystic pneumonia
– Oesophageal Candidiasis
– Lymphoid interstitial pneumonitis
– Kaposi’s sarcoma
– Cryptococcal meningitis
 STAGE WISE ART
INDICATION
WHO STAGE
I & II ART ONLY CD4 GUIDED
III Treat All*
IV Treat All

§Stabilize First any underlying Opportunistic

Infection(s) before starting ART
§CD4 Baseline- to monitor efficacy of ART
§*In Children with Pulm. TB or /L. Node TB- CD4
Guided ART
 OI in Pediatric HIV/AIDS
• Bacterial: -- TB
--Sepsis, meningitis etc
- MAC: Mycobacterium Avium Complex

• Viral infections : - CMV

- HSV
- Varicella
- Herpes zoster

• Fungal infections: - - Pneumocystis Pneumonia

- Candidiasis
- Cryptococcus
- Penicilliosis

• Protozoal infections: - Toxoplasmosis

- Cryptosporodia
- Isospora
 PCP
• SUSPECT: When
Child < 12 mth of age
Ø Tachypnoea
Ø Dyspneic
Ø Cyanosis
Ø Few crypts relative to cyanosis
• DIAGNOSIS:
• X-ray- B/L Diffuse parenchymal infilterates with ground glass or reticulo
granular appearance
• Arterial Blood gases- Hypoxia
• LDH-Increased levels
• Demo Organism in Gastric lavage/sputum/brohoalveolar lavage (BAL)-
with Gomori or Giemsa stain
• Tt: TMP/SMX 15-20mg/kg of TMP iv or oral in 4 divided doses X 14
days.
• If paO2 < 70 mm Hg at room air- Steroids
Chest radiograph of an HIV-infected patient, CD4 count of
<200 cells/µL, revealing bilateral, predominantly central,
granular opacities and 3 thin-walled air-containing cysts
(pneumatoceles) suggestive of PCP
There is increased white (opacity) in the lower lungs on
both sides, characteristic of Pneumocystis pneumonia
 TUBERCULOSIS
SUSPECT: IF
H/O contact with adult patient of TB
Fever & / or cough > 3 wks
With or without weight loss or poor/no wt gain
Pneumonia not responding to A/B
Recent glandular enlargement
HIV –TB COINFECTION:
48% cases, extra-pulmonary TB & Miliary TB are more
common in children
DIAGNOSIS: Combination of
CXR,C/F, Mx’ Test positive> 5 mm etc.
 RNTCP REGIMEN
Category Type of patients Intensive phase
Continuation phase

I. New Sputum +ve PTB 2 H 3 R3 Z 3 E 3 4H3

R3
L. Node TB, unilateral pleural
TB OR
New Sputum –ve PTB, TBM,
Disseminated/Miliary TB,
GI /pericardial/pleural TB.
II. Sputum smear +ve relapse 2 S 3 H 3 R 3 Z 3 E 3+ 5 H 3 R 3 E 3
Sputum +ve treatment failure 1 H3 R 3 Z 3 E 3
Sputum +ve defaulter
III New Sputum –ve , not sick 2 H 3 R 3 Z 3 4H3R3
New Extrapulm TB, not sick

INH-10G/KG, RMP-10-20MG/KG,PZ-30 MG/KG, ETB-15 MG/KG

 M.A.C.
MAC –various non Tb mycobateria- M.avium,
M.intracellulare, M.paratubercolosis
C/F – recurrent fever, wt. loss, night sweats, fatigue,
chronic diarrhoea, abddominal pain ,
Lymphadenopathy, hepatosplenomegaly,
Pancytopenia.
DIAGNOSIS: Demo Org in Blood, bone marrow or
L.node
TREATMENT-Clarithromycin 10mg/kg/day PO BD
plus Ethambutol 15-20 mg/kg PO OD plus Ciproflox
20-30mg/kg IV or PO
Life long Secondary prophylaxis (after Treatment)
needed-
Clarithromycin- 15 mg/kg PO BD – if CD4 count is
less.
 Toxoplasmosis
• Caused by Toxoplasma gondii
• Vertical transmission risk is 81% if infection occurs last few weeks of
pregnancy
• CNS involvement is common
• Asymptomatic at birth, During infancy : rash ,hepato-splenomegaly,
lymphadenopathy, jaundice, hydrocephalus, microcephaly,
intracranial calcifications & seizures
• Older children develop fever, malaise, headache, altered mental
status & focal neurological deficits
• Detection of IgM antibodies in infants <6months of age or
persistence of IgG beyond 12 months
• Imaging: ring enhancing lesions in the basal ganglia and cortico -
medullary junction
 Toxoplasmosis
Treatment :
• Congenital Toxoplasmosis:
• Pyrimethamine (loading dose of 2 mg/kg/day) for 2
days and then 1 mg/kg/day for 2-6 months followed by
1 mg/kg administered three times a week
+
Sulfadiazine (50 mg/kg/dose twice daily)
+
Folinic acid (10-25 mg daily)
• Recommended duration of therapy – 12 months
 HIV infected children with acquired CNS, ocular or
systemic toxoplasmosis:

• Pyrimethamine (2 mg/kg/day for 3 days, followed by 1

mg/kg/day)
+
Sulfadiazine (25-50 mg/kg/dose 4 times daily)
+
Folinic Acid (10-25 mg/day)
• Therapy should be continued for 6 weeks and longer
courses may be required with extensive disease or
poor response.
• Alternative treatment:
-TMP 5 mg / SMX 25 mg iv/oral bid (not studied in
children)
-spiramycin:1.5-3 lakh units/kg/day in divided doses
 Toxoplasmosis
Prophylaxis:-
• Secondary prophylaxis – Life-long
suppression is indicated to prevent recurrence
Sulphadiazine (80-100mg/kg/day) +
Pyrimethamine (1mg/kg/day) PO+ Folinic acid
(5mg/day PO)

• Primary prophylaxis – TMP/SMX also

provides prophylaxis against Toxoplasmosis
 DIARRHOEA IN HIV INFECTED
CHILDREN
1. PROTOZOA: E. histolytica, Giardia
lamblia, Cryptosporidium parvum, Iospor
belli, Microsporidia, Cyclospora
2. BACTERIA: Salmonella, campylobacter,
Shigella, Closridium dificile & MAC
3. VIRUSES: CMV, HIV, HSV & rotavirus
 Treatment
Immune restoration by HAART may result in
clearance of cryptosporidium &
microsporidia
1. Cryptosporidium: Nitazoxanide
2. Microspordia: Nitazoxanide
3. Isospora: TMP/SMX-20mg/kg in 4 divided
doses X 10 days & then BD X 3 days.
4. Cyclospora: TMP/SMX-10mg/kg in 2
divided doses X 7 days.
 Cryptococcosis
• Caused by Cryptococcus neoformans.
• Less frequent among children
• Presents as acute or sub-acute meningitis, encephalitis

• Fever, headache, malaise & altered mental status

• Neck stiffness & focal deficit are rare

• Diagnosis: CSF Exam :
Protein, sugar & cell count may be normal, Elevated opening pressure is a
diagnostic clue, India ink stain demonstrates the organism (low sensitivity)
• Cryptococcal antigen & fungal culture (more sensitivity)
• Treatment: Amphotericin-B: 0.7mg -1.5mg/kg/day iv x 8-10weeks
 Cryptococcosis
Treatment :
• Induction phase:
- Amphotericin-B: 0.7mg -1.5mg/kg/day iv x 2 weeks

• Consolidation phase:
- Amphotericin-B: 0.7mg -1.5mg/kg/day iv x 8-10 wks
or until CSF is sterile or toxicity develop.
or
- Fluconazole: 5-6mg/kg/day iv or orally x 8-10 weeks
 CANDIDA INFECTION
ORAL CANDIDA: Clotrimazole application 4-6
hrly X 7-14 days. If failure to treatment- oral
Fluconazole 3-6 mg/kg/day OD X 7-14 days or
Itraconazole 2-5 mg?kg/dose OC BD X 7 days
ESOPHAGEAL CANDIDA: Fluconazole X 21 days
SYSTEMIC CANDIDIASIS: Amphotericin B 0.5 –
1.5 mg/kg/OD/IV over 1-2 hours X 14-21 days
after disappearance of S/S
 Cytomegalovirus
Epidemiology:

• CMV is a human herpes virus type-5

• Infection is usually asymptomatic
• Congenital CMV or acquired infection through contact with
saliva urine or breast milk
• CMV Retinitis:Commonest CMV disease: Asymptomatic &
usually discovered on routine ophthalmic evaluation,
Children present with floaters & loss of vision, Fundoscopy :
retinal infiltrates & hemorrhages,
• Half yearly ophthalmologic evaluation is a must in all children
 CMV retinitis
Retinal infiltrates & hemorrhages,
 CMV retinitis
Treatment :
• Ganciclovir 5 mg/kg/dose iv bid x 14 to 21days
• Foscarnet in resistant cases
• Intravitreal Ganciclovir given in a few referral
centres

Secondary prophylaxis :
• Oral Ganciclovir 30 mg/kg/day until CD4% suggests
immune recovery
Primary prophylaxis:
If CD4 < 50 /cumm oral Ganciclovir 30 mg/kg PO
TDS
 Cryptococcosis
Prophylaxis :
• Primary :
- not recommended
• Secondary:
- Fluconazole 3-6mg/kg/day life long or
until CD4% suggests immune recovery
 Penicilliosis
• Caused by Pencillium marnefei, a dimorphic fungus
• Endemic in north eastern part of India (Manipur)
• Clinically presents with fever, papular rash with central
umbilication over face, ears & extremities which looks
similar to molluscum
• May be associated with lymph node & hepatic involvement
• Wright staining of the skin scraping ,bone marrow or lymph
node biopsy demonstrates organism
• Treatment: Amphotericin–B – 0.6 mg/kg/day iv x 2 weeks
followed by oral Itraconazole – 2 to 5 mg/kg/day x 8 – 10
weeks
Penicilliosis
 Herpes simplex virus
• HSV has 2 types: HSV-1 and HSV -2
• Vertical & horizontal transmission occur
• HSV persistent > 1month or visceral HSV
infection are AIDS indicator conditions
• Neonatal HSV involves CNS, skin, eyes & mouth
• Older infants & children develop ulcers in &
around the mouth (gingivo stomatitis)
• Giemsa staining of scrapings of the lesions
shows multinucleated giant cells and
intranuclear inclusions which are similar to
Varicella zoster
HSV-1
 Herpes simplex virus
Treatment :
• Acyclovir is the drug of choice
• Neonatal HSV and HSV encephalitis should receive iv
Acyclovir 10 mg/kg/dose tid x 7-14days
• Gingivo stomatitis: oral acyclovir 20 mg/kg/dose 5 times/day
x 7-14days
 Varicella
• Varicella virus belongs to Herpes group
• Can cause severe disease in HIV infected children
-large extensive vesicles
-prolonged exanthematous phase
-complications like pneumonia, otitis, encephalitis
are
common
• Tzanck smear of scraping from the lesions
• Oral acyclovir 20 mg/kg/dose qid /day x 7days for
mild cases
• IV acyclovir 10 mg/kg/dose tid x in severe cases
 Herpes zoster
• Herpes zoster usually occurs as reactivation of
previous varicella infection
• Vesicles may occur in multiple dermatomes
• May have associated retinitis, pneumonitis &
encephalitis
• May have prolonged clinical course
• Healing is associated with extensive scarring
• Mild disease: oral Acyclovir 20 mg/kg/dose qid
x7days
• Severe form: iv Acyclovir 10 mg/kg/dose tid x 7-14
days
 Recommended first line therapy
• Regimen of 2 NRTI plus 1 NNRTI
– AZT + 3TC + NVP/ EFV
– d4T + 3TC + NVP/ EFV
– ABC* + 3TC + NVP/ EFV

• *ABC presently not available through the national program

• Never use AZT and d4T together
• AZT – 1st choice in non-anemic children (Hb > 9 gm%)
• d4T – 1st choice in those who are anemic
AZT-Zidovudine, 3 TC-Lamivudine, d4T-stavudine, NVP-
Nevirapine,
EFV-Efavirenz, ABC-abacavir
What 1st line regimen to use if the
child is on rifampicin?

If starting ART after rifampicin-based anti-TB treatment

Preferred regimen
2NRTI + NVP (in children < 3 years old or
weigh < 10 kg)
2 NRTI + EFV (in children >= 3 years old)
Continue treatment after completing
rifampicin-based anti-TB treatment.
 Single dose ARV formulations
• Zidovudine • Nevirapine
– 10 mg/mL
– 100 mg cap – 10 mg/ mL
– 300 mg tab – 200 mg tab
• Lamivudine • Efavirenz
– 10 mg/ mL
– 150 mg – 200 mg cap
• Stavudine – 600 mg cap
– 1 mg/ mL – 30 mg/ mL
– 30 mg cap
– 40 mg cap
• Abacavir
– 300 mg tab
 ARV formulations – Dual drug
FDC
• AZT + 3TC
– AZT 300 mg + 3TC 150 mg

• d4T + 3TC
– d4T 30 mg + 3TC 150 mg
– d4T 40 mg + 3TC 150 mg
– d4T 12 mg + 3TC 60 mg DT
– d4T 10 mg + 3TC 40 mg/ 5 mL (needs
refrigeration)
 ARV formulations - FDC: Triple
drug
Pediatric FDCs
– 10 mg + 40 mg + 70 mg/ 5 mL (needs refrigeration)
– 6 mg + 30 mg + 50 mg Dispersible tablet (Small dose
tablet)
– 12 mg + 60 mg + 100 mg Dispersible tablet (Bigger dose
tablet)
– 10 mg + 40 mg + 70 mg Dispersible tablet
 Severe toxicities and substitutions
First-line ARV drug Most frequent significant toxicity
for the ARV drug
AZT Severe anemia or neutropenia d4T or ABC
Lactic acidosis ABC
Severe gastrointestinal intolerance d4T or ABC
d4T Lactic acidosis ABC
Peripheral neuropathy AZT or ABC
Pancreatitis
Lipoatrophy/metabolic problem
EFV Persistent severe CNS toxicity NVP
Potential teratogenicity
NVP Acute symptomatic hepatitis A third NRTI or PI
(presently not available
Hypersensitivity reaction
through the program)
Severe or life-threatening rash (SJS)
ABC Hypersensitivity reaction AZT
PEDIATRIC ART DOSING
DISC
3 DRUG FDC: FOR CHILDREN > 5 KG (NVP containing regimen) in
initial 2 weeks period NVP is given only once a day

1.FDC 6- STA 6, LAM 30, NVP- 50

2.FDC 10- STA 10, LAM 40, NVP -70

3.FDC 30- STA 30, LAM 150, NVP 200

2 DRUG FDC: (FOR CHILDREN > 10 KG, OLDER THAN 3 YEARS)

PLUS EFV IS
ADMINSITERED IN EVENING (2.5 ml syp EFV-50 mg)

1.FDC 6- STA 6, LAM 30

2.FDC 10- STA 10, LAM 40

3.FDC 30- STA 30, LAM 150