The approach to the numerous opportunistic infections in HIV-infected patients involves treatment and prophylaxis for infections likely to occur as CD4 cells are depleted. With potent antiretroviral therapy and immune reconstitution, routine prophylaxis for common opportunistic infections depends on the child’s age and CD4 count. Infants born to HIV-infected mothers receive prophylaxis for P. jiroveci pneumonia with trimethoprim-sulfamethoxazole (TMP-SMZ) beginning at 4 to 6 weeks of age and continued for the first year of life or discontinued if HIV infection is subsequently excluded. TMP-SMZ prophylaxis for P. jiroveci pneumonia for older children and adolescents is provided if CD4 cell counts are less than 200/ mm3 or there is history of oropharyngeal candidiasis. Clarithromycin prophylaxis for Mycobacterium avium-complexinfection is provided if CD4 cell counts are below 50/mm3.
P. jiroveci pneumonia is treated with high-dose TMP-SMZ and corticosteroids. Oral and gastrointestinal candidiasis is common in children and usually responds to imidazole therapy. VZV infection may be severe and should be treated with acyclovir or other antivirals. Recurrent herpes simplex virus (HSV) infections also may require long-term antiviral prophylaxis. Other common infections in HIV-infected patients include toxoplasmosis, CMV, Epstein-Barr virus infection, salmonellosis, and tuberculosis.
Children and adults with HIV are prone to malignancies, especially non-Hodgkin lymphomas, with the gastrointestinal tract being the most common site. Leiomyosarcomas are the second most common tumors among HIV-infected children. Kaposi sarcoma, caused by HHV-8, is distinctly rare in children with HIV. It was once common among adults with AIDS and is now infrequent with HAART.
The availability of HAART has improved the prognosis for HIV and AIDS dramatically. Risk of death is directly related to the degree of immunosuppression, viral load, and young age.
Children less than 1 year of age with very low CD4 percentiles and high viral loads have the poorest prognosis.
Identification of HIV-infected women before or during pregnancy is crucial to providing optimal therapy for infected women and their infants and to preventing perinatal transmission. Prenatal HIV counseling and testing with consent should be provided for all pregnant women in the United States.
The rate of vertical transmission is reduced to less than 8% by chemoprophylaxis with a regimen of zidovudine to the mother (100 mg five times/24 hours orally) started by 4 weeks gestation, continued during delivery (2 mg/kg loading dose intravenously followed by 1 mg/kg/hour intravenously), and then administered to the newborn for the first 6 weeks of life (2 mg/kg every 6 hours orally). Other regimens incorporating single-dose nevirapine for infants have been shown to be similarly effective and are used in developing countries. The current recommendations for the United States include a 6-week prophylactic with zidovudine for the infant in combination with maternal intrapartum therapy. The maternal regimen includes continuation of antiretroviral therapy (if appropriate) and intravenous zidovudine if the mother’s viral load is >400 copies/mL or is unknown ( http://aidsinfo.nih.gov/ contentfiles/lvguidelines/peri_recommendations.pdf ). Scheduled cesarean section at 38 weeks to prevent vertical transmission is recommended for women with HIV RNA levels greater than 1000 copies/mL, but it is unclear whether cesarean section is beneficial when viral load is less than 1000 copies/mL or when membranes have already ruptured.