An estimated 40 million people globally are living with HIV. AIDS in children was first recognized in 1982. An increasing number of children are reporting with AIDS worldwide. AIDS is caused by a human immunodeficiency virus (HIV) which is a retrovirus.
HIV was discovered by Institute Pasteur of France and in 1985. A common misconception about HIV/AIDS is that it is only present in Africa and the US. The reality, however, is that HIV/AIDS is everywhere and can affect any race, sex, and culture. It is found that children who were openly living with HIV or AIDS were discriminated against at school, medical facilities, and they were lacking protection from families and the government. UNICEF found that mothers and fathers didn’t know if they were HIV positive or if their children were positive. The few families that did know thrived in their time of despair because they could get medication, administer the medication, and provide a solid base for their child. Unfortunately, most families affected by HIV/AIDS that know their child is positive hide the diagnosis from their friends and the child. So, most children do not even know that they are positive and pose a threat to spread the virus. One major problem, affecting children is mother-child transmission, 93% of cases looked at in this study were from this form of transmission.
1. Mother-to-child transmission of HIV is responsible for most paediatric HIV infections.
2. Exposure to the contaminated blood, blood products, infected needles & syringes.
3. Sexual abuse of children by the person infected with HIV.
4. Through the skin piercing procedures.
5. Through the blood transfusion or blood products that are contaminated.
Modes of HIV transmission to children
6. Mother-to-child transmission (MTCT) accounts for most HIV-infected children.
7. Sexual abuse: particularly in countries with a high level of child abuse, such as South Africa.
8. Transmission by blood transfusion: rare as long as transfused blood is carefully screened. There is a risk where the blood donor was in the window period.
9. Insufficiently sterilized instruments, traditional scarification.
10. Wet-nursing with HIV-contaminated breast milk.
Clinical manifestation seen in children
1. Repeated episodes of infections like Diarrhoea, Candidiasis, Upper respiratory tract infections
2. Generalized lymph – adenopathy other than inguinal
3. Failure to thrive
4. Neurological abnormalities like Delayed mile stones, Encephalopathy
5. Severe bacterial infections, especially if recurrent
6. Persistent or recurrent oral thrush
7. Bilateral painless parotid swelling
9. Persistent or recurrent fever
10. Herpes zoster – single dermatome
11. Persistent generalized dermatitis not responding to treatment
Signs and conditions very specific to HIV-infection
■ Pneumocytisis jiroveci pneumonia (PCP)
■ Oesophageal candidiasis
■ Extrapulmonary cryptococcosis
■ Invasive salmonella infection
■ Lymphoid interstitial pneumonitis (LIP)
■ Herpes zoster affecting several dermatomes
■ Kaposi’s sarcoma
■ Lymphoma (not necessarily)
■ Rectovaginal or rectovesical fistula.
■ Eat small, regular meals 5–6 times per day.
■ Make the food look and taste good. Children who are sick have a poor appetite. Provide at least 1 fruit and 1 vegetable (not including potato) every day.
■ If there is space at home, plant a vegetable garden, so that vegetables are always available.
■ Early implementation
■ Enhance immune function
■ Maintain/improve growth
■ Improve quality of life
■ Provide preventive nutrition counseling:
Vitamin A-rich foods include:
- fortified maize meal and/or bread
- Carrots, sweet potato, mangoes and pawpaw
- Dark-green leafy vegetables e.g. Morogo / imifino and spinach
- Liver, eggs, full-cream milk and small fish
Iron-rich foods include:
- Dark-green leafy vegetables
- Germinated foods
- Meat, kidney, spleen, chicken
Good sources of antioxidants include:
- Vitamin C – berries, oranges, dark-green leafy vegetables
- Vitamin E – nuts, vegetable oils, rice, bran
- Selenium – nuts, grains, vegetables
■ Home-cooked food is better than pre-cooked food in tins or packets. These are expensive and may not be very healthy. Take-away foods like fried chicken are also expensive and not very healthy.
■ Sweets, chocolates and crisps are allowed but should not be eaten in place of food. If these snacks are eaten too often, the child will have no appetite for nutritious food like enriched pap, cereals, vegetables and meat.
■ Dry beans (sugar beans and brown beans) have a nutritional value similar to meat and should be eaten as often as possible.
■ Try to offer at least one portion per day of one of the following: fish, chicken, meat, dry beans, eggs, peanut butter.
■ Add margarine or fish oil when cooking the food.
■ Bread, pap, samp (dried corn kernels), rice, mealies(made from maize) or other cereal should be eaten as much as the child wants, provided they are mixed with one of the above and/or sour milk to increase the food value.
■ Children with a poor appetite should be encouraged to drink frequently during the day, for example, sour milk, milk, custard, yoghurt, soup or fruit juice.
■ Milk is an important part of the child’s diet. After 6 months, the child can drink boiled fresh milk (cows’ or goats’ milk). Children over 1 year of age should drink 2–3 glasses every day of fresh milk
or full-cream powdered milk.
■ To increase the nutritional value of soup, add some of the following: fish, oil, margarine, dry beans, meat or bones, milk or milk powder, vegetables.
■ To increase the nutritional value of porridge add some of the following: eggs, sugar, margarine or oil, peanut butter, sour milk or milk.
Treating Children with HIV/AIDS
Even when children are diagnosed with HIV, the barriers to treatment are significant. In the developing world, there is limited infrastructure and a lack of trained personnel to address the special needs of children. If special pediatric formulations are available, they are expensive and complex to use. In addition, children require a wide range of social services to ensure that they are able to live relatively normal lives.
The decision to begin supportive (terminal) care is difficult and should be made on a case-by-case basis preferably by a team of professionals with the family’s involvement. Once this decision has been made, it should be clearly communicated to other health-care workers involved in the care of the child. This communication can take the form of a letter, which the family may be able to present to other health workers.
In managing HIV-positive children and their caregivers, apply the following principles, which are consistent with the practice of palliative care medicine:
§ Do not discriminate.
§ Be compassionate and show empathy.
§ Maintain confidentiality at all times.
§ Establish and maintain clear two-way communication between all levels of the health-care system (clinics and hospitals) regarding management of the child.
§ Involve all health-care personnel and parents/caregivers in important patient care decisions.
§ Pay attention to pain and suffering, and preserve quality of life for as long as possible, particularly in the later stages of the illness.
a) Use universal precaution measures to prevent infections.
b) General management is like other infectious diseases.
c) Hands should be washed before and after taking care of the patient.
d) Disposable gloves & plastic apron should be worn while handling blood or any blood stained fluids or contaminated equipments.
e) Protective mask should be used.
f) Do not cough or sneeze during any procedure.
g) Used needles should be discarded in a container that is puncture resistant & water proof.
h) The clinical specimen from patients, who are known cases of HIV, should be labeled with “risk of infection”.
i) Spillage of blood & body fluids should be covered with the disinfectant for few minutes & then cleaned.
o Home care of the terminally ill child should be encouraged if the parent(s) or caregiver(s) are able to care for the child at home.
o There should be no need for intravenous fluids or other intensive treatment.
o Reassure the parent(s)/caregiver(s) that the child has not been abandoned by the health service, and that they can re-visit the clinic and have the child readmitted to the hospital at any time.
o Discussions and decisions regarding the institution of home care should be clearly recorded in the child’s records.
o The possibility of chronic/terminal care at a hospice facility should be discussed with parent(s) / caregiver(s) if there are inadequate resources for the care of the child at home.
Prevention of paediatric HIV-infection
§ Prevention of primary infection
§ Reduce heterosexual transmission, ensuring that men are involved in these interventions to reduce the epidemic.
§ Prevent infection during pregnancy and lactation – educate men and women about the increased risk of HIV-infection during pregnancy and lactation.
§ Keep adolescent girls and boys in school with appropriate health/sexuality education.
§ Comprehensive management of sexually transmitted infections (STIs).
Prevention of unintended pregnancies among HIV-infected women
§ Integration of family planning with the prevention of mother-to-child transmission programme (PMTCT).
§ Counseling regarding the dual risk of unintended pregnancies and STIs and HIV.
Safer delivery technique
§ Most of the MTCT occurs during labour and delivery.
§ The risk is increased by prolonged rupture of membranes, assisted instrumental delivery, invasive monitoring procedures, episiotomy and prematurity.
§ Restrict suctioning of the baby to the presence of meconium-stained liquor.
§ The neonate should be dried carefully at birth.
§ Elective caesarean section reduces the MTCT risk appreciably, but is not recommended as a routine.
A. J. School of Nursing