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Questions & Answers: Clinical Management

Question

I have a foster child diagnosed as HIV at birth. He was given AZT at birth and has since tested negative twice (he's a year old), the most recent test done at 1 year. My question is this: What are the chances he will remain negative?

-- Foster Parent, CA


Answer

Understanding HIV testing can be very confusing at times. There is a difference between being diagnosed with HIV at birth and being exposed to HIV. All babies born to women with HIV infection will have HIV antibodies which are transmitted from the mother to the baby in utero (in the womb). Only about 25% of babies born to women who have HIV infection will get the virus. If mother and baby are given AZT before and after birth, the chance of getting HIV is reduced to 8%.

In order to determine whether a baby received the virus itself from the mother, we do either an HIV-DNA PCR or HIV culture test. These two tests, if positive, allow us to diagnose HIV in infants as early as four months. The antibody test is not useful to diagnose HIV until the child reaches 18 months. At that time a positive antibody test indicates that the child is truly infected. Before 18 months, there is no way to indicate whether the antibody is the mother's or the baby's antibody.

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It is difficult to comment with any level of certainty about your child's negative status without knowing which HIV tests your healthcare provider is doing. Two negative HIV DNA PCR tests, one of which must be after 4 months, means that HIV can reasonably be ruled out. It is recommended that HIV antibody testing be done again at 12 months and again at 18 months for complete certainty. Babies who are exposed to HIV should receive trimethoprim/sulfamethoxazole (TMP-SMX) beginning at 6 weeks and continuing until HIV is ruled out, or if the CD4 T cell count is measured regularly and is in a safe range, the doctor may consider stopping TMP-SMX.



Question

Do you have any information on the new immunization recommendations and how they apply to HIV exposed and infected children?


Answer

Children should be immunized according to the American Academy of Pediatrics (AAP) http://www.aap.org/family/parents/immunize.htm with these exceptions: polio vaccine should be given as OPV and not IPV. Varicella vaccine to prevent chicken pox is not recommended. MMR would only be held in the case of severe immunosuppression (CD4 T cell less than 15%). If you have any further questions regarding this topic, please feel free to email us again.



Question

My wife and I are trying to adopt a child. One particular child we have identified is an 11-week old girl from a third world country. When she was taken to the orphanage at 4-5 weeks old, she was tested for HIV antibodies and was positive (level of 16 -- I don't know what test). We understand that this may not necessarily mean that she has HIV. Our doctors have said we should have a viral load (PCR) test conducted (and we are) to detect any levels of the virus. My questions are these: if the viral load test comes back negative (or undetectable) does this mean she does not have the virus (and to what level of certainty)? Does it mean she will not develop the virus (and to what level of certainty)? I think it is safe to assume the mother had no treatment before or during pregnancy and the child has had none either. Also, it is unknown at what stage the mother was during the pregnancy. Thank you!


Answer

Thank you for your questions. Understanding HIV testing and diagnosing in babies is complicated. Having a baby with positive HIV antibodies does not mean that the baby has HIV infection. Your doctor is correct, in that, the baby should have an HIV DNA PCR test done to detect the presence of HIV. HIV DNA PCR simply measures the presence of the virus. Another test called HIV RNA PCR measures the amount of virus that the person with HIV infection has and this is called the viral load. At 3 months of age, a negative HIV DNA PCR would be strong evidence against infection (>95% if done in a good laboratory). If this test is positive, it should be repeated to confirm the result. This means the baby has HIV. Two negative HIV DNA PCR tests, one which must be after 4 months, means that HIV can reasonably be ruled out. It is recommended that HIV antibody testing be done again at 12 months and again at 18 months for complete certainty. Babies who are exposed to HIV should receive trimethroprim/sulfamethoxazole (TMP-SMX) beginning at 6 weeks and continuing until HIV is ruled out, or if the CD4 T cell count is measured regularly and is in a safe range, the doctor may consider stopping TMP-SMX.



Question

Can you please offer suggestions on ways to make antiretroviral drugs more palatable?


Answer

Attempts to shock or distract the taste buds by giving a sour-tasting or tart candy (e.g., Warheads®, Lemonheads®, Pixy Stix®), or tart substance such as Jello® powder, Tang crystals, or breath freshener drops prior to administering the bitter ritonavir is often successful. Some advocate "freezing" the taste buds by pre-administering ice pops or frozen juice concentrates or giving a strongly flavored chewing gum. Post-ingestion vomiting may be abetted by administration of too great a volume of liquid to "wash the medicine down" and may be ameliorated by more modest volumes of liquid. Pediatric Nurse Practitioners at our clinic would be helpful resources to problem solve concerning individual patients and can be contacted by email: ortegaes@umdnj.edu. (Address the question to a pediatric nurse practitioner.) A successful solution may have a limited period of efficacy and those responsible for administration often have to vary methods and be infinitely creative. On more than rare occasions (especially with ritonavir), we have had to concede defeat and abandon this drug.



Question

I am putting together an HIV education video targeting young heterosexual women. I am searching for an accurate, up to date figure concerning how many more times likely it is for a woman to be infected by a man than the other way around. I have answers ranging from 4 to 20.

-- Dawn's Dad/Educator, Issaquah, Washington USA


Answer

We have spent some time reading your e-mail and deciding how to answer it. Yes, technically speaking women are more likely to become infected from a man based on the fact that women have more surface area where the infection could enter. However, the Nevada AIDS Hotline might be a better place for you to find the answer you are looking for. Their e-mail address is: nvhotline@aol.com. They have questions like this posted with answers on their web site. You can also call and speak with a hotline staff person at 1-800-842-AIDS.


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