Dr. Ira Shah
Incharge Pediatric HIV and TB Clinic, B.J.Wadia Hospital for Children, Mumbai, India Consultant in Pediatric Infectious Diseases, Nanavati Hospital, Mumbai, India

Pediatric HIV primarily is a vertically transmitted infection with over 80% of the patients acquiring HIV through this route. Children infected pertinently with HIV vary greatly in how rapidly they develop immune suppression and symptoms or signs of disease. Systemic and pulmonary findings were common in the first HIV infected children who presented in the USA and in Europe; whereas chronic diarrhea, wasting and severe malnutrition are predominant presentations in Africa. In India, common clinical presentations are hepatosplenomegaly, lymphadenopathy, tuberculosis, failure to thrive, chronic dermatitis, pyrexia of unknown origin, recurrent respiratory tract infections, chronic otitis media and chronic diarrhea.

Clinical presentation in Infants
Among the early manifestations of HIV in children reported are HIV encephalopathy & opportunistic infections especially with pneumocystis jiroveci (PCP), cytomegalovirus (CMV), respiratory viruses and bacterial pneumonia. Recurrent gastrointestinal infections and oral thrush are commonly found. Lymphadenopathy, splenomegaly and hepatomegaly often are seen in the 1st year of life. Up to 10% of infants presenting with HIV have severe developmental delay and encephalopathy.

Rapid progressors
Few infants (15-25% infected newborns in developed countries) may develop AIDS within the first few months of life and if left untreated they have a median survival time of 6-9 months. Opportunistic infections and neurological complications are features seen more commonly in this group. These are the children that are infected intra-uterine with most of them showing positive HIV-1 culture and/or detectable viral load (median level 11,000copies/ml) in blood in the first 48 hr of life.

Long-term non-progressors (LTNP)
5–15% of HIV-infected individuals do not experience clinical or immunological progression despite a long duration of infection in the absence of HAART. They are known as long term non-progressors. They maintain good CD4 counts and tend to have low viral loads. Elite controllers (EC) are those who constitute <1% of HIV-infected individuals who maintain undetectable viral loads (<50 copies/mL) in the absence of HAART. EC generally have very slow disease progression, with some infected for 25 years without signs of AIDS.

Clinical Presentation in children
Growth failure, fever, diarrhea and secondary infections are seen beyond infancy. Many children who present with HIV may have had mild symptoms for many years. They may present with recurrent ear infections with sinusitis, chronic parotitis, chronic otitis media, nail fungal infections and molluscum contagiosum. Hepatosplenomegaly and lymphadenopathy persist.

HIV in older children
Older children have growth failure, delayed puberty and subtle cognitive dysfunction. Systemic manifestations such as HIV cardiomyopathy, idiopathic thrombocytopenic purpura (ITP) are seen in older children and adolescents.