HIV positive children of calcutta- survival strategies without ARV

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HIV POSITIVE CHILDREN OF CALCUTTA-

SURVIVAL STRATEGIES WITHOUT ANTIRETROVIRAL DRUGS

Author- Dr. S. Bhattacharyya, Asst. Professor, Dept. of Pediatrics &

Incharge Pediatric HIV/AIDS Clinic, Medical College, University of

Calcutta, Calcutta, India.

Summary :- Pediatric HIV is rapidly progressive than adult HIV

infection. Antiretroviral drugs are costly and thus are beyond the

reach of the families of HIV positive children. In this study some

non-retroviral strategies were tried for the prolongation of

survival of 65 (42 males and 23 females) HIV positive children (2-11

years) who were mostly from poor families. They were longitudinally

followed up for three and a half years at Calcutta, India with

regular checkup, counseling regarding high standard of hygiene and

nutrition, nutritional supplementation, aggressive management of

opportunistic infections, and CD4 count monitoring. Significant

number of children (83%) were found to be maintaining good health,

schooling and near normal CD4 count with significant decrease in the

mortality (8 %).

Introduction:- As per UNAIDS 2002 report by the end of 2002 there

were 240,000 children under 15 years with AIDS. The epidemic

continues to shift towards women and young people with about 25 % of

all HIV infections occurring in women. This also adds to the mother

to child transmission and pediatric HIV. In 2001 580,000 children

died due to HIV/AIDS. More than 90% HIV infected children live in

developing countries. India and Thailand dominate the HIV epidemic

in South East Asia (1). Considering 25 million births per year in

India and seroprevalence rate among pregnant ladies of 1% and

vertical transmission 30% (varies between 36%-48% as reported in

different studies) we would expect to have 75,000 HIV infected

neonates born every year (2). HIV infection in children progresses

more rapidly than in adults and some untreated children die within

the first 2 years of their life. Sixty to 80% of pediatric HIV

patients follow slow progression of the disease with median

survival time of 6 years and a small percentage (< 5%) of pediatric

HIV have minimal or no progression for longer than 8 years (1).

Antiretroviral therapy is recommended for all children with HIV

related symptoms (Clinical categories A,B and C) or evidence of

immune suppression (CD4 lymphocyte counts in categories 2 or 3)

(1,3). Many clinicians advocate treating asymptomatic children of

age one year and more to prevent immunologic deterioration (1).

Antiretroviral treatment has several limitations. Firstly, viral

resistance to drugs is increasing. Most importantly, it remains

unaffordable for 95% of infected adults and children worldwide. Even

if the cost issue was resolved, the complexity of the various

regimens and the many side effects make adherence difficult. The

infrastructure needed to support antiretroviral treatment limits its

widespread availability mainly in developing countries. Rather than

rejecting antiretroviral treatment because of this alternative and

innovative treatment options have to be found for resource poor

settings (4). Moreover in a family of HIV positive child usually it

is found that more than one member is suffering from HIV/AIDS. Some

of these children are orphans or have single surviving parent and

mostly are from poor families. There is a lot else one can do for

management of such children (5).

In Indian setup it seems that at present nutritional rehabilitation,

managing and preventing infections are the only therapeutic

intervention feasible (6). Chronic diarrhoea, opportunistic

infections or HIV infection per se maybe responsible for protein

energy malnutrition. This is the commonest clinical feature of

immunodefiency noticed in India therefore nutritional intervention

should be instituted early in the care plan of these children (7).

Requisite effort must be put in to ensure an adequate intake of food

item that are inexpensive and culturally acceptable. Results of such

intervention are often very gratifying (5). Early nutritional

intervention may prevent severe malnutrition, decrease the incidence

and the severity of the infection, less fatigue and provide some

protection of the immune system, enabling a better quality of life

for the infected children. They are also at a risk of micronutrient

deficiencies like Fe,Se,Zn, Thiamin, cyanocobalamin and pyridoxine,

which may further aggravate immune dysfunction. Supplementation of

these micronutrients may enhance a nutritional rehabitational

programme (3,8).

These children are more susceptible to food borne illness like

salmonella, shigella, campylobactor and S.typhimurium and necessary

precaution should be used to prevent severe infection (9). So

nutritional evaluation, food hygiene and counseling should be a part

of early care before the problem arises (3).

Oppurtunistic infection like TB can accelerate the course of HIV

infection by increasing the plasma viral load greatly (9).

Tuberculosis is one of the most common oppurtunistic infection in a

HIV positive child occurring at higher CD4 count when the immune

deficiency is comparitively less advanced (10). So early diagnosis

and treatment of this opportunistic infection by regular follow up

improves the quality of life of HIV positive children. In this study

some non-retroviral strategies were tried for the prolongation of

survival of HIV positive children of Calcutta.

Material and method:- Study was undertaken at Pediatric HIV/AIDS

clinic, Apex Referral Center, Medical College and Hospital,

Calcutta, India. Sixty-five HIV positive (confirmed by two different

ELISA for HIV and in some cases by Western Blot) children (2-11

years) were longitudinally followed up for three and a half years.

These patients were mostly from poor families out of which about 32

(50%) had single surviving parent and 6 (9.2%) were orphans. Forty-

two were males and 23 were females. Forty-five (69%) had acquired

the infection perinatally from mother to child. Twenty (31%) got the

infection through blood transfusion – who are mostly thalassaemic

children.

The following approaches were taken up during the three and a half

years of follow up.

A) Monthly to two monthly thorough check up which included detailed

history taking, thorough clinical examination, height/weight

measurement, and simple investigations like hemogram, chest x-ray,

mantoux test urine and stool examination were undertaken if and

when required.

All patients and their family members were advised to maintain

high standards of personal hygiene like stringent hand washing

before meals, regular bathing at home (avoiding pond/pool bathing)

maintaining personal cleanliness, advice regarding safe drinking

water (i.e drinking boiled water if required), food habits like

thorough cleaning of all raw vegetables and fruits, encourage to

take freshly prepared home cooked food and to avoid food from

outside as far as possible. Also advised to maintain high standard

of environmental hygiene like sanitation, home cleaning and keeping

the surrounding clean.

C) Encouraged to take home cooked, easily available, wholesome

nutritious food like rice, pulses, fresh vegetables, milk (properly

boiled), fish, eggs (properly cooked) and if possible meat and fresh

fruits. Nutrition supplementation with multivitamin syrup especially

Vitamin A (5000 IU/day) and Zinc (20 mg/day) along with other

multivitamin and minerals was advised to all HIV positive children.

D) Early diagnosis of opportunistic infections were undertaken by

regular follow up, thorough clinical examinations and

investigations. Aggressive and adequate management of infection were

undertaken.

E) CD4 count was undertaken once or twice a year according to

clinical need. This investigation was subsidized in our hospital

still expensive for these poor families. Viral load is costly and

not available in our hospital.

Result:- Out of 65 HIV positive children 5 patients were lost during

three and a half years follow up. Significant number of children

83.3%(n=50) were found to be maintaining good health without any

immunosuppression and maintaining a normal or a slightly low normal

CD4 count.(CDC) (1). Forty (66%) children maintained schooling and

education, around 10(16.6%) suffered from recurrent diarrhoea,

respiratory infections with moderate immunosuppression(CDC).

Recurrent itchy and seborrhic dermatitis were observed in 12(20%) of

these children. There was significant decrease in the mortality rate

with only 5 (8.3%) children died due to tubercular meningitis and

bacterial pneumonia.

Conclusion :-Results show that with the above approaches most of

these HIV positive children maintained good health and two-third of

these children maintained schooling. A small percentage of them

suffered from recurrent diarrhoea and respiratory infections which

could be managed when regular follow up and supportive options were

undertaken. It was found with these approaches the mortality rate

was low. Hence, strict maintenance of high standard of hygiene, good

nutrition, early and aggressive management of opportunistic

infection and frequent counseling prolonged survival of these HIV

positive children who could not afford antiretroviral therapy.

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