HIV IN CHILDREN : PROGNOSIS

 

• Hematologic disturbances such as anemia, thrombocytopenia, and neutropenia increase the risk of complications and mortality. Resolution of anemia improves the prognosis, and the treatment of anemia with erythropoietin improves survival. Neutropenia significantly increases the risk of bacterial infection, and treatment of neutropenia with G-CSF significantly decreases the risk of bacteremia and death.

• MAC has been shown to hasten death, especially with coexisting anemia defined by a hematocrit level less than 25%.

• The following factors are associated with rapidly progressive disease in infants:

• Advanced maternal disease 
• High maternal viral load 
• Low maternal CD4 count 
• Prematurity 
• In utero transmission 
• High viral load within the first 2 months of life 
• Lack of neutralizing antibodies 
• P24 antigen presence 
• AIDS-defining illnesses 
• Early CMV infection 
• Early neurologic disease 
• Failure to thrive 
• Early-onset diarrhea

• Each logarithmic decrease in the viral load after therapy initiation decreases the risk of progression by 54%.

• Overall progression and prognosis is followed up by using the CDC classification system for children infected with HIV. Both a clinical category letter and an immunologic number determine each stage of disease progression.

• The clinical categories are determined by the presence of clinic manifestations listed in the letter category (see Table 6), and the immunologic category is based on the age-dependent CD4 count (see Table 7).

• Once an advanced class is assigned, the disease cannot be reassignment to a lesser class, even if the clinical or immunologic manifestations resolve.

• Category C and clinical manifestations of advanced disease are synonymous with AIDS.Table 6. CDC Clinical Categories for HIV-Infected Children

   

  Category	Manifestation
  N – Asymptomatic	One of the manifestations in category A or no symptoms listed in the other categories
  A – Mildly symptomatic	Two or more: dermatitis, hepatomegaly, lymphadenopathy (>5 mm at multiple sites), splenomegaly, parotitis Recurrent or persistent sinusitis, otitis, or upper respiratory infection (URI)
  B – Moderately symptomatic	Invasive bacterial infection Persistent (>2 mo) oropharyngeal candidiasis (patients aged >6 mo) Cardiomyopathy Congenital CMV infection (onset before patient aged 1 mo) Chronic or recurrent diarrhea Persistent (>1 mo) fever Persistent (>1 mo) hematologic disorders Anemia (<8 mg/dL) Neutropenia (<1000/mm3) Thrombocytopenia (<100,000/mm3) Hepatitis HSVinfection Recurrent (>2 episodes/y) stomatitis Multiple dermatomes or recurrent (>2 episodes) zoster infection Early-onset (patient aged <1 mo) bronchitis, pneumonitis, or esophagitis Leiomyosarcoma Lymphoid interstitial pneumonia Pulmonary lymphoid hyperplasia complex Nephropathy Nocardiosis Congenital toxoplasmosis (patient age a onset <1 mo) Disseminated varicella
  C – Late symptomatic	Pulmonary or esophageal candidiasis Coccidioidomycosis Extrapulmonary cryptococcosis Cryptosporidiosis CMV infection Histoplasmosis Chronic mucocutaneous HSV infection Encephalopathy Isosporiasis KS Lymphoma MAC infection Mycobacterium kansasii infection PCP Recurrent pneumonia Progressive multifocal encephalopathy Salmonellosis TB Toxoplasmosis
  Late disease	MAC infection Disseminated CMV retinitis Cryptococcal meningitis Dementia, histoplasmosis Disseminated CNS lymphoma Progressive multifocal leukoencephalopathy (PML) Wasting syndrome

  Table 7. CDC Immunologic Categories for HIV-Infection in Children by Absolute CD4 Count

   

   

   

  Category	Patient Age, >12 y	Patient Age, 6-12 y	Patient Age, 1-5 y	Patient Age, <1 y
  1 – No suppression	>500 (>29)	>500 (>24)	>1000 (>24)	>1500 (>24)
  2 – Moderate suppression	>200 (>13)	>200 (>14)	>500 (>14)	>750 (>14)
  3 – Severe suppression	<200 (<14)	<200 (<15)	<500 (<15)	<750 (<15)

  Note: Data are the absolute CD4 count X 10⁹. Data in parentheses are percentages.

 

 

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