Research, treatment, vaccination, indications and prevention of HIV infection.
Infection caused by the human immunodeficiency virus is caused by the HIV-1 retrovirus. The disease leads to a progressive depletion of the immune system and the development of opportunistic infections and neoplasms; in the terminal stage, acquired immunodeficiency syndrome. The diagnosis is based on the detection of antiviral antibodies in children older than 18 months, as well as PCR-diagnosis in children younger than 18 months. The treatment is carried out with a combination of anti-retroviral drugs.
In general, the pathophysiology of HIV infection in children is similar to that of adults; However, the mechanism of infection, clinical manifestations and treatment often differ. HIV-infected children also have specific problems associated with social integration.
HIV infection - epidemiology
In the US, HIV in children began to appear at about the same time as in adults, but for several years was not clinically diagnosed.To date, more than 9,300 cases of HIV infection have been observed in children and adolescents, which represents only 1% of the total number of cases.
Over 90% of children in the United States became infected from their mothers either in utero or intra-natally. Most of the remaining received transfusions of infected blood or its preparations. Several infections occurred as a result of sexual assault. In less than 5% of cases, there is no obvious source of infection. The vertical transmission is observed in almost all cases of reported diseases in children in the United States before adolescence.
Worldwide, about 2.5 million children are living with HIV infection, and about 700 thousand children are infected every year. In sub-Saharan Africa, where the epidemic lasts the longest, some prenatal centers report that from 25 to 40% of all women of childbearing age are seropositive. HIV infection is spreading rapidly in India, China, Southeast Asia and some areas of Eastern Europe and Russia. About 500 thousand children die from HIV infection every year in the world.
The risk of infection for an infant born to an HIV-positive mother who did not receive antiretroviral therapy during pregnancy is between 13 and 39%.The highest risk is observed in infants born to mothers in whom seroconversion occurred during pregnancy, as well as manifest forms of AIDS in the mother, low levels of CD4 + T-lymphocytes in peripheral blood, late rupture of the membranes.
There is no reason to limit adoption and upbringing of HIV-infected children. Conditions that may pose an increased risk to others may require special precautions.
The number of school staff who are aware of the child’s condition should be kept to the minimum necessary to ensure proper care. The family has the right to inform the school, but those involved in the care and education of the child must respect the child’s right to secrecy. Information can be disseminated only with the consent of the parents or legal guardians, as well as the consent of the child himself, taking into account his age.
At high viral load, it is detected by determining a high concentration of viral protein p24 in the blood, quantitative isolation of the virus or determining the concentration of RNA. In childbirth per vias naturales, in a twin who is born first, the risk of infection is higher than in a second born, although this relationship does not seem to be the same in developing countries.
A caesarean section can reduce the risk of mother-to-child transmission of HIV. However, it is clear that the risk of mother-to-child transmission of HIV can be significantly reduced by using antiretroviral therapy [including zidovudine] in the mother and newborn. Monotherapy ZDV reduces the risk of mother-to-child transmission of HIV to approximately 8%; with modern, highly active antiretroviral regimens, the risk of mother-to-child transmission of HIV infection in the United States is less than 2%.
HIV was detected in both the cellular and extracellular fractions of human milk. Transmission of HIV during breastfeeding is observed with a frequency of approximately 6 cases per 100 breastfed children per year. The overall risk of HIV transmission through breastfeeding is estimated at 12-14%, reflecting the different duration of feeding. The risk of HIV transmission through breastfeeding is higher in mothers with a higher viral load.
HIV infection in the adolescent period significantly influences the growth of cases in young people. Ways of transmission in adolescents are similar to those in adults, mainly through unprotected sexual intercourse and less commonly with intravenous drug addiction.
Classification.HIV infection causes a wide range of diseases, of which AIDS is the most serious. Epidemiological classification schemes adopted by the CDC take into account the progression of clinical and immunological disorders. In children under 13 years of age, the clinical categories N, A, B, and C are asymptomatic and mild, moderate and severe, manifest, respectively.
Category N: Asymptomatic HIV Infection
Children who have no symptoms or signs considered to be a consequence of HIV infection, or one of the conditions listed in Category A is noted. Category A: easy manifest Children with 2 or more conditions listed below, in the absence of conditions listed in categories B and With dermatitis, hepatomegaly, lymphadenopathy, parotitis. Recurrent or persistent upper respiratory tract infection, sinusitis or otitis media. Splenomegaly.
Category B: moderate HIV infection
Children who have clinical signs characteristic of HIV infection other than those listed in category A, but not listed in category C. Examples include but are not limited to the following:
Anemia, neutropenia, or thrombocytopenia persisting for more than 30 days
Bacterial meningitis, pneumonia or sepsis
Oral pharyngeal candidiasis persisting in children older than 6 months
Cytomegalovirus infection with onset at the age of 1 month
Diarrhea, recurrent or chronic
Herpetic stomatitis, recurrent Herpetic bronchitis, pneumonitis or esophagitis, with onset at the age of 1 month Herpes zoster at least 2 separate episodes or covering more than 1 dermatoma Leiomyosarcoma
Lymphatic interstitial pneumonitis or pulmonary complex lymphoid hyperplasia
Prolonged fever Toxoplasmosis with onset at the age of 1 month Chickenpox, generalized forms.
Category C: severe HIV infection
Serious bacterial infections, repeated or recurrent, of the following types: septicemia, pneumonia, meningitis, infection of a bone or joint, or an abscess of an internal organ or cavity Candidiasis of the esophagus or respiratory tract
Coccidiomycosis, disseminated Cryptococcosis, extrapulmonary
Cryptosporidiosis or isosporia with diarrhea persisting for more than 1 month. Cytomegalovirus infection with onset over 1 month of age.
1) the absence at the appropriate age or loss of acquired skills and abilities or a decrease in intellectual abilities, confirmed by standard developmental scales or neuropsychological tests;
2) brain growth disorder or acquired microcephaly, demonstrated by measuring the circumference of the head, or brain atrophy, as demonstrated by CT or MRI;
3) acquired symmetric motor deficiency, manifested by two or more syndromes from the following: paresis, pathological reflexes, ataxia, gait disturbance. Herpetic infection, manifested by the formation of ulcers on the skin and mucous membranes, which last more than 1 month; or bronchitis, pneumonitis or esophagitis for any duration, affecting children over the age of 1 month
Histoplasmosis, disseminated by Kaposi's Sarcoma
Lymphoma, primary, brain.
Small cell lymphoma
Small cell lymphoma, or immunoblastic, or large cell B-cell lymphoma, or lymphoma with an unknown immunophenotype of Mycobacterium tuberculosis, with dissemination or extrapulmonary localization of Mycobacterium, other species or unidentified species, with dissemination.
Pneumonia caused by Pneumocystis jiroveci Progressive multifocal leukoencephalopathy Salmonella septicemia, recurrent Brain toxoplasmosis with onset over 1 month of age Depletion in the absence of a concomitant disease, other than HIV infection, which could explain the following findings:
1) permanent weight loss of more than 10% of the original, or
2) a downward intersection of at least 2 of the following percentile lines on a standard body mass curve in a child over 1 year old, or
3) less than 5th percentile on standard mass-growth curves with 2 consecutive measurements with an interval of 30 days plus chronic diarrhea or documented increase in body temperature of HSV - herpes simplex virus.
1 Categories form a unidirectional hierarchy so that the patient's illness goes from category N to A, then to B, then to C. For example, if a child has hepatomegaly and lymphadenopathy and he develops permanent anemia, then the child goes into category B. If anemia in eventually disappears, the child will remain classified in category B. If pneumocystis pneumonia develops, the child is reclassified into category C.Similarly, immunological categories form a unidirectional hierarchy; if a child with CD4 + lymphocytes corresponding to category 2 has such an increase in CD4 + lymphocytes during therapy, that the number of cells is enough to fall into category 1, the child nevertheless remains classified in immunological category 2.
Adapted from: Centers for Disease Control and Prevention. 1994 Revised classification of children for less than 13 years of age; official authorized addenda: ICD-9-CM. MMWR 1994; 43, pp. 1-19.
Mild, moderate, and severe immunodeficiency are referred to as categories 1, 2, or 3, respectively; they are determined by the level of CD4 + T-lymphocytes, taking into account the age of the child. Thus, the child, according to the classification having a stage of OT, will have moderately pronounced clinical manifestations and severe impairment of immunity.
With intrapartum infection, clinical manifestations are usually absent during the first few months of life. Although the average age of onset of symptoms is approximately 3 years, in some children, clinical manifestations are absent up to 5 years or more, and with adequate antiretroviral therapy, patients can live to adulthood. Before using ARV therapy, about 10–15% of children had a rapidly progressive course of the disease,with the development of symptoms in the first year of life and death at the age of 18–36 months; It is assumed that these children became infected with HIV at an earlier stage of intrauterine development. Most children, however, are more likely to transmit the infection during childbirth or in the early postpartum period, and they have a slower progression of the disease.
The most common manifestations of HIV infection in children include generalized lymphadenopathy, hepatomegaly, splenomegaly, hypotrophy, oral candidiasis, CNS damage, lymphatic interstitial pneumonitis, recurrent bacteremia, opportunistic infections, relapsing diarrhea, mumps, cardiomyopathy, hepatitis, non-fropatia and malignant neoplasms.
Complications.Pneumonia caused by Pneumocystis jiroveci is the most common severe opportunistic infection in HIV-infected children and has a high mortality rate. Pneumocystis pneumonia can develop as early as the age of 4-6 weeks, but in most cases occurs in infants between the ages of 3 and 6 months who become infected during childbirth or shortly before or after them.Infants and children with pneumocystis pneumonia are characterized by the development of subacute diffuse pneumonitis with dyspnea at rest, tachypnea, decreased saturation 02, unproductive cough and fever.
Other common opportunistic infections include candidal esophagitis, generalized cytomegalovirus infection and chronic or generalized herpetic or varicella-caused infection and less often complicated infections caused by Mycobacterium tuberculosis and Mycobacterium avium, chronic enteritis caused by cryptosporidia or other microorganisms, and disseminated or with CNS infection caused by cryptococcus.
Malignant neoplasms in immunosuppressed children with HIV infection are relatively rare, but leiomyosarcoma and some lymphomas, including CNS lymphomas and non-Hodgkin B-cell lymphomas, are significantly more common than in children without immunosuppression. Kaposi's sarcoma is very rare in HIV-infected children.
Diagnosis. HIV specific tests
In children older than 18 months, the diagnosis is made on the basis of a serological study with the determination of antibodies in the blood serum [ELISA assay and confirmatory immunoblotting], as in adults.Only very rarely an HIV-infected older child may have a deficiency of anti-HIV antibodies due to pronounced hypogammaglobulinemia.
In children younger than 18 months, maternal antibodies persist, leading to false positive results from ELISA, so the diagnosis is made based on the definition of HIV infection DNA by PCR, and approximately 30% of all births and almost 100% at 4-6 months of age can be diagnosed . Virological research has acceptable sensitivity and specificity, but is technically more demanding and dangerous, so in most laboratories it was replaced by DNA detection by PCR. Determination of HIV RNA by PCR in children who have not received ARV therapy is also sensitive, as is DNA determination by PCR. At the same time, due to the possible insensitivity of the method in children receiving ARV therapy and the possible nonspecificity of low RNA concentrations, the determination of HIV RNA by PCR is not recommended for diagnosis in children of the first year of life. The modified test for detection of p24 viral antigen is less sensitive than the determination of HIV DNA by PCR and virological method, and should be used only if the latter are not available.
The initial test for determining the DNA of HIV by the PCR method should be performed. Specific rapid tests will give mostly false positive results. At the same time, if the expected probability of HIV is high, the predictive value of positive results increases.
Before a child is tested for HIV, the mother or person caring for him and the child, if he is old enough, should be informed of the possible psychosocial risks and benefits of the examination. Written or oral consent must be obtained and registered on the patient's card, in accordance with state and local and hospital laws and regulations. Requirements for consultation and consent should not be deterred from conducting a survey if there are medical indications for it; The refusal of the patient or guardian to give consent does not relieve doctors of their professional and legal responsibility, and sometimes permission to conduct the examination must be obtained by other means. The results of the survey should be discussed personally with the family, the person providing primary care for the child, and the child himself,if he is old enough; if the child is HIV-positive, appropriate counseling and follow-up should be provided. In all cases, it is important to maintain confidentiality.
Children and adolescents who meet the AIDS criteria should be notified to the appropriate health department. In many states, it is also necessary to report all cases of HIV infection.
Other Methods for Researching HIV Infection
Infected children need to determine the number of lymphocytes T-helpers CD4 + and T-suppressors CD8 + and measure the concentration of viral RNA in plasma to determine the stage of the disease and the prognosis. The first within the first two weeks of life, approximately at the age of 1 month, and between the 4th and 6th months of life. A positive test must be confirmed immediately using the same or a different method. If all consecutive tests for the determination of HIV DNA by the PCR method are negative, the child is considered uninfected with more than 95% confidence. Subsequent studies to determine antibodies are performed to rule out HIV infection and confirm seroreversion.If a child under the age of 18 months with a positive ELISA result, but a negative indicator of virological research develops an AIDS-related disease, then he is diagnosed with HIV infection.
Recently, rapid tests for the detection of anti-HIV antibodies, derived from an ELISA method, which provide results within minutes or hours, have become available. They can be carried out on an emergency basis in samples of saliva, whole blood or serum. In the United States, these tests are most reliably useful for screening women with unknown HIV serostatus during labor, thus enabling women to be counseled in a timely manner, initiating ARV therapy to prevent mother-to-child transmission of HIV and conducting a newborn screening during the first postpartum visit . Similar benefits are noted in other episodic situations and in developing countries. Rapid tests require confirmatory reactions, for example, a Western blot method. If the expected HIV prevalence is low, even initially the number of CD4 + T lymphocytes can be normal,but ultimately decline. The number of CD8 + T-lymphocytes usually increases at the beginning and does not decrease until the late stages of the disease. These changes in the T-lymphocyte population lead to a decrease in the CD4 +: CD8 + cell ratio, which is characteristic of HIV infection. The concentration of viral RNA in plasma in untreated children younger than 12 months is usually very high. By the age of 24 months, the concentration of the virus in untreated children is decreasing. Although the wide range of variations in the HIV RNA concentration in children makes the predictive value of its determination in relation to morbidity and mortality lower than in adults, determining the concentration of viral RNA in plasma in combination with determining the number of CD4 + T lymphocytes nevertheless provides more accurate information about prediction than the definition of each of the markers separately. Less expensive alternative markers, such as total lymphocyte count and serum albumin levels, can also predict child mortality from AIDS, which can be used in developing countries.
Although the concentration of immunoglobulins in the serum is not measured routinely, it is often markedly elevated, especially IgG and IgA, but sometimes panhypogammaglobulinemiamia develops in children.Patients may experience anergy during skin tests.
With adequate use of HAART schemes
With adequate use of HAART-schemes, most perinatally infected children live more than 5 years. About 10–15% of children in industrial countries that have not received treatment die before the age of 4, most of them do not even live to 18 months. In developing countries, child mortality from AIDS is much higher in the first few years of life.
Opportunistic infections, especially pneumocystic pneumonia, progressive neurological disorders, severe dystrophy are associated with a poor prognosis; with pneumocysmoid pneumonia, mortality ranges from 5 to 40% in children who received treatment, and almost 100% in children who did not receive treatment. Also, the prognosis is unfavorable in children in whom the virus was detected early or with the development of clinical symptoms in the first year of life. At the same time, with the advent of HAART and antimicrobial prophylaxis of diseases caused by R. jiroveci, the frequency of opportunistic infections and malignant neoplasms has drastically decreased in children who are well following the treatment regimen. When infected with HIV in adolescence, patients experience a slower progression of the disease than in adults.
Treatment of HIV infection in children
About two dozen ARV drugs are known, including complex drugs available in the US, containing several ARV drugs, each of which can cause side effects and interact with other ARV drugs or common antibiotics, anticonvulsants, and sedatives. New ARVs, immuno-modulators and vaccines are being developed.
Standard treatment is carried out with the use of HAART regimens, which include combinations of drugs to maximize viral suppression and minimize cystic selective drug-resistant strains. Most often, HAART consists of a “framework” of 2 nucleoside reverse transcriptase inhibitors that are combined with a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor. Other combinations:
Frequent: about 98% - local reactions at the injection site
Rare: hypersensitivity reactions
(The most frequently suggested doses and noticeable side effects are listed here; other doses, drug interactions and side effects are possible. For more information, see: Working Group on Antiretroviral Therapy and Drug Treatment of HIV-Infected Children,established under the National Pediatric and Family HIV Resource Center, the Office of Resources and Health Services and the National Institute of Health. Guidelines for the use of antiretroviral agents for HIV infection in children. Available at http://www.aidsinfo.nih.gov/.)
TDF is functionally related to the group of NRTIs, however, by chemical structure, it is a nucleotide reverse transcriptase inhibitor.
ZDV, lamivudine and abacavir; regimens with two protease inhibitors; Tenofovir regimens are also used, but there is little evidence to support their effectiveness as first-line regimens. The results of monotherapy or therapy with two nucleoside reverse transcriptase inhibitors are inconclusive. Since expert opinions on HIV treatment strategies are changing rapidly, it is strongly recommended to consult with a specialist. Constantly updated tutorials are available on some websites, the most useful ones.http://www.aidsinfo.nih.gov,http://www.hivguide-lines.org,www.unaids.org.
Therapy will be effective only if the family and the child are able to comply with possibly complex drug regimens. Not following treatment regimens not only leads to failure in HIV control,but also to the selection of drug-resistant strains of HIV, which limits the possibilities of drug therapy in the future. Obstacles to adherence should be clarified before initiating therapy. These may include the availability and taste of tablets and suspensions; drug interactions with current therapy; pharmacokinetic factors, such as the need to take drugs with food or on an empty stomach; The fact that the child is dependent on taking drugs from other people; in adolescents, denial of the disease or fear, distrust of the medical institution and insufficient support from family members.
Initiation of antiretroviral therapy depends on virological, immunological, and clinical criteria; The opinions of specialists in their respects differ. The goal is to suppress HIV replication and maintain or achieve a normal number and percentage of CD4 + lymphocytes.
ARV therapy is indicated for all children older than 12 months with severe clinical or immunological manifestations, regardless of viral load. The appointment of therapy should be considered in children older than 12 months with mild or moderate manifestations,as well as for HIV RNA viral load more than 100 000 copies / ml. Some experts use the lower limit of these indicators. Children without clinical manifestations or immunosuppression may be monitored without antiretroviral therapy if HIV RNA has a viral load of less than 50,000–100,000 copies / ml.
Therapy should be initiated in all children under the age of 12 months if they have clinical manifestations or immunosuppression, regardless of viral load. Many specialists treat children younger than 12 months in the absence of manifestations, as there is a tendency to the rapid progression of HIV infection in the first year of life.
Monitoring. Clinical and laboratory monitoring is essential for detecting drug toxicity and treatment failure. Physical examination and monitoring of blood cell count, HIV RNA viral load and lymphocyte subpopulations should be performed every 3-4 months; biochemical analysis of blood, including liver enzymes, lipid profile and level of amylase and lipase should be monitored at least 1 or 2 times a year.
Vaccination of children with HIV, manifested clinically
In general, live viral and bacterial should not be used in children with AIDS or other HIV manifestations characterized by immunosuppression. An exception is the vaccine against measles-mumps-epidemic mumps in patients who are not in strong immunosuppression; If possible, this vaccination should be done at the age of 12 months to increase the likelihood of an immune response, i.e. before the decrease in immunity develops. A second dose can be administered as early as 4 weeks to try and induce seroconversion as early as possible. If the risk of contact with measles is increased, for example during an outbreak, vaccination should be given at an earlier age, for example, 6-9 months.
Other childhood vaccines such as diphtheria and tetanus toxoids combined with non-cellular pertussis vaccine against hepatitis B, Haemophylus influenzae type b and Streptococcus pneumoniae conjugated vaccines, and Streptococcus pneumoniae and inactivated polio-lytic vaccine are administered in the usual terms according to the vaccination schedule. It is also recommended to vaccinate the pneumococcal polysaccharide vaccine at 2 years and with the inactivated flu vaccine annually from 6 months.
Since children with clinically manifested HIV infection usually have a low immune response to vaccination, if they are in contact with the disease against which the vaccine is administered, they should be considered susceptible to it, despite vaccination. Therefore, when indicated, they should be passively immunized with immunoglobulin. Immunoglobulin must also be administered to any non-immunized family member who is a contact for measles.
Vaccination in children with asymptomatic HIV infection
Such children should be vaccinated with DTP, IPV, conjugated vaccines of H. influenzae type b and S. pneumoniae, HBV and against measles-rubella epidemic mumps according to the general vaccination schedule. Although oral poliovirus vaccine did not cause adverse effects in such patients, live polioviruses can be released into the environment and transmitted to immunosuppressed contact persons, creating an increased risk of developing poliomyelitis caused by the vaccine strain.
Vaccination against chickenpox is safe and is recommended for patients with the early stages of HIV infection. Since HIV-infected children 2 years and older are at increased risk of invasive pneumococcal infection,they must be vaccinated with a polysaccharide pneumococcal vaccine at the age of 2 years. It is also recommended to conduct revaccination after reaching the age of 3-5 years. Every year, HIV-infected children older than 6 months should be vaccinated with an inactivated flu vaccine.
BCG vaccination is not recommended in the USA and regions with a low incidence of TB. Nevertheless, in developing countries where the incidence of TB is high, WHO recommends that all infants without clinical manifestations, regardless of HIV infection of the mother, be vaccinated with BCG. A few cases of disseminated BCG infection have been reported in patients with severe immunodeficiency in AIDS.
It is advisable to passive immunization in contact with measles, tetanus and chickenpox.
Vaccination of seronegative children living with patients with clinically manifested HIV infection
Such children, as well as seropositive, should be vaccinated with IPV, and not OPV. Vaccination against measles, rubella and mumps can be given as these vaccine viruses are not transmitted and do not cause disease. To reduce the risk of influenza in patients with clinically manifestedHIV infection annual flu vaccine is shown to all family members in contact with the patient.
Vaccination against varicella sibes and susceptible adults caring for an HIV-infected child is strongly supported to prevent infection with wild varicella-zoster virus, which can cause serious illness in immunodeficient patients; At the same time, the transmission of the varicella-zoster vaccine virus from person to person is rarely observed.
Adequate antiretroviral therapy is aimed at trying to optimize maternal health, interrupt the transmission of HIV infection from mother to child and minimize the toxic effects of drugs on the fetus. In the United States and other countries where ARV drugs are available and there is an infrastructure for diagnosing HIV, treatment with ARV drugs is the standard in all HIV-infected pregnant women. In HIV-infected women who have not previously received treatment with ARV drugs that do not meet the criteria for prescribing HAART, ZDV is prescribed orally on 300 mg 2 times a day, starting from the 14th to 34th week of gestation, and continues throughout pregnancy, and ZDV is also administered intravenously during labor at a dose of 2 mg / kg in the first hour, and then at 1 mg / before the birth of the child.ZDV, 2 mg / kg orally, is administered to the newborn 4 times a day for the first 6 weeks of life. Women who are not yet shown to start HAART by clinical or immunological indicators, however, are recommended to do this if the viral load is more than 1000 copies / ml. Immediately after birth, it is decided whether to continue the therapy of the mother. Women whose clinical or immunological status meets the criteria for initiating treatment should receive combination regimens using several drugs, preferably including ZDV.
Pregnancy is not a contraindication for HAART, regimens, although a pregnant woman and her doctor should discuss the possible benefits and risks of such therapy, as well as the lack of definitive data on her safety. ZDV therapy reduces the likelihood of infecting a child from the mother from 25% to 8%; Many ARV combinations are also effective. In the US, with modern HAART schemes, the frequency of HIV transmission from mother to child is less than 2%. Thus, although the final decision on ARV therapy remains for a pregnant woman, it should be emphasized that the proven positive effects of therapy outweigh the theoretical risk of fetal toxicity.
Most experts believe that an HIV-infected woman who is already receiving ARV therapy by the time of pregnancy should continue this therapy, even during the 1st trimester; The alternative view is that therapy should be canceled before the start of the 2nd trimester, then it should be resumed.
To reduce the infection of a child from an HIV-infected mother, who has started labor and has not previously received therapy, the doctors used a combination of combination ARV therapy and cesarean section. Express diagnostics in a pregnant woman with ancestral labor and lack of information about HIV serostatus may allow immediate action to be taken. In such situations, you should immediately consult with an expert on HIV infection in children and mothers.
HIV-infected women are not recommended breastfeeding or donation of breast milk in countries where alternative feeding products are safe and available. At the same time, in countries where infectious diseases and malnutrition are important causes of early infant mortality,and safe and affordable artificial mixtures are not available, protection from the risk of death from infection with respiratory diseases and the gastrointestinal tract that breastfeeding can counterbalance the risk of HIV infection. In these developing countries, WHO encourages mothers to continue breastfeeding.
Prevention of infection in adolescence
Since adolescents are especially at risk of HIV infection, they should have information, the opportunity to be tested and find out their serostatus. Teenagers should be told how HIV is transmitted, what it is, how to protect it, including abstinence from a lifestyle that poses a high risk of infection, and promoting safe sex for sexually active adolescents.
Efforts should be concentrated on adolescents at high risk of HIV infection. Patient consent is required for examination and disclosure of information about his serostatus. The decision whether to report HIV status to a sexual partner of an HIV-infected patient without his consent should be based on the likelihood of risk to the partner,whether he has reasons to presume a risk and take precautions, the existence of legally established requirements for the preservation or disclosure of such information and the possible impact on the future relationship of this information.
Prevention of opportunistic infections
Prevention of Pneumocystis pneumonia is indicated for HIV-infected children with severe immunodeficiency. In general, chemoprophylaxis continues throughout life, although at the end of adolescence and children on HAART treatment regimens with improved immune status, prophylaxis can be canceled as long as the immunological category remains 1 or 2. Currently, lifelong chemoprophylaxis regardless of the amount of CD4 + who suffered an episode of pneumocystic pneumonia. Prevention of PMS is also indicated for all newborns from HIV-infected mothers from the 4th to 6th weeks of life. Prophylaxis can be stopped if HIV is reliably excluded with successive examinations using PCR or a virological method. The drug of choice is 75 mgTMP / 375 mg SMK / m trimethoprim-sulfa-methoxazole2inside 2 times a day for 3 days in a row per week; alternative regimens use the same total dose once a day, 3 days a week or 2 times a day every day of the week, or every other day. Patients 5 years and older who do not tolerate TMP-QMS, it is possible to prescribe pentamidine in an aerosol once a month. Intravenous forms of pentamidine were also used, but proved less effective and potentially more toxic. Another alternative, especially in children under 5, is dapsone by mouth once a day. Other drugs that may be effective include pyrimethamine with dapzone, pyrimethamine-sulfadoxine and oral atovaquone. At the same time, the experience of using these drugs is very limited, and one should only think about them if the recommended schemes are not tolerated by the child or they can not be used.
For the prevention of infections caused by Mycobacterium avium in children 6 years and older with a CD4 + lymphocyte count of less than 50 / μl, azithromycin once a week or clarithromycin daily as well as daily rifabutin as an alternative are the drugs of choice. For the prevention of other opportunistic infections, such as cytomegalovirus infection, fungal diseases, toxoplasma encephalitis, the data are limited.