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Pediatric HIV disease is marked by several common events. Failure to thrive, or the lack
of normal weight gain and growth is common. Sometimes HIV-infected children are slow to
develop motor and other skills such as crawling, walking and talking. Some children with
advanced HIV disease show signs of neurologic problems. These can include problems
walking, seizures, mental retardation and poor school performance. In addition to the
usual childhood diseases, opportunistic infections can create havoc. Relentless diaper
rash, oral thrush and other problems related to immune deficiency make growth and
development more challenging. Medical care and access to social programs are crucial
during childhood to prevent more devastating and long-term effects of HIV disease and its
complications. Several recommendations have been made for the best possible care,
including:
- provide appropriate and adequate nutrition
- provide timely immunizations
- individualize antiretroviral treatment and prevention strategies for other infections
- support the social structure of the family care unit.
Government Response: Influencing Trends in Care for Pediatric Chronic
Disease
The U.S. Department of Health and Human Services Health Resources and Services
Administration has published a document that discusses an agenda for pediatric HIV/AIDS
programs. It noted the trends in providing care for children with chronic conditions as
requiring services for a broader range of conditions, for the "whole child" as
opposed to the specific medical condition, and a multidisciplinary and multi-agency
approach. Healthcare access problems were recognized as significant issues for the
pediatric population. Pediatric AIDS cases reported to CDC were more common in underserved
populations. Fifty-eight percent of children with AIDS are of African American descent and
23% are Hispanic.
C. Everett Koop, MD, then U.S. Surgeon General, stated the importance of building a
strong community-based service system to support all aspects of care provided locally for
children with chronic disease and their families. This was an important foundation for the
concept of integrated, timely and consistent medical care that supported cultural
diversity and normal living patterns.
Approximately 5 million dollars in funding was made available for the Pediatric
HIV/AIDS Health Care Demonstration Projects, Pediatric HIV/AIDS Comprehensive Centers and
a National Resource Center (see end of article for a list of programs by state).
Collaboration between community agencies was encouraged. Basic principles were set forth
to outline the concept of family-centered care. Key elements included recognition of the
family unit as a constant in the child’s life, facilitation of parental and
professional collaboration at personal and policy levels of care, sharing information in
an unbiased and appropriate manner, implementation of programs and policies that support
the psychosocial and economic needs of the families, recognition and respect for
individuality and coping ability, incorporating developmental needs of the child and
family unit into care, facilitation of interfamily support, and assurance of flexibility,
accessibility and responsiveness to individual family needs.
The primary expected outcome was a contribution to the ability of children and their
families to lead productive and independent lives. The economics were justified based on
the expectation that improved health, increased independence, decreased family stress and
reduced healthcare costs would result.
Clinically Speaking
More information is becoming available on the long-term issues surrounding HIV disease
management in children. Unlike adults, children with HIV have the added challenges of
growing, physically and mentally maturing, and keeping a step ahead of HIV to prevent
setbacks. If a child becomes malnourished, the ability of the immune system to keep
working well may be in jeopardy. This can lead to more problems with infections and HIV
disease progression. Because many HIV positive children are already at high risk for
malnutrition, the potential for immune suppression is even greater.
Treatment regimens can be complex. Treatment of HIV infection is important to this
discussion because there is evidence that children improve the rate of weight gain (with
even some catch-up growth for children who were growth-retarded before treatment), mental
functioning and survival when effectively treated with a tolerable anti-HIV regimen.
Current treatment guidelines include the initiation of antiretroviral therapy when
symptoms and/or immune suppression are evident (categories N2, N3, A1-3, B1-3, C1-3) or
the child is less than 12 months old. A combination of 3 drugs that includes 2 reverse
transcriptase inhibitors and 1 protease inhibitor is recommended. The choice of protease
inhibitor may depend on the child’s ability to swallow capsules. The federal
government updated its Guidelines for the Use of Antiretroviral Agents in Pediatric HIV
Infection in April (available in the April 17 issue of Morbidity and Mortality
Weekly Report and on the web at www.hivatis/org/trtgdlns.html).
Depending on which regimens are chosen, dietary issues once again come into play. The
child must be well nourished to make the most of treatment with the fewest side effects.
In addition, interactions with foods can make a difference in how well drugs work. Table 1
shows some of the relevant drug-food interactions. The treatment of HIV infection is
crucial to long-term survival. It is sometimes difficult to follow the guidelines
recommended by the healthcare provider down to the finer details. Keeping medication
diaries, setting timers and other strategies can help. Following some of the food tips in
Table 1 may make medications more tolerable. The caregiver should be alert for symptoms
that may make medication regimens difficult to follow. It is important to report any of
these side effects to the physician.
Table 1. Food-Medication Interactions with Antiretroviral Drugs
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