The issues in the management of HIV infected children include immunization, breastfeeding, growth and development monitoring, nutritional support, treatment of opportunistic infections and other complications, prophylaxis for PCP, anti - retroviral drug therapy, psychosocial support and last but not the least transmission of HIV infection.

It is obvious that it needs a multidisciplinary approach to treat an HIV infected child. It is better to take help of person experienced in caring for and treating HIV infected children. Some of the above issues are discussed in detail here:

Immunization :

There are 2 important issues related to immunization of HIV infected patients. First is that there could be suboptimal response to vaccination and second is that certain live vaccines could be contraindicated, die to presence of immunodeficiency.

Suboptimal response: One may need to give double the dose at each vaccination (e.g. with hepatitis B vaccine), and or use additional doses (e.g. 0,1,2,12 schedule with hepatitis B or 2 dose instead of 1 dose with varicella vaccine) to induce maximum possible response. It may also be prudent to check for seroconversion and titres at the end of vaccination to check for efficacy whenever possible (e.g. following hepatitis B vaccine). One should follow the instruction of the vaccine manufacturer while giving vaccine to HIV infected children.

Contraindications: As a rule, live vaccines are contraindicated in immunodeficient patients. All inactivated vaccines are safe in HIV patients. In HIV patients who are asymptomatic and are not immunodeficient, even live vaccines are safe to be used. Hence practically speaking BCG, as it is given at birth, is safe in HIV patients as no newborn that is HIV infected is immunodeficient. Similarly primary doses of OPV which are given before 14 weeks of age are also safe. Booster doses of OPV given later are also safe as they lead to only local gut infection and do not spread systemically. Measles is an exception as it is recommended to be used even in symptomatic HIV patients as wild measles can be fatal in them. Mumps and rubella vaccines are not recommended in immunodeficient HIV patients. Similarly oral typhoid vaccine is contraindicated especially when alternative Vi vaccine is available. Varicella vaccine is safe in HIV patients provided absolute lymphocyte count is above 1200/cu. mm or CD4 cell count is > 25%.

Nutritional support:
Malnutrition in HIV infected child is due to various factors like poor intake, malabsorption, increased requirements due to catabolic state and most importantly due to emotional deprivation.

Management of malnutrition includes the following:

1. Treatment of oral and esophageal candidiasis with antifungals.
2. Prevention and treatment of opportunistic infections.
3. Improved diet with high calories, proteins and vitamins from the available home made food especially during recovery phase of associated opportunistic infections.
4. Energetic treatment of specific diseases like diarrhea, tuberculosis etc.
5. Psychosocial support, emotional support, economical support, immunization guidance and health education of whole family.
6. In the extreme case one may have to resort to tube feeding or total parenteral nutrition for a short time.
   

Growth and development monitoring:
Monitoring of physical growth in form of height and weight velocity and of mental development in form of head circumference and milestones should be done regularly. HIV and other opportunistic infections can affect brain and lead to HIV encephalopathy with poor cognitive ability. Recurrent infections can lead to malnutrition and growth failure. Initially it may present as lesser than expected increase in weight and height and patient going down the percentiles. Later on it can lead to static growth or even weight loss. Hence charting of height, weight and head circumference can predict disease progression. It can also be one of the indications of starting ARVT. Lastly improvement in growth and development after ARVT suggest good efficacy of ARVT.



Like with most of the viral infections, there are very few antiviral drugs available which act against HIV. Various drugs used to treat HIV infection block one of the steps in HIV replication. None of them are true virucidal in the sense that none of them acts on resting virus. They act only when the virus & the host cell replicate. Hence none of them can act on the infected dormant host cells. Other problems is that HIV is hypermutable & hence develops resistance to drug. Both these factors lead to lack of cure with present drugs. There are three types of ARVT available for clinical use: