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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
ReferencesReferences Potterton, J.L. & van Aswegen, H. 2006. Paediatric HIV in South Africa: Potterton, J.L. & van Aswegen, H. 2006. Paediatric HIV in South Africa:
An Overview for Physiotherapists An Overview for Physiotherapists SA Journal of Physiotherapy SA Journal of Physiotherapy 26(1):19 26(1):19 -22-22
Potterton, JL. 2001. The prevalence of developmental delays in infants Potterton, JL. 2001. The prevalence of developmental delays in infants who are HIV positive. who are HIV positive. SA Journal of Physiotherapy SA Journal of Physiotherapy 57(3):11-1457(3):11-14
Smith, R. 2008. HIV & the role of the physiotherapist in Paediatric Smith, R. 2008. HIV & the role of the physiotherapist in Paediatric Dictate, UFS (unpublished) pp257 -Dictate, UFS (unpublished) pp257 -
Collet, L., Valla, S., Kigundu, B., Harding, S. & Sesele, R. 2009. The Collet, L., Valla, S., Kigundu, B., Harding, S. & Sesele, R. 2009. The prevalence of neurodevelopmental delays in HIV-infected infants prevalence of neurodevelopmental delays in HIV-infected infants currently receiving HAART. UFS student research project (unpublishedcurrently receiving HAART. UFS student research project (unpublished
Cotton, MCotton, M. . 2006. TB-HIV: What is the research agenda in children. 2006. TB-HIV: What is the research agenda in children. http://209.85.229.132/search?q=cache:0fJXjnnDbt8J:www.ias2007.org/pag/ppt/http://209.85.229.132/search?q=cache:0fJXjnnDbt8J:www.ias2007.org/pag/ppt/
SUSA503.ppt+Tuberculosis+in+HIV-+infected+children&cd=8&hl=en&ct=clnk&gl=zaSUSA503.ppt+Tuberculosis+in+HIV-+infected+children&cd=8&hl=en&ct=clnk&gl=za
ReferencesReferences Chinniah,K.; Mody, G. M.; Bhimma, R.& Adhikari, M. 2005. Arthritis in Chinniah,K.; Mody, G. M.; Bhimma, R.& Adhikari, M. 2005. Arthritis in
association with human immunodeficiency virus infection in Black association with human immunodeficiency virus infection in Black African children: causal or coincidental? African children: causal or coincidental? RheumatologyRheumatology 44(7):915-920 44(7):915-920
Patient UK. 2009. reactive arthritis. Retrieved 19 November 2009. Patient UK. 2009. reactive arthritis. Retrieved 19 November 2009.
available from available from http://www.patient.co.uk/doctor/Reactive-Arthritis.htmhttp://www.patient.co.uk/doctor/Reactive-Arthritis.htm
Innocenti, D.M. & Anderson, J. M. 1992. applying Chest physiotherapy Innocenti, D.M. & Anderson, J. M. 1992. applying Chest physiotherapy in some conditions. In Cash’s Textbook of Chest, heart and Vascular in some conditions. In Cash’s Textbook of Chest, heart and Vascular Disorders for Physiotherapists.4ed. Downie, P.A. (eds). Mosby-Disorders for Physiotherapists.4ed. Downie, P.A. (eds). Mosby-Yearbook Ltd. London. Pp 507-535Yearbook Ltd. London. Pp 507-535
Smith, R. 2009. Peripheral nerve lesions in HIV infected children. Smith, R. 2009. Peripheral nerve lesions in HIV infected children. Paediatric dictate, UFS (unpublished)Paediatric dictate, UFS (unpublished)