|U.S. Updates Clinical Guidelines for Prevention and Treatment of Opportunistic Infections among HIV-Exposed and HIV-Infected Children
New guidelines to assist health care workers in preventing and treating the secondary
infections that can afflict U.S. children exposed to, or infected
with, HIV, were published by the National Institutes of Health
and the Centers for Disease Control and Prevention.
The new guidelines provide a reference manual for the treatment of these secondary
infections, describing warning signs of potentially hazardous interactions
between drugs used to treat HIV and its secondary infections, current
standards for treating the inflammation accompanying the immune
system recovery made possible by new anti-HIV drugs, as well as
when to discontinue preventative treatment no longer needed after
the immune system has recovered.
HIV cripples the immune system, leaving infected people more vulnerable than
the general population to numerous other infectious diseases. These
diseases, which ordinarily do not cause problems for people with
fully functioning immune systems, are known as opportunistic infections.
HIV-associated opportunistic infections are a leading cause of
hospitalization and death among HIV-infected children in the United
States. Some of these opportunistic infections can also afflict
children who do not have HIV but who have one or both parents with
HIV and specific HIV-related opportunistic infections.
"The guidelines will help health care workers and public health officials who
work with children to save lives that might otherwise be lost," said Kathleen
Sebelius, secretary of the U.S. Department of Health and Human Services. "The
infections that can accompany HIV are often the major cause of illness and death
of HIV-infected children."
The report, Guidelines for Prevention and Treatment of Opportunistic Infections
in HIV-Exposed and HIV-Infected Children, updates recommendations on topics such
as the importance of starting antiretroviral treatment early and interactions
between drugs that treat HIV and drugs that treat opportunistic infections.
The report, the first update of the guidelines in five years, appears in the
Sept. 4 issue of Morbidity and Mortality Weekly Report (MMWR). The NIH and CDC
produced the update in cooperation with the HIV Medicine Association of the Infectious
Diseases Society of America, the American Academy of Pediatrics, and the Pediatric
Infectious Disease Society.
The new guidelines apply to 23 opportunistic infectious diseases. A panel of
more than 30 government and non-government pediatric HIV and infectious disease
experts developed the guidelines. The guidelines update and combine two previous
publications, a 2002 publication on the prevention of opportunistic infections
in HIV-infected adults and children and a 2004 publication on the treatment of
opportunistic infections in children.
In recent years, the number of HIV-associated opportunistic infections in children
has declined significantly in the United States. The decrease is primarily due
to advances in antiretroviral therapy. But the infections continue to occur,
and they can be serious or even fatal.
"Health care providers must be vigilant for the signs and symptoms of
these infections and know how to prevent and treat them," said Lynne Mofenson,
M.D., a coauthor of the new guidelines and chief of NICHD's Pediatric, Adolescent,
and Maternal AIDS Branch.
Because children's immune systems are not as developed as adults, even children
who do not have HIV may be at high risk of catching certain opportunistic infections,
such as tuberculosis, if one or both parents have HIV and an accompanying opportunistic
infection. Like HIV itself, some opportunistic infections, such as cytomegalovirus
or hepatitis viruses, can be passed from mother to child.
"Guidelines for preventing and treating opportunistic infections in children
must consider the risk of infections among both HIV-infected children and children
who were HIV-exposed through birth to an HIV-infected mother." Dr. Mofenson said.
In recent years, HIV infection has increased among adolescents.
"We hope that doctors and clinicians make use of these new guidelines to ensure
that adolescents with HIV are not severely impacted by other infections," said
Kenneth L. Dominguez, M.D., a coauthor of the new guidelines and epidemiologist
at CDC's Divsion of HIV/AIDS Prevention. "Despite our country's strong success
in preventing perinatally HIV-infected infants, we must protect the significant
numbers of current HIV-infected children and adolescents who are able to live
longer, healthier lives due to advances in HIV therapy."
Drug doses and response to treatment may differ for children or adolescents entering
puberty than for adults. Guidelines for adults and postpubertal adolescents appear
in another report, Guidelines for Prevention and Treatment of Opportunistic Infections
in HIV-Infected Adults and Adolescents, published in the April 10, 2009, issue
Major changes in the pediatric guidelines include:
- Emphasis on the importance of effective antiretroviral therapy to improve children’s
immune function. The development of new therapies for HIV in children in recent
years has shown that successful treatment of HIV itself is pivotal to preventing
and controlling opportunistic infections.
- Information on diagnosing and managing
immune reconstitution inflammatory syndrome. In this condition, the immune system
begins to recover but then responds to a previously acquired opportunistic infection
with an overwhelming response that worsens the symptoms of infection. Despite
the worsening symptoms, continuing antiretroviral treatment is critical, the
- Information on the management of antiretroviral therapy in children
with opportunistic infections, including potential drug-drug interactions.
guidance on use of antibiotic drugs to prevent Pneumocystis jirovecii pneumonia
in infants. Previously, doctors were advised to give an antibiotic to all infants
born to HIV-infected mothers to prevent infection with Pneumocystis jirovecii
pneumonia, starting at 4-6 weeks until the infant tested negative for HIV at
4-6 months of age or was found to be HIV-infected. With advances in diagnostic
testing and effective prevention of mother to child transmission, the new guidelines
note that if infants have two negative tests for HIV at early timepoints (one
at 2 weeks or older and one at 4 weeks or older), use of antibiotics to prevent
this infection may be avoided.
- Updated immunization recommendations for HIV-exposed
and -infected children, including hepatitis A, human papillomavirus, meningococcal,
and rotavirus vaccines.
- A new section outlining treatments for malaria, which
may become an opportunistic infection in HIV-infected immigrant children or HIV-infected
children who travel to countries with malaria.
- New recommendations on when to
discontinue medication for preventing opportunistic infections. Previously, medications
to prevent opportunistic infections were given for life. Now, however, new therapies
that inhibit HIV may allow the immune system to recover. When the immune system has
recovered sufficiently, the medications to prevent opportunistic infections may
no longer be needed. The guidelines list diagnostic criteria for discontinuing
The new guidelines (as well as all federal HIV prevention and treatment guidelines)
appear on the AIDSinfo Web site, http://www.aidsinfo.nih.gov/. Because treatment
of opportunistic infections in children continues to evolve, NIH and CDC will
update the recommendations as new treatments or clinical data on existing treatments
The Centers for Disease Control and Prevention (CDC), part of the U.S. Department
of Health and Human Services, protects people's health and safety by preventing
and controlling diseases and injuries; enhances health decisions by providing
credible information on critical health issues; and promotes healthy living through
strong partnerships with local, national, and international organizations. For
more information about CDC and its programs, visit http://www.cdc.gov.
The NICHD sponsors research on development, before and after birth; maternal,
child, and family health; reproductive biology and population issues; and medical
rehabilitation. For more information, visit the Institute’s Web site at http://www.nichd.nih.gov/.
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Medical Research Agency — includes 27 Institutes and
Centers and is a component of the U.S. Department of Health and
Human Services. It is the primary federal agency for conducting
and supporting basic, clinical and translational medical research,
and it investigates the causes, treatments, and cures for both
common and rare diseases. For more information about NIH and
its programs, visit www.nih.gov.