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Table: WHO clinical staging of HIV / AIDS for children with confirmed HIV infection

Clinical Stage 1

  • Asymptomatic Q   -  Persistent generalized lymphadenopathy(PGL)  

Clinical Stage 2

  • Unexplained persistent hepatosplenomegaly  - Papular pruritic eruptions
  • Fungal nail infection  - Angular cheilitis
  • Lineal gingival erythema  - Extensive wart virus infection
  • Extensive molluscum contagiosum  - Recurrent oral ulceration
  • Unexplained persistent parotid enlargement  - Herpes zoster
    Recurrent or chronic upper respiratory tract infections (otitis media, otorrhea, sinusitis, tonsillitis)  

Clinical Stage 3

  1. Unexplained moderate malnutrition or wasting not adequately responding to standard therapy
  2. Unexplained persistent diarrhoea (14 days or more)
  3. Unexplained persistent fever (above 37.50 C intermittent or constant, for longer than one month)
  4. Persistent oral candidiasis (after the first 6-8 weeks of life)
  5. Oral hairy leukoplakia
  6. Acute necrotizing ulcerative gingivitis or periodontitis
  7. Lymph node or pulmonary tuberculosis
  8. Severe, recurrent bacterial pneumonia
  9. Symptomatic lymphoid interstitial pneumonitis
  10. Chronic lung disease including bronchiectasis
  11. Unexplained anemia (<8 g/dl), neutropenia (<0.5 x 109/L) or chronic thrombocytopenia (<50 x 109/L)  

Clinical Stage 4

  1. Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
  2. Pneumocystis pneumonia
  3. Recurrent severe bacterial infections (e.g. empyema, pyomyositis, bone or joint infection, meningitis)
  4. Chronic herpes simplex infection (oro labial, cutaneous >1 month duration or visceral at any site)
  5. Esophageal candidiasis (or candidiasis of trachea, bronchi, lungs)
  6. Extrapulmonary or disseminated TB
  7. Kaposi sarcoma
  8. Cytomegalovirus infection: retinitis or CMV infection affecting another organ, with onset at age >1 month Central nervous system toxoplasmosis (after one month of life)
  9. Extrapulmonary cryptococcosis (including meningitis)
  10. HIV encephalopathy
  11. Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidioidomycosis)
  12. Disseminated non-tuberculous mycobacterial infection
  13. Chronic cryptosporidiosis (with diarrhea)
  14. Chronic isosporiasis
  15. Cerebral or B cell non-Hodgkin lymphoma Progressive multifocal leukoencephalopathy
  16. Symptomatic HIV-associated nephropathy or HIV-associated cardiomyopathy  

Unexplained refers to where the condition is not explained by other causes

Some additional conditions can also be included in regional classifications (e.g. reactivation of American trypanosomiasis in Americas region, penicilliosis in Asia and HIV-associated rectovaginal fistula in Africa)


Classification of severity of immune suppression in relation to CD4 levels


Age related CD4 cell values


<11 months (CD4%)

12-35 months (CD4%)

36-59 months (CD4%)

5 years (cells / mm3)

Not significant
















<25% or


<20% or

<750 / mm3

<15% or


<15% or <200/mm3


Essential Pediatrics


Fig: HIV diagnosis in children below the age of 18 months with DNA-PCR


Table: Commonly used antiretroviral drugs


Side effects




Peripheral neuropathy, pancreatitis, abdominal pain, diarrhea

Lamivudine (3TC)

Pancreatitis, neuropathy, neutropenia

Stavudine (d4T)

Headache, GI upset, neuropathy


Rash, peripheral neuropathy, pancreatitis


Anemia, myopathy

Non-nucleoside reverse transcriptase inhibitors

Nevirapine (NVP)

Skin rash, Steven Johnson syndrome


Skin rash, CNS symptoms, increase transaminases

Protease inhibitors




Hyperbilirubinemia, nephrolithiasisQ

Lopinavir / Ritonavir

Diarrhea, fatigue, headache, nausea, increased cholesterol and triglycerides


Diarrhea, abdominal pain


Bad taste, vomiting, nausea, diarrhea; rarely hepatitis


Diarrhea, headache, rash

  1. Modes of transmission:
    1. majority (90%) of pediatric HIV infections are acquired from infected mother (vertical transmission)
    2. In utero 30-40%.
    3. During delivery 60-70%
    4. Breast feeding   increases risk by 14-16 %
    5. Horizontal transmission i.e. sexual intercourse , needle sticks ,contaminated blood and blood products 10-15% cases of AIDS. 
  2. Rate of vertical transmission:
    1. Without any intervention
    2. Without breastfeeding 15-30%
    3. With breastfeeding       20-45%
    4. With intervention
      (ARV prophylaxis+ caesarean section+ no breastfeeding) <2%Q 
  3. Factors increasing the rate of transmission from mother to child are:   
    1. Viral factors
      1. High viral load              
      2. Non syncytium inducing phenotype                
      3. HIV 1
    2. Maternal factors
      1. Advanced disease(low CD4, symptoms of AIDS)    
      2. Primary infection                  
      3. First of twins                                       
      4. Rupture of membranes >4 hrs            
      5. Maternal bleeding
      6. Not on ART                          
      7. Vaginal delivery
      8. Other STD                          
      9. Isolated HIV 1 infection
    3. Fetoplacental factors
      1. Chorioamnionitis                    
      2. Placenta previa
      3. Prematurity (increased peripartum transmission)
    4. Infant factors
      1. ​​HLA concordance with motherQ
    5. Postnatal factors
      1. Breast feeding
      2. Higher breast milk virus load
      3. Mastitis or maternal nipple lesions
      4. Maternal seroconversion during breastfeeding
      5. Infant thrush at <6 month age (in breastfeeding infant) Q 
  4. Case definitions:
    1. HIV infected
      child<18 months born to HIV infected mother and has two positive results on one of following tests:
      1. HIV culture. (Result take longtime)
      2. HIV specific DNA PCR. (Most specific and sensitize)
    2. >18months : born to HIV infected mother  or infected by blood, blood products who is HIV antibody positive
      1. by ELISA  
      2. Confirmatory test positive (e.g. western blot or immunofluorescence.)
    3. Clinical course of vertically transmitted infection:
      1. Rapid disease seen in upto 85% of cases in resource poor countries :onset of symptoms at 3-4months of age.  PCP pneumonia is the presenting symptom in 40%patients.
      2. Rest present with LAP, HSM, growth failure, encephalopathy or candida infection.
      3. Median survival time :24-28 months.
      4. Age<1 yr; PCP and CD4 counts <750 /ul.
      5. 20% slow progresses presenting feature is LIP (lymphocyte interstitial pneumonia): it is defined as reticulonodular infiltrates persisting for >2 months with or without LAP.
      6. Carries a better prognosis.
      7. Opportunistic infection at CD4 counts less than 200-400/ul. 
  5. Treatment:
    1. No specific treatment available.
    2. Present treatment only suppresses viral replication and modify course of disease.
    3. All infants and all children >1 year with symptoms should be treated.
    4. All children >1 year with CD4 count <25% should be treated.
      1. preferred therapy is 2 nucleoside analogue reverse transcriptase inhibitors along with one protease inhibitor.
      2. response to therapy monitored by HIV copy number and CD4 lymphocyte count .
      3. maximum response occurs in 12-16 weeks.
      4. Pneumocystis cranii prophylaxis started at 4-6 week of age in all children born to HIV positive mother (Given daily).
      5. Toxoplasma prophylaxis started at CD4 count <100/ul.
      6. CMV prophylaxis started at CD4 count <50/ul. 
  6. Prevention of vertical transmission:
    1. Caesarean section is preventive.
    2. Zidovudine prophylaxis started in the mother at 28 weeks 300 mg twice a day per orally. 600 mg at onset of labour and 300 mg twice a day for 7 days in postpartum period
    3. Mother also receives Nevirapine 200 mg at onset of labour
    4. New born given Zidovudine 4 mg/kg twice a day for 7 days and 2 mg/kg oral Nevirapine immediately after birth

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