Welcome Applicants!! - LSU School of Medicine
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Transcript Welcome Applicants!! - LSU School of Medicine
Morning Report: Friday, January 20th
Epidemiology, diagnosis, prevention
and treatment of HIV/AIDS has changed
dramatically over the past 25 years
Rates of new infections in infants has
plummeted
Effective screening and prevention strategies
Children born with HIV are surviving into young
adulthood
Adolescents acquiring HIV at an alarming rate
Worldwide:
33.2 million people living with HIV
2.5 million are children younger than 15
In 2007, 2.1 million AIDS deaths occurred
330,000 were children
In the US:
In 2006, 2181 cases of AIDS were reported among
children and adolescents through age 24
Only 38 cases were in children <13yo
Pediatric burden of infection now rests in the adolescent
population!
Lentivirus in the retrovirus
Family
Infection occurs when the
virus enters the body and
binds to the CD4 receptors
on host T lymphocytes
Binding fusion of HIV envelope with lymphocyte
cell membrane viral RNA and enzymes (RT) enter
host cell viral RNA reverse transcribed into DNA
viral DNA enters host cell nucleus integration into
host cell genome activation of host cell virion
production and release spread to other cells
This viremic phase preceeds antibody response and is
the period of HIGHESET INFECTIVITY!!
Viremic phase corresponds with the acute retroviral
syndrome:
Fever, LAD, rash, myalgias/ arthralgias, HA, diarrhea,
oral ulcers, leukopenia/ thrombocytopenia,
transaminitis
During this “window period” between host cell
infection and antibody response:
HIV antibody test negative
HIV RNA positive
Seroconversion occurs b/t 10-14 days and 6 months
after infection
Transmission by two principal modes
*Mother-to-child
Antepartum: transplacental transfer
Intrapartum: exposure to maternal blood, amniotic fluid or
cervicovaginal secretions during delivery
Postpartum: Breastfeeding
Behavioral
Unprotected sex
Traumatic sex
Active genital ulcer disease
Douching before sex
Injection drug use
So what do we do?!
*Mother-to-child
ART
Intrapartum zidovudine
Neonatal zidovudine
Safe replacement feeding
Elective C/S before the onset of labor in women with
persistent viremia
Behavioral
*COUNSEL, COUNSEL, COUNSEL!!
Abstinence
Consistent and correct use of condoms
*Remember that all infants
Born to HIV-positive mothers
Will test positive for the HIV
Antibody due to maternal
Transfer of Ig
HIV-exposed infants
HIV DNA/RNA PCR at 2 weeks, 2 months, and 4
months
Definitive exclusion of infection
Negative results for two virologic tests
First at age 1 month or older
Second at 4 months of age or older
Confirmatory antibody test at 12-18 mos optional
HIV-positive mothers and BF
Testing should continue throughout period of BF and 6
months after
Children and adolescents
All children of HIV-positive mothers should be screened
Adolescents should be screened as a part of routine
health care
Age 13 and older
High-risk adolescents should be screened yearly!
First step: referral to an HIV specialist!
Antiretroviral therapy
Goals: (maximize quality and longevity of life)
Complete suppression of viral replication
Preservation or restoration of immunologic function
Prevention of or improvement in clinical disease
Antiretrovirals
What to start?
ART should be planned and monitored in collaboration with
an HIV specialist
Triple-drug combination ART
3 drugs from 2 categories: one non-nucleoside reverse
transcriptase inhibitor (NNRTI) OR protease inhibitor PLUS two
nucleoside or nucleotide reverse transcriptase inhibitors
Viral load to monitor adherence
Non-detectable viral load within 3-6 months
Failure to achieve this goal strongly suggests suboptimal
adherence rather than resistance
Prevention of Opportunistic Infections
Pneumocystis jiroveci pneumonia (PCP)
Most common OI
Bactrim prophylaxis for:
All HIV-exposed infants until infection is reasonably excluded
All HIV-infected infants <12mos
All HIV-infected children and adolescents with severe immune
suppression
CD4 percentage< 15% or CD4 count< 200 cells/mm3
Mycobacterium avium complex
Azithromycin prophylaxis for:
Age≥ 6yo with CD4 count <50 cells/mm3
Ages 2-5yo with CD4 count <75 cells/mm3
Ages 1-2 yo with CD4 count <500 cells/mm3
Age< 1yo with CD4 count <750 cells/mm3
Prevention of opportunistic infections
Toxoplasmosis
Less common in children
Bactrim prophylaxis in:
Toxoplasma IgG positive individuals with severe
immunosuppression (CD4%< 15% or CD4 count < 100 cells/mm3
Immunization schedule same as for healthy children
with a few small exceptions:
CD4 percentage< 15% or CD4 count< 200 cells/mm3=
NO VARICELLA OR MMR
Only killed, injectable formulations of the influenza
vaccine
Coping with the diagnosis and prognosis
Offer hope and reassurance about the
availability of effective treatment
*Disclosure of HIV Infection status
Planned disclosure to family and friends can increase
support for the HIV-positive person
Sexual partners can make informed decisions about how
to protect themselves
Adherence to Care and Treatment
Requires 90-100% adherence to drug regimens to avoid
the development of resistance
School and sports participation
HIV-infected children and adolescents can participate
fully in the educational and extracurricular activities at
school
*No obligation to notify school personnel of student’s
HIV infection status
Some experts advise athletes with a detectable viral load
to avoid high-contact sports (boxing, wrestling)
Transition to adult health care
Complete and coherent medical record
Advance care planning and palliative care
http://aidsinfo.nih.gov
Thanks so much for your attention!!
Noon conference: Lung Function, Dr. Edell