Hospitalists should also heed how they introduce the need for the test. “To be honest, I think in many ways we have made the testing process too scary,” says Dr. Barton. She believes patients and their families may become unduly alarmed because of the emphasis on informed consent, as well as the secrecy of results. Her approach with families in the hospital or at the clinic is to tell parents she wants to do an HIV test to “make sure that every stone is uncovered” in making a diagnosis. “We should all do our best to explain to families what our plan is or what kind of testing we will be doing, whether it’s an HIV test or not,” she says.
Dr. Barton also cautions pediatric hospitalist colleagues to be sensitive to parents’ wishes when a diagnostic work-up includes a CD4 count or HIV test. If the child has been seen in an outpatient setting, it is possible the parents have not yet told their child that he or she is HIV-infected. “Try to be cognizant of the parents’ involvement and wishes,” she advises. “To have a perfect stranger [the hospitalist] tell you that you’re HIV-infected can be shocking.”
HIV in Children
The numbers of children with HIV in the United States tend to be small in comparison with the world’s estimated 2.5 million children under 15 living with the virus. From the start of the epidemic until 2002, 9,300 U.S. children under 13 had been reported to the CDC as living with HIV/AIDS. The majority of those children acquired the virus from their mothers before or during birth or through breast-feeding.
Most cases of HIV infection in infants are diagnosed at birth, according to Dr. Barton. With the advent of AZT (zidovudine) and HAART, only 92 new cases of pediatric AIDS were reported in 2002. The patterns of pediatric HIV/AIDS rates parallel those in adult groups: rates are higher among minority and economically disadvantaged inner-city populations.2
As with adult HIV populations, healthy children with HIV do not often present in the hospital setting because their condition is well controlled. However, Dr. Barton is seeing teenagers with acute retroviral syndrome—which occurs in those recently infected—and immigrant children with HIV-related diseases. The latter group, she says, do not have access to ongoing outpatient care, and their disease has gone undiagnosed until it brings them to the hospital.
The incidence of opportunistic infections differs in children, where pneumoncystis pneumonia (PCP) and cytomegalovirus (CMV) are primary infections. In adults these diseases usually result from the reactivation of latent infections. Lymphocytic interstitial pneumonitis is more common in children than in adults. Severe candidiasis, a yeast infection, can cause constant diaper rash or manifest as oral thrush.
Dr. Barton emphasizes that pediatric hospitalists should keep a low threshold for thinking about HIV when diagnosing children. Possible reasons to test for HIV include:
- Failure to thrive;
- Delayed developmental milestones, such as crawling, walking, and talking;
- Severe presentation of common illnesses, such as diarrhea;
- Chronic appearance of common illnesses, such as colds; and
- Seizures, fever, dehydration, and pneumonia.
Finding appropriate drug regimens for children with HIV can be even more of a challenge than for adult HIV patients. Children with HIV are treated with HAART. Many drugs approved for adults are not available in liquid form for younger children. Even if children can swallow pills, the dose may be too high for them. HAART in the pediatric setting also carries risks of multiple toxicities and drug resistance.