Medical management of children with HIV infection.

CQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) the symptomatic end stage of infection with thehuman immunodeficiency virus (HIV). TheHIV epidemic is sustained and continues because ofintravenous drug use and sexual spread both heter-osexually and homosexually. Currently, children be-come infected through perinatal exposure to their HIV-infected mothers. Older children and adolescents canacquire HIV through sexual abuse. Prior to March 1985,a limited number of individuals were infected becauseof exposure to contaminated blood or blood products.This last mode of acquisition is in large part undercontrol in countries that screen blood donors.An important question for public health in theUnited States is whether this epidemic will sustain itselfin populations where there is predominantly heterosex-ual spread, as in Africa, or whether less transmissionwill occur as it moves from areas of high drug use, aswith Hepatitis B. In Newark, New Jersey, we have bothintravenous drug use and heterosexual spread. Be-tween 1982 and 1984, we noted that most women whohad an HIV-infected child were intravenous drug users.However, by 1989 almost half of the women with anHIV-infected child did not use drugs, and their onlyHIV risk factor was heterosexual contact with an HIV-infected male (Palumbo et al. 1988). Other than in thehomosexual community, HIV infection is linked topoverty and drug use, with women of childbearing ageusually being infected. Among the minority, poorpopulations who are disproportionately infected withHIV, the issue of limited access to health care has alwaysexisted. The HIV epidemic has simply focused thisinequity in health care-- especially for women and theirchildren.The first dilemma faced by the pediatrician caring forchildren at risk for HIV infection is that of accurate andtimely diagnosis. The classical means of identifyingHIV-infected patients is by serology (ELISA confirmedby Western blot). However, all infants born to infectedwomen will have passively (i.e., maternally) acquiredHIV antibody lasting for up to 15-18 monthMP-yun et al.1987).It is estimated that maternal-infant transfer of HIVoccurs with an incidence of 25-50% (Scott et al. 1985;Mok et al. 1987; Semprini et al. 1987). The timing of viralinfection from mother to offspring currently is understudy, but evidence supports both fetal and perinataltransfer. There are new diagnostic assays under devel-opment that may be able to differentiate the infant whois truly HIV-infected at birth from the infant with onlypassive maternal HIV antibody. These include antigendetection, improved viral cultures, detection of viralgenetic material in mononuclear cells (polymerasechain reaction or PCR) (Ou et al. 1988; Rogers et al. 1989),and determination of antibody production in newbornserum or immune cells. The ability to detect HIV-in-fected infants will assist in identifying those who shouldreceive antiviral therapy with drugs such as AZT. By1991, there may be more than 20,000 HIV-infected chil-dren in the United States, and by the year 2000 morethan one million infected women and children world-wide (Oleske 1990).Clinical SpectrumThe HIV-infected infant and child suffers from achronic condition with multiorgan system involve-ment. Nonspecific findings related to chronic viral in-fection, malnutrition, and immunodeficiency are com-mon. These findings include:1. Fever2. Failure to thrive3. Diffuse adenopathy4. Hepatosplenomegaly5. Chronic diarrhea6. Dermatitis.Given the history of a child living in a high-risk area forHIV, serology should be performed as part of the evalu-PEDIATRIC DENTISTRY: