eMedicine Specialties > Dermatology > Viral Infections

Childhood HIV Disease: Follow-up

Author: Mark Abdelmalek, MD, Chief, Division of Laser and Dermatologic Surgery, Assistant Professor, Department of Dermatology, Drexel University College of Medicine
Coauthor(s): Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center; Kathleen B Elmer, MD, Consulting Staff, Department of Dermatology, First Medical Group, Langley Air Force Base
Contributor Information and Disclosures

Updated: Jul 15, 2008

Follow-up

Further Inpatient Care

  • Based on the patient's living arrangements and stage of infection, inpatient care may be warranted at some time during the patient's illness.
    • The extensive testing required to rule out an underlying infection or a malignancy may be easiest performed if the child is admitted to a health care facility.
    • If an infection or a malignancy is detected, hospital admission may be appropriate. For example, if intravenous antibiotics are given, a child is usually admitted to the hospital. A serious reaction to an antiviral drug may also mandate hospitalization to follow up on the progression of the reaction and to observe the patient if new drugs are begun.

Further Outpatient Care

  • Maintain an established vaccination schedule in children who are HIV positive to protect them against vaccine-preventable illnesses.
  • Based on the child's age and immune status, clinical outpatient follow-up is necessary. CD4+ counts must be closely monitored, and neurodevelopment should be frequently assessed. In younger children, evaluations should occur every 1-6 months. In older children, a review of systems is advised every 3 months and a physical evaluation should be performed every year. CD4+ counts must be checked every 3-6 months.
  • Accurate and routine height and weight documentation is important in children with AIDS because HIV is known to adversely affect growth rates in children. Evidence18 indicates that children with improved height growth velocity are less likely to exhibit virologic or immunologic failure and less likely to have clinical disease progression.
  • Examinations by specialists should occur routinely. The patient should follow up with an ophthalmologist every 6-12 months and a dentist every 3-6 months.
  • The requirement of laboratory monitoring for the specific antiviral drug dictates the frequency of laboratory monitoring.

Deterrence/Prevention

  • To prevent the spread of HIV disease, appropriate education on the transmission of the virus is needed. School-based programs and community-based interventions should be emphasized.
    • A focus on abstinence and/or condom use with partner notification is important. Behavioral modification to reduce drug abuse is also critical. Immunizations to prevent the spread of other viruses, such as hepatitis B, can reduce sexual transmission of these additional infections.
    • A focus of prenatal screening and maternal care can assist in preventing babies being born with HIV infection. According to the World Health Organization's most recent report, transmission from infected mothers to infants can be reduced to just 2% with successful interventions. Unfortunately, these interventions may not be widely available in areas where they are needed most because of high HIV burdens. Without intervention, 20-25% of infants will become infected by vertical transmission from their infected mothers.
  • The prevention of perinatal transmission of HIV by administering zidovudine chemoprophylaxis to pregnant women has made a dramatic impact on lessening the burden of pediatric HIV disease.
    • More and more developing countries are adopting and implementing antiretroviral therapy for HIV-infected pregnant women. According to the World Health Organization, as of 2004, more than 100 low- and middle-income countries have established Preventing Mother to Child Transmission programs. Although many mothers are not receiving antiretrovirals at this time, the trend is towards improvement; now, approximately 10% of infected mothers globally receive antiretrovirals.
    • In most the significantly affected area, sub-Saharan Africa, 3 countries have made dramatic strides. Namibia, South Africa, and Swaziland have more than doubled their maternal antiretroviral prophylaxis rates from 2004 to 2005.
  • In addition to antiretrovirals, elective cesarian delivery and strict avoidance of breastfeeding can decrease the risk of infant infection to 2%. In developed and industrialized nations, these practices have dramatically reduced the number of new pediatric HIV cases.

Complications

  • Because the immunosuppressed state allows for a wide variety of illnesses, significant complications of HIV infection are expected.

    • The neurologic state of patients infected with HIV is of paramount importance. Routine screening and appropriate therapy to treat such infections is necessary. As outlined above, adherence to a regular follow-up schedule is important.
    • The numerous medications that children with HIV infection take make appropriate laboratory and clinical follow-up important. The possibility of cross-reactions with the many drugs must be addressed.

Prognosis

  • Although HIV infection is usually deadly in children, especially in developing countries, the development of new antiretroviral drugs is promising. The lack of access to antiretroviral agents by children in developing countries is of particular concern.
  • The nutritional status of the child and the diligence with which viral replication is controlled are paramount in determining the outcome of most children with HIV disease.
  • Aggressive treatment of opportunistic infections prevents the more deleterious effects of secondary disease from progressing and further weakening the patient.
  • The social setting of children and the stressors to which they are exposed have also been linked to the progression of the disease.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • As with any disease, appropriate diagnosis and follow-up must be accomplished to ensure that appropriate patient care is rendered. Documentation of patient counseling and medication risks and benefits is necessary.
  • The diagnosis of HIV infection should be reported to the appropriate state and local agencies as mandated by law, while ensuring that the patient's rights are respected. The treatment and evaluation of contacts must also be conducted without violating the patient's right to privacy.
  • If child sexual abuse is suspected, appropriate measures must be taken to allow for investigation. Preservation of medical data is important.
  • Issues involving power of attorney and estate planning may be broached in an appropriate manner while the patient is still competent. Health care providers may be requested to carefully document the patient's mental status if issues of a legal nature are being determined.

Special Concerns

  • Vertical transmission of HIV from mother to child is the main route by which childhood HIV infection is acquired; the risk of perinatal acquisition is 25% (see Background and Age). Recent African epidemiologic data of almost 2000 infants indicate that female infants may be more susceptible to HIV infection before birth and continuing after birth compared with male infants.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.



More on Childhood HIV Disease

Overview: Childhood HIV Disease
Differential Diagnoses & Workup: Childhood HIV Disease
Treatment & Medication: Childhood HIV Disease
Follow-up: Childhood HIV Disease
References
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Further Reading

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Keywords

pediatric HIV infection, HIV-positive children, cutaneous findings of HIV, human immunodeficiency virus, human immunodeficiency virus type 1, HIV-1, human immunodeficiency virus type 2, HIV-2, acquired immune deficiency syndrome, AIDS, immunocompromise

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Contributor Information and Disclosures

Author

Mark Abdelmalek, MD, Chief, Division of Laser and Dermatologic Surgery, Assistant Professor, Department of Dermatology, Drexel University College of Medicine
Mark Abdelmalek, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Kathleen B Elmer, MD, Consulting Staff, Department of Dermatology, First Medical Group, Langley Air Force Base
Disclosure: Nothing to disclose.

Medical Editor

Robin Travers, MD, Professor, Department of Dermatology, Boston University School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey
Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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