The impact of HIV on the The impact of HIV on the Paediatric Population in South Paediatric Population in South

AfricaAfrica

Robyn SmithRobyn SmithUFSUFS

Dept. PhysiotherapyDept. Physiotherapy20112011

EpidemiologyEpidemiology

Perspective on the HIV Perspective on the HIV epidemic in Africaepidemic in Africa

HIV is one of the most HIV is one of the most significant health issues facing significant health issues facing children in South Africachildren in South Africa

Significant cause of Significant cause of morbiditymorbidity and and mortalitymortality in children South in children South Africa (SA)Africa (SA)

HIV has swept across Africa HIV has swept across Africa like a wild fire since the early like a wild fire since the early 1980’s causing massive 1980’s causing massive economic and social economic and social devastation.devastation.

2.8 million HIV infected 2.8 million HIV infected children in sub-Saharan Africa children in sub-Saharan Africa

85% of the world 85% of the world paediatricpaediatric HIV population lies in Sub-HIV population lies in Sub-Saharan AfricaSaharan Africa

According UNAIDS (2008) 280 According UNAIDS (2008) 280 000 children living with HIV in 000 children living with HIV in South AfricaSouth Africa

Although the HIV pandemic Although the HIV pandemic has started to stabilise, the has started to stabilise, the number of HIV-infected number of HIV-infected children in SA continues to children in SA continues to riserise

Perspective on the Perspective on the HIV epidemic in AfricaHIV epidemic in Africa

With the increasing number of HIV- infected children and With the increasing number of HIV- infected children and the rollout of ARV’s children are living for longer with the rollout of ARV’s children are living for longer with greater morbidities greater morbidities

Places a significant burden on the health-care system and Places a significant burden on the health-care system and health-care professionalshealth-care professionals

Most HIV-infected infants are dependant on the crumbling Most HIV-infected infants are dependant on the crumbling

and overextended public healthcare systemand overextended public healthcare system..

Prevalence of HIVPrevalence of HIV The highest worldwide The highest worldwide

incidence of HIV is in sub-incidence of HIV is in sub-Saharan AfricaSaharan Africa

Why are children so Why are children so vulnerable to contracting HIV?vulnerable to contracting HIV?

Highest incidence (28%) of Highest incidence (28%) of HIV in SA is amongst HIV in SA is amongst women between the ages women between the ages of 20-34 years.of 20-34 years.

This is significant as this This is significant as this constitutes the child constitutes the child bearing female populationbearing female population

There is lack of access to There is lack of access to antenatal care especially in antenatal care especially in rural areas so the mothers rural areas so the mothers status not determinedstatus not determined

The slow rollout of The slow rollout of antenatal ARV’s further antenatal ARV’s further compounds the problemcompounds the problem

What is the Human What is the Human Immunodeficiency Virus (HIV)?Immunodeficiency Virus (HIV)?

HIV caused by human HIV caused by human immunodeficiency virusimmunodeficiency virus

Belongs to the retrovirus familyBelongs to the retrovirus family The The virus infects the T- virus infects the T-

lymphocyteslymphocytes T- lymphocytes pillar of T- lymphocytes pillar of

immune systemimmune system Results in immune collapseResults in immune collapse And eventually progress to And eventually progress to

AIDSAIDS

HIV transmission routesHIV transmission routes Main route in SA is from Main route in SA is from

mother to childmother to child Vertical transmissionVertical transmission Transmission rate of 30%Transmission rate of 30% Transmission may occur in Transmission may occur in

utero, during labour or utero, during labour or during breast feedingduring breast feeding

→ → breast feeding increases breast feeding increases risk by 30%risk by 30%

Intravenous routesIntravenous routes Sexual contactSexual contact through through

child abuse at home, child abuse at home, school or within their school or within their communitiescommunities

DiagnosisDiagnosis

Diagnosis in children under 18 months is Diagnosis in children under 18 months is complicated by the presence of maternal complicated by the presence of maternal antibodies in the child’s bloodstreamantibodies in the child’s bloodstream

→ → May lead to false positive resultsMay lead to false positive results

Serologic testing least expensiveSerologic testing least expensive

ELISA USED children >15 mnths

2 positive tests for diagnosis neededCan be unreliable

PCRPolymerase Chain Reaction

Detects HIV DNAUsed children < 15mnths

ExpensiveNot always available SA

WESTERN BLOTMore specific

Not widely usedDue technical

problems

WHO staging of clinical HIVWHO staging of clinical HIV

Stage IStage I Asymptomatic Asymptomatic Generalized nodesGeneralized nodes

Stage IIStage II Chronic DiarrheaChronic DiarrheaSevere/recurrent CandidaSevere/recurrent CandidaFailure to thrive/weight lossFailure to thrive/weight lossPersistent feverPersistent feverRecurrent bacterial infection Recurrent bacterial infection

Stage IIIStage III AIDS defining opportunistic infectionsAIDS defining opportunistic infectionsSevere failure to thriveSevere failure to thriveProgressive encephalopathyProgressive encephalopathyMalignancyMalignancyRecurrent infections or meningitisRecurrent infections or meningitis

Slow vs. Fast progressorsSlow vs. Fast progressors The course of the disease is variable and The course of the disease is variable and

patients are divided into 2 groupspatients are divided into 2 groups

Fast progressorFast progressor

10-25% of children 10-25% of children infectedinfected

Rapidly develop Rapidly develop profound immuno-profound immuno-suppression within the suppression within the first few months of life first few months of life e.g. PCP, severe e.g. PCP, severe encephalopathyencephalopathy

Usually die within the Usually die within the first 2 years of life if first 2 years of life if not placed on anti-not placed on anti-retroviral therapyretroviral therapy

Slow ProgressorSlow Progressor

Majority of children Majority of children infectedinfected

Usually survive to the Usually survive to the age of 6- 9 yearsage of 6- 9 years

Elizabeth Glaser Pediatric Elizabeth Glaser Pediatric AIDS Foundation (2008)AIDS Foundation (2008)

Common presentations of Common presentations of HIV in childrenHIV in children

Diarrhea Diarrhea and and pneumoniapneumonia are most common are most common cause morbidity (75%)cause morbidity (75%)

LymphadenopathyLymphadenopathy (70%) (70%) Neurological abnormalitiesNeurological abnormalities (58%) (58%) Failure to thrive, candida, skin rashes, Failure to thrive, candida, skin rashes,

herpes simplex, CMV, herpes zoster &herpes simplex, CMV, herpes zoster &chicken pox are also commonly notedchicken pox are also commonly noted

TBTB also commonly associated with HIV also commonly associated with HIVthis is extremely relevant in SA with the highthis is extremely relevant in SA with the highincidence of TBincidence of TB

Antiretroviral TherapyAntiretroviral Therapy

Antiretroviral therapyAntiretroviral therapy

Antiretroviral (ARV) rollout Antiretroviral (ARV) rollout program started in SA in April program started in SA in April 20042004

Also Also HAARTHAART =highly active =highly active antiretroviral therapyantiretroviral therapy

In SA children are eligible when In SA children are eligible when their CD4 count reaches 15% of their CD4 count reaches 15% of the normal.the normal.

Implies there is already a severe Implies there is already a severe level of immuno-compromise level of immuno-compromise before treatment is startedbefore treatment is started

With more access to antiretroviral With more access to antiretroviral therapy we will see more and therapy we will see more and more that HIV will survive for a more that HIV will survive for a longer period of time.longer period of time.

All children under age 1 year All children under age 1 year eligible ARV therapyeligible ARV therapy

Antiretroviral therapyAntiretroviral therapy ARV drugs ARV drugs classified according to the way actclassified according to the way act

Children in SA placed on Children in SA placed on combination therapy combination therapy to reduce risk to reduce risk resistanceresistance

Nucleotide reverse transcriptase: prevents HIV RNA converted into Nucleotide reverse transcriptase: prevents HIV RNA converted into DNA which replicates virusDNA which replicates virus

Protease inhibitors stops protease from cutting virus into shorter Protease inhibitors stops protease from cutting virus into shorter useful parts. HIV copies cannot infect CDuseful parts. HIV copies cannot infect CD44 cells cells

Strict compliance is essential Strict compliance is essential and parents are carefully screened and parents are carefully screened before starting on programbefore starting on program

Side effects Side effects from the use of ARV’s is still a concern e.g. pancreatitis, from the use of ARV’s is still a concern e.g. pancreatitis, bone marrow suppression, perihperal neuropathies.bone marrow suppression, perihperal neuropathies.

Kline Kline et alet al (2002) (2002) Dept. of Health(2003)Dept. of Health(2003)

Clinical manifestations Clinical manifestations of HIVof HIV

Pneumocystis jirovecciPneumocystis jirovecci

Pneumocystis jirovecciPneumocystis jirovecci

Pneumocystis Carinii Pneumonia (PCP)Pneumocystis Carinii Pneumonia (PCP)

Previously known as PCPPreviously known as PCP Severe Severe fungal fungal pneumoniapneumonia Often fatal in infants under 15 monthsOften fatal in infants under 15 months Cause of 50% of severe acute Cause of 50% of severe acute

pulmonary disease in HIVpulmonary disease in HIV Spread by airborne transmissionSpread by airborne transmission Present with tachypnoea, dyspnoea, Present with tachypnoea, dyspnoea,

fever and fever and unproductive coughunproductive cough Significant hypoxiaSignificant hypoxia Progressive conditionProgressive condition CD4 count below 200 cells/mmCD4 count below 200 cells/mm33

Pneumocystis Pneumocystis jiroveccijirovecci

Disease has 2 phases:Disease has 2 phases:

Exudative phaseExudative phase characterized by interstitial characterized by interstitial oedema and formation of oedema and formation of hyaline membraneshyaline membranes

Prolipherative phaseProlipherative phase characterized by interstitial characterized by interstitial oedema, fibrosis and oedema, fibrosis and regeneration of alveolar regeneration of alveolar epitheliumepithelium

Once reaches the alveolus it Once reaches the alveolus it attaches wall and replicatesattaches wall and replicates

Causes diffuse alveolar Causes diffuse alveolar damage and pneumonitisdamage and pneumonitis

ARDS common complicationARDS common complication

On auscultation few On auscultation few abnormal breath sounds abnormal breath sounds heard –at times few fine heard –at times few fine cracklescrackles

CXR diffuse infiltration, CXR diffuse infiltration, start in the perihilar region start in the perihilar region and spreads to the and spreads to the periphery, apices are last periphery, apices are last affectedaffected

PneumocystisPneumocystis jiroveccijirovecci

Typical clinical signs and Typical clinical signs and symptoms:symptoms:

Tachypnoea, dyspnoea and Tachypnoea, dyspnoea and cyanosis worsencyanosis worsen

Child becomes more and more Child becomes more and more hypoxemichypoxemic

Oxygenation and not a respiration Oxygenation and not a respiration problemproblem

Treatment is supplemental Treatment is supplemental oxygen, oxygen, Bactrim®Bactrim®, Prednisone, Prednisone

Decision to mechanically ventilate Decision to mechanically ventilate depends on individual unit depends on individual unit protocolsprotocols

PneumocystisPneumocystis jiroveccijirovecci

Role of Physiotherapy in PCPRole of Physiotherapy in PCP

Role of physiotherapy has not been fully investigated...

Patients often do not require manual techniques as they are unproductive

Some indications that PEP mask may be beneficial

Dyspnoea management and positioning Assist with the collection of induced sputum Breathing exercises (age dependant)

TuberculosisTuberculosis

Tuberculosis (TB)Tuberculosis (TB) Caused by Caused by mycobactarium mycobactarium

tuberculosis tuberculosis infection by infection by an individual who is an individual who is sputum positive.sputum positive.

When a susceptible child When a susceptible child inhales the bacilli a inhales the bacilli a primary infection develops primary infection develops when the bacilli are when the bacilli are deposited in the alveoli deposited in the alveoli

The The presence of HIV presence of HIV increases the risk of increases the risk of contracting TBcontracting TB

Tuberculosis (TB)Tuberculosis (TB) One million children world-One million children world-

wide are infected with TB wide are infected with TB annually, 420 000 of these annually, 420 000 of these are believed to be HIV -are believed to be HIV -positivepositive

The presence of HIV The presence of HIV increases the risk of increases the risk of contracting TB. 23.4/ 100 contracting TB. 23.4/ 100 children with HIV will also children with HIV will also contract TBcontract TB

Co-infection is common and Co-infection is common and is of huge concern as these is of huge concern as these children are six times more children are six times more at risk of dyingat risk of dying

TB may further lower the TB may further lower the child’s CDchild’s CD44 count and count and exacerbates the exacerbates the immunosupressionimmunosupression

HIV- infection also often HIV- infection also often makes that diagnosis of TB makes that diagnosis of TB more difficult as it may more difficult as it may mask the clinical signs and mask the clinical signs and symptomssymptoms

Diagnosis made based on Diagnosis made based on clinical signs, radiology clinical signs, radiology sputum and gastric sputum and gastric aspirate cultures and a aspirate cultures and a positive skin test.positive skin test.

Tuberculosis (TB)Tuberculosis (TB) Clinical signs & symptomsClinical signs & symptoms

Enlarged lymph nodesEnlarged lymph nodes Persistent feverPersistent fever MalaiseMalaise Night sweats Night sweats Weight lossWeight loss

Tuberculosis (TB)Tuberculosis (TB)

Physiotherapy treatmentPhysiotherapy treatment

Assist with sputum collection for diagnosisAssist with sputum collection for diagnosis Localised breathing exercises (age dependant)Localised breathing exercises (age dependant) In the case of tuberculous In the case of tuberculous bronchiectasis bronchiectasis it is advised to do it is advised to do

postural drainage, percussions not advised due to the risk postural drainage, percussions not advised due to the risk of haemoptysis of haemoptysis

In the case of In the case of tuberculous meningitis tuberculous meningitis the management the management included passive movements and stretches within the limits included passive movements and stretches within the limits of pain in the acute phase, positioning and later of pain in the acute phase, positioning and later neurological rehabilitation to achieve maximal functional neurological rehabilitation to achieve maximal functional independence independence

Tuberculosis (TB)Tuberculosis (TB)

ManagementManagement

According WHO all neonates to receive BCG According WHO all neonates to receive BCG which helps in preventing disseminated TBwhich helps in preventing disseminated TB

? ? INH prophylaxis INH prophylaxis for HIV- infected children for HIV- infected children

TB medication regime:TB medication regime:

Increased level of resistance to TB drugsIncreased level of resistance to TB drugs

Non-compliance a concern Non-compliance a concern

Start 2 weeks before ARV therapy is commencedStart 2 weeks before ARV therapy is commenced

Reactive ArthritisReactive Arthritis

Reactive ArthritisReactive Arthritis Reactive arthritis is an Reactive arthritis is an

autoimmune condition autoimmune condition that that develops in response to an develops in response to an infection infection

= = Reiter’s syndromeReiter’s syndrome

The exact pathogenesis is The exact pathogenesis is not yet fully understood. not yet fully understood. Suspected that it is multi-Suspected that it is multi-factorial and may involve factorial and may involve direct viral invasion of joint direct viral invasion of joint tissue,tissue, indirect indirect involvement via an involvement via an activated immune system, activated immune system, genetic and environmental genetic and environmental factors.factors.

Reactive ArthritisReactive Arthritis Arthritic conditions are Arthritic conditions are

associated with HIV infection associated with HIV infection prevalence is greater in the prevalence is greater in the later stages of the diseaselater stages of the disease

An increasing number of HIV An increasing number of HIV infected children are being infected children are being seen with rheumatological seen with rheumatological conditions (34%)conditions (34%)

Believed that boys are more Believed that boys are more susceptiblesusceptible

Reactive arthritis is often the Reactive arthritis is often the first manifestation of the first manifestation of the diseasedisease

HIV- related reactive arthritis HIV- related reactive arthritis involves mainly the lower involves mainly the lower limbslimbs

Reactive ArthritisReactive ArthritisClinical signs and symptomsClinical signs and symptoms

Onset is most often acute, Onset is most often acute, with malaise, fatigue, and with malaise, fatigue, and fever fever

asymmetrical asymmetrical predominately lower predominately lower extremity oligo-arthritis extremity oligo-arthritis (usually no more than 6 (usually no more than 6 joints)joints)

Stiffness may develop at Stiffness may develop at first before pain first before pain

Joints may become quite Joints may become quite swollen. swollen.

The severity of pain and The severity of pain and swelling can vary from swelling can vary from mild to severemild to severe

TreatmentTreatment

Rest Rest Physiotherapy Physiotherapy

maintain and restore maintain and restore joint ROMjoint ROM

NWB gait with crutches NWB gait with crutches initiallyinitially

Maintain muscle strengthMaintain muscle strengthSplinting may be useful Splinting may be useful

to to relieve painrelieve painPain managementPain management

NSAIDSNSAIDS CorticosteroidsCorticosteroids Antibiotic therapyAntibiotic therapy Arthritic drug therapyArthritic drug therapy

Reactive ArthritisReactive Arthritis

PrognosisPrognosis Resolution of Resolution of

symptoms by 3-12 symptoms by 3-12 months, but symptoms months, but symptoms may persist for 12 may persist for 12 months or more. months or more.

About 15% of patients About 15% of patients develop a long-term, develop a long-term, and sometimes and sometimes destructive arthritisdestructive arthritis

There is a high There is a high incidence of recurrence incidence of recurrence

Lymphoid Interstitial Lymphoid Interstitial PneumonitisPneumonitis

Lymphoid Interstitial Pneumonitis Lymphoid Interstitial Pneumonitis (LIP)(LIP)

Slowly progressive Slowly progressive interstitial lung diseaseinterstitial lung disease

Unknown causeUnknown cause Characterised Characterised

peribronchiolar lymphoid peribronchiolar lymphoid nodulescausing diffuse nodulescausing diffuse infiltration of the alveolar infiltration of the alveolar septaeseptae

Later leads to widespread Later leads to widespread Bronchiectasis with a Bronchiectasis with a clinical picture similar to clinical picture similar to Cystic FibrosisCystic Fibrosis

Usually the older HIV-Usually the older HIV-infected childreninfected children

Often leads to chronic Often leads to chronic bronchiectasisbronchiectasis

Clinical signs and Clinical signs and symptoms:symptoms:

TachypnoeaTachypnoea Productive coughProductive cough WheezingWheezing HypoxaemiaHypoxaemia Right heart failureRight heart failure

Lymphoid Interstitial Lymphoid Interstitial Pneumonitis (LIP)Pneumonitis (LIP)

Role of Physiotherapy in LIPRole of Physiotherapy in LIP Role of physiotherapy here has not been well describedRole of physiotherapy here has not been well described

Similar to the management of Bronchiectasis, children Similar to the management of Bronchiectasis, children admitted with CHF may slightly more complicated to treat in admitted with CHF may slightly more complicated to treat in acute phase where severe dyspnoea and SOB is present acute phase where severe dyspnoea and SOB is present

Due to the destruction of the cilia postural drainage is Due to the destruction of the cilia postural drainage is essential essential

Dyspnoea managementDyspnoea management Forced expiratory techniques e.g. Huffing/coughForced expiratory techniques e.g. Huffing/cough Active cycle of breathingActive cycle of breathing ““Flutter” or bronchi-vibe/ bubble PEPFlutter” or bronchi-vibe/ bubble PEP Localised breathing exercises to improve ventilationLocalised breathing exercises to improve ventilation Individualised CVS exercise programme to maintain and Individualised CVS exercise programme to maintain and

improve endurance and functional abilitiesimprove endurance and functional abilities

Central Nervous System Central Nervous System InvolvementInvolvement

Involvement of the Central Involvement of the Central Nervous SystemNervous System

HIV- infected children has HIV- infected children has an increased risk of an increased risk of developing CNS pathologydeveloping CNS pathology

This occurs when the HIV This occurs when the HIV virus crosses the blood virus crosses the blood brain barrierbrain barrier

The brain cells most The brain cells most commonly affected are the commonly affected are the macrophages in the white macrophages in the white matter, basal ganglia and matter, basal ganglia and around the blood vesselsaround the blood vessels

Imaging often shows Imaging often shows cerebral atrophy –and cerebral atrophy –and observable microcephalyobservable microcephaly

Developmental delay & HIV Developmental delay & HIV related encephalopathyrelated encephalopathy

Neurological abnormalities Neurological abnormalities may present as early as 2-3 may present as early as 2-3 months of agemonths of age

Studies have shown the Studies have shown the incidence of developmental incidence of developmental delays to be between 40 -delays to be between 40 -70%70%

Neurological sequelae are Neurological sequelae are common and often severe common and often severe complication of HIV-related complication of HIV-related disease in children disease in children

Developmental delay is Developmental delay is often the first sign of often the first sign of neurological involvement, neurological involvement, often present in the absence often present in the absence of any other clinical signs of any other clinical signs and symptoms.and symptoms.

Signs of early neurological Signs of early neurological involvement may include:involvement may include:

Palmar thumbing Palmar thumbing Abnormal tone Abnormal tone Abnormal posturingAbnormal posturing Developmental delay Developmental delay –most –most

studies have indicated the studies have indicated the main aspect of the delay main aspect of the delay often involved issues relating often involved issues relating to central control ie. Head, to central control ie. Head, shoulder girdle and pelvic shoulder girdle and pelvic controlcontrol

Regression of milestones Regression of milestones Focal neurological signsFocal neurological signs

Developmental delay & HIV- Developmental delay & HIV- related encephalopathyrelated encephalopathy

Apart from developmental Apart from developmental delays, other clinical delays, other clinical manifestations of HIV-manifestations of HIV-related encephalopathy related encephalopathy may include:may include:

Opportunitstic infections Opportunitstic infections e.g. TBM and brain abscesse.g. TBM and brain abscess

Cerebral PalsyCerebral Palsy CVACVA Brain tumours (stage III)Brain tumours (stage III) PNLPNL EpilepsyEpilepsy

Developmental delay may Developmental delay may progress to more progress to more significant neurological significant neurological involvement over time with involvement over time with clear neurological signs clear neurological signs and impairmentsand impairments

Progression of the Progression of the encephalopathy may be encephalopathy may be halted and even reversed halted and even reversed through the administration through the administration of ARV’sof ARV’s

Developmental delay & HIV- Developmental delay & HIV- related encephalopathyrelated encephalopathy

The role of physiotherapy in HIV-related Developmental delay The role of physiotherapy in HIV-related Developmental delay & encephalopathy& encephalopathy

The role of the physiotherapist relating to HIV- related The role of the physiotherapist relating to HIV- related neurological sequelae has been poorly researched to dateneurological sequelae has been poorly researched to date

? Value of ? Value of routine screening of HIV- exposed routine screening of HIV- exposed and and infected infected infants infants to identify areas of concern at the earliest possible to identify areas of concern at the earliest possible point in timepoint in time

Early intervention Early intervention – holistic approach– holistic approach Early access to ARV’s Early access to ARV’s NDT principles NDT principles applied to assist the child in achieving applied to assist the child in achieving

maximal independence or maintain functional abilities in the maximal independence or maintain functional abilities in the light of progressive neurological disorderslight of progressive neurological disorders

Training caregiver Training caregiver regarding home based programme/ group regarding home based programme/ group therapytherapy

Peripheral nerve Peripheral nerve lesionslesions

Peripheral nerve lesions Peripheral nerve lesions (PNL)(PNL)

One of the most common complications of HIV infection One of the most common complications of HIV infection Can also be a side effect of ARV therapyCan also be a side effect of ARV therapy Estimated 33% of HIV- infected patients will develop PNL Estimated 33% of HIV- infected patients will develop PNL Also referred to as Also referred to as distal symmetrical polyneuropathydistal symmetrical polyneuropathy Less well described in the paediatric population ??? Older Less well described in the paediatric population ??? Older

children usually.children usually. As HIV- infected patients on HAART live for longer, PNL will As HIV- infected patients on HAART live for longer, PNL will

become a more common complicationbecome a more common complication Can be a severely debilitating condition with a significant Can be a severely debilitating condition with a significant

impact on quality of lifeimpact on quality of life

Peripheral nerve lesions Peripheral nerve lesions (PNL)(PNL)

Clinical SymptomsClinical Symptoms

More often affects the More often affects the lower limbslower limbs

NumbnessNumbness Burning sensation in the Burning sensation in the

limbs and feetlimbs and feet TinglingTingling Pins & needlesPins & needles Paraesthesia Paraesthesia AnaesthesiaAnaesthesia HyperasthesiaHyperasthesia

Decreased tendon reflexes Decreased tendon reflexes over timeover time

Progessive weakness Progessive weakness Loss of functional abilities Loss of functional abilities

e.g. standing, walkinge.g. standing, walking PAIN !!!PAIN !!!

Peripheral nerve lesions Peripheral nerve lesions (PNL)(PNL)

Medical TreatmentMedical Treatment

Fibre rich dietFibre rich diet Management of pain Management of pain

(Tegretol)(Tegretol) Immunomodulation e.g. Immunomodulation e.g.

plasmaphoresis, plasmaphoresis, immunoglobulins or immunoglobulins or corticosteroidscorticosteroids

Physiotherapy TreatmentPhysiotherapy Treatment

Electrotherapy modalities Electrotherapy modalities for pain managementfor pain management

Maintain ROMMaintain ROM Maintain muscle lengthsMaintain muscle lengths Orthoses e.g. AFO to Orthoses e.g. AFO to

prevent drop feet and prevent drop feet and walking aidswalking aids

Maintain and improve Maintain and improve muscle strengthmuscle strength

Advice regarding sensory Advice regarding sensory aspectsaspects

Do physiotherapists have a Do physiotherapists have a role to play in the role to play in the

management paediatric HIV?management paediatric HIV?

Most of physiotherapists in Most of physiotherapists in practice concur that practice concur that physiotherapists have a significant physiotherapists have a significant contribution to make herecontribution to make here

Do date Do date inadequate volume of inadequate volume of research research regarding the role of the regarding the role of the physiotherapist in the physiotherapist in the management of HIV related management of HIV related conditions in children, especially conditions in children, especially in a South African contextin a South African context

Therefore lack of evidence to Therefore lack of evidence to support the role physiotherapy in support the role physiotherapy in the long term care of these the long term care of these patients patients

Other considerations when Other considerations when treating HIV- infected childrentreating HIV- infected children

Other important Other important management considerationsmanagement considerationsCounsellingCounselling

Parents must receive pre- Parents must receive pre- and post test counselling and post test counselling by a trained counsellorby a trained counsellor

BreastfeedingBreastfeeding Exclusive breastfeeding Exclusive breastfeeding

advised (reduces risk of advised (reduces risk of transmission by 38%)transmission by 38%)

Formula feeding (reduces Formula feeding (reduces risk of transmission by 50-risk of transmission by 50-68%)68%)

No mixed feeding !!!No mixed feeding !!!

Other important management Other important management considerationsconsiderations

NutritionNutrition

Parents to be advised by Parents to be advised by the dietician regarding a the dietician regarding a high calorie diethigh calorie diet

Multvitamin Multvitamin supplementationsupplementation

Growth and development Growth and development do be plotted on CDC do be plotted on CDC graphs –weight and length graphs –weight and length for agefor age

Re-hydration critical during Re-hydration critical during episodes of diarrhoea episodes of diarrhoea

Management of Management of opportunistic infections:opportunistic infections:

PCP – Bactrim PCP – Bactrim ®® prohylaxis and Prednison prohylaxis and Prednison as neededas needed

Oral Candida: MycostatinOral Candida: Mycostatin INH prophylaxisINH prophylaxis

Other important management Other important management considerationsconsiderations

Psychological aspectsPsychological aspects

Counselling and support Counselling and support for parentsfor parents

Older children may suffer Older children may suffer depression depression

Negative effects of Negative effects of prolonged hospitalisations prolonged hospitalisations and chronic illness on the and chronic illness on the psychological well being of psychological well being of the childthe child

Management of PainManagement of Pain

This aspect often This aspect often overlookedoverlooked

Children with neural and Children with neural and joint pain and reactive joint pain and reactive arthritis may endure arthritis may endure severe painsevere pain

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