HIV IN CHILDREN : It can be managed, with our help

HIV or Human Immunodeficiency Virus infection is one of the most fearsome disease in human history. It attacks the white cells which make up a large proportion of human immune system and render them insufficient in number to fight infections, even infections which seldom pose problems to normal humans. Up to this time when this article is written, there is no effective cure or vaccine for this curse. As much as we wish to halt the spread of HIV infection, there are insurmountable obstacles i.e. war and political instability, stigma and denial, increased travel, poverty and domestic violence.

Children are not spared. The main bulk of children who are infected by HIV acquire the disease from their HIV positive mothers. Small numbers contracted the disease by unprotected sex with an infected person, blood-blood contacts e.g. transfusion and injection drug use. The latter modes of transmission usually occurs among adolescents and adults. Seems to me whenever a child is diagnosed to have HIV infection, he or she does not deserve to receive such life-sentence.

Each time a child is diagnosed to have HIV, I always say, “The child is innocent. It is unfair.” More often than not, we start to judge the parents without looking at the larger pictures. Yes, the parent(s) might be promiscuous or involved in substance abuse (drug addiction). The complexity of the whole issue is further exacerbated by blaming games. The husband is the culprit, the mother was a prostitute. However, this is not always the case. Furthermore, no one really look into the situation and factors driving them to such state of despair. We, the community as a whole, should bear some responsibility when the entire family was floored by this disease. What about the governments, NGOs and media? Yes, all of us are guilty, and we should look at ourselves, before we start to judge. Have we done enough to help, is the money placed where it should be, have we overlooked the opportunity for improvement?

Grim as it may appear, there is still some hope. The advancement of human science and medical knowledge has catapulted improvement of prevention and care of HIV infection. Mothers known to be HIV positive are given antiviral drugs during pregnancy to suppress the virus level in order to prevent transmission to the newborns. Other measures taken to reduce the risk of transmission include planned Caesarean section, avoidance of invasive procedures and premature delivery. When these steps are carefully undertaken, the risk can be as low as 3 percent. This figure would be impossible to achieve had we not started screening all mother-to-be for HIV infection. THEREFORE ALL PREGNANT MOTHERS SHOULD BE SCREENED FOR HIV SO THAT PREVENTIVE MECHANISM CAN KICK START TO AVOID TRANSMISSION TO NEWBORNS.

Soon after delivery, preferably within 6-12 hours of life, the baby should be started promptly on antiviral medications for the next 6 weeks and then antibiotic is commenced after that to protect the child from serious opportunistic infections. Multiple blood tests are ordered to look for evidence of HIV infection at 2 and 6 weeks, and 4-6 months of age. Mother is told not to breastfeed the infant because it can be a form of transmission.

Having mentioned all these, there are some mothers and babies, for some reasons, escape the net of prevention. When children are already infected by HIV, they usually manifest symptoms of opportunistic infections during the first year of life. This is due to their immature immune system and rapid replication of HIV virus, which further dampens the defence mechanisms.

However, when these babies are detected early by conscientious parents, caretakers, nurses and/or doctors, they can be treated with proper antimicrobial agents and started on combined antiretroviral therapy (cART) against HIV. Personally, I have seen a number of such cases of this nature and these children fare excellently well after thorough assessment and appropriate treatment. When they start to get well, the number of medicines will be reduced over time, provided that their regular blood test shows rising white cells and they remain clinically asymptomatic.

The burden of therapy is overwhelming for some children. Consider the number of pills and medications that these children have to ingest everyday, and believe me, some are not palatable to taste and they can have unbearable side effects. Despite constant encouragement from both caretakers and doctors, changing of types of drugs giving rise to side effects and incentive-based rewards, the children may still find it extremely difficult to take these medicines without fail. The stormy and defiant period of adolescent years, fuelled by social problems and lack of support rubs salt to the wound. Non-compliance to cART translates into failing treatment because HIV viruses become resistant to the medications particularly when they are not taken regularly. We do not have many alternatives available because the number of effective drugs for this kind of disease is very limited. The outcome of such circumstance would be AIDS, Acquired Immunedeficiency Syndrome, a condition when a patient with immune suppression caused by high viral load of HIV that leads to severe opportunistic infection(s).

One of the methods of ensuring good adherence to cART is to let the children know about their status when they reach the age of maturity so that they can understand the condition well and the need for life-time therapy. This is easier said than done. It is no stroll in the park when it comes to breaking this kind bad news to these unfortunate children. They will start to ask questions, “Why me? Why do I have to suffer this? It is unfair!….” In this critical moments, the parents and caretakers will be the pillar of strength. Emotional support for and empowerment of these young ones tend to come from family members and friends. Although it should be present from the beginning, it should abound even more when the situation requires such response and love from everyone.

HIV infection in children is a complicated matter. All we can do as doctors and health care providers is to carry out our duty responsibly and adding on to our knowledge and skills everyday to better our care for the HIV-infected and HIV-exposed children. As a community at large, we should learn to love  and provide financial, social and emotional support for them and their family so that they can be uplifted in spirit and to make their lives as painless as possible. This is should be done not at occasional opportunity, but at every opportunity.

( This feature article is written by Dr Ng Khuen Foong )