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NANASI 54: April 2007

In this issue of NANASI:

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  • Case Study: sick infant
  • Growth monitoring in HIV infected infants and children
  • Microbicides


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Case Study: sick infant

This 4-month-old girl had been born to an HIV positive mother. Neither the mother nor the child received prophylactic nevirapine or other ARVs. The mother has oral thrush, but no other signs or symptoms of AIDS. The baby weighed 2,100 grams at birth and seemed to nurse vigorously.

At the age of 4 months, the baby weighs 3,200 grams and has experienced one episode of pneumonia, which was treated satisfactorily with antibiotics. Today, the baby is brought again to clinic with fever, dyspnea and a respiratory rate of 65/minute. The baby has crepitations throughout the chest.

How would you assess and treat the baby?
What tests would you request?
What medicines you will prescribe for this baby?

Discuss the case as a group, and then refer to the comments at the end of this newsletter.

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Why is growth monitoring so important for HIV infected infants and children
(Question from a nurse practitioner at an HIV clinic in Nairobi)

Answer from Dr. Aziz Abdallah

Growth monitoring is an integral part of clinical care for all infants and children. It is an inexpensive and effective way to identify children who require additional monitoring and is easily assessed using height, weight and head circumference measurements.

Growth is a pediatric ‘vital sign' and an optimal nutritional indicator in children. Clinical manifestations of growth failure include:

  • Slow weight gain or weight loss is first to occur
  • Prolonged period, linear growth affected
  • Brain growth as measured by head circumference; it is the last to be affected

It is therefore important to think of growth parameters the same way we think of traditional vital sign measurements (temperature, pulse, respirations). Accurate assessments of clinical status cannot occur without them.

HIV affects growth in children. Growth abnormalities are common in HIV-exposed and infected children and can begin early in life, occur throughout course of HIV disease, can be primary manifestations of HIV disease in exposed infants and can be secondary to opportunistic infections as well as other complications of HIV. Worldwide, malnutrition is the most common cause of immunodeficiency and a leading contributor to childhood mortality. When malnutrition accompanies the immunodeficiency of HIV disease, immune function is further impaired.

Why is growth monitoring important?

  • Growth is a highly sensitive clinical indicator of disease in the HIV-exposed infant
  • Poor growth or failure-to-thrive can be an indication for ARV therapy in an HIV-infected child (Moderate malnutrition (WHO Stage 3), Severe malnutrition/wasting (WHO Stage 4))
  • Poor growth or failure-to thrive in a child receiving ARV therapy can be an indication of treatment failure

According to a study by Pollack H.J. et al (Impaired early growth of infants perinatally infected with HIV: correlation with viral load. J Pediatr 1997; 130(6):715-722), poor growth is associated with high viral load; infants with a high viral load in the first 6 months of life were at high risk for growth failure; viral load was significantly increased at 3, 4, 12, and 18 months in infants that developed growth failure. Poor growth has been shown to precede CD4 decline and the development of opportunistic infections and growth monitoring is the very easy "low-tech" way to monitor disease.

Growth monitoring begins with measuring and charting weight, length and head circumference— all should be done but weight is the optimal indicator because it is a composite of different nutritional factors:

  • Weight: if only one measurement can be done, this is the most crucial
  • Head circumference: this is the second most crucial in children under 2 years of age as it indicates brain growth
  • Height/length


Growth measurements should be obtained either by the clinician during the clinic visit or by other staff trained in conducting measurements before the clinician sees the child. Poor growth may be the only symptom present and needs to be recognized before the child leaves the clinic.

Microbicides

What they are?

Microbicides are compounds that can be applied inside the vagina or rectum to protect against sexually transmitted infections (STIs) including HIV. They can be formulated as gels, creams, films, or suppositories. Microbicides may or may not have spermicidal activity (contraceptive effect). At present, an effective microbicide is not available in the market but research is going on. The first generation of microbicides could be available in the market in as little as 5 to 7 years.

Why they are Important?

It is important to support the development of microbicides because:

  • Despite the knowledge of successful HIV prevention strategies - such as condom use, reduction in the number of sexual partners, diagnosis and treatment of sexually transmitted infections - HIV continues to spread at an alarming rate especially among women in developing countries.
  • Without a preventive HIV vaccine, microbicides offer an alternative to condoms as the most feasible method for primary prevention of HIV.
  • Currently available HIV prevention techniques are often not feasible for many women who live in resource poor settings. The availability of microbicides would greatly empower women to protect themselves and their partners. Unlike male or female condoms, microbicides are a potential preventive option that women can easily control and do not require the cooperation, consent or even knowledge of the partner.

How do they work?

There are different ways in which microbicides act to prevent infection with genital pathogens:

  • They provide a physical barrier that keeps HIV and other pathogens from reaching their target.
  • They act by enhancing the natural vaginal defense mechanisms by maintaining an acidic pH, which protects the vagina.
  • They kill or disable pathogens by stripping them of their outer covering.
  • They act by preventing replication of the virus after it has entered the cell.

There are 23 microbicide products in various stages of clinical development.

How effective will microbicides be?

Microbicides will help people reduce risk of infection—but will not eliminate the risk. The first microbicides are only likely to be 40-60% protective against HIV.  Microbicides should be promoted as a BACK-UP to condoms, not as a replacement.

  • "Use a microbicide with your condom for added pleasure and protection''
  • "Use a male or female condom every time you have sex; if you absolutely can't use a condom, use a microbicide.''


When can we expect a microbicide?

Earliest results from current research are expected in 2008 - 2009. If shown to be effective, a microbicide may be available in a few countries via introductory studies in the next 5 years. If not, we will have to wait a little longer.

As we wait for the microbicides, we still need to advocate for all the HIV prevention methods in use.

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ANSWER TO THE CASE STUDY FROM PAGE 1

This is an HIV-exposed child; a child born to an HIV positive mother. This child of low birth weight, failure to thrive and repeated chest infections may be HIV positive. The child will need the following:

  • Normal examination and good growth (plot the growth chart)
  • Empiric treatment for PCP (pneumocystis carinii pneumonia) as it is common in the first year of life in children living with HIV
  • Start cotrimoxazole prophylaxis
  • Give routine vaccines
  • Send samples for DNA PCR for HIV testing (if available)
  • Counseling on exclusive breastfeeding for 6 months
  • Follow-up in 2 weeks to assess progress


The child should receive cotrimoxazole prophylaxis even without a definitive diagnosis of HIV. Why provide cotrimoxazole prophylaxis to infants whose HIV status is unknown?

  • PCP presents and kills early (3-6 months)
  • HIV is often diagnosed late (15-18 months)
  • Cotrimoxazole is safe, effective and saves lives


If you wait for a definitive diagnosis of HIV, you will lose the opportunity to save many lives. Cotrimoxazole has been shown to help children with HIV live longer and feel better. However, cotrimoxazole is not an antiretroviral medicine and does not treat or cure the HIV virus.

HIV infection in infants and children is generally rapidly progressing. In situations of rapidly deteriorating health status and lack of virologic test availability, a presumptive diagnosis can be made on the following criteria:

  • HIV exposed/antibody positive
  • < 18 months of age
  • Symptomatic with at least two of:
  1. Oral thrush
  2. Severe pneumonia
  3. Severe wasting/malnutrition
  4. Severe sepsis
  5. Recent HIV-related maternal death, advanced HIV disease in the mother and/or CD4 <25% will also support this diagnosis

A presumptive diagnosis then necessitates management of presenting acute illnesses and management of the HIV including the initiation of ART when indicated.


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