Editors Mamatha M Lala
Medical Advisor and Consultant Pediatrician Committed Communities Development Trust (CCDT) Medecins Sans Frontieres (MSF) Society for Human and Environmental Development
Other Attachments Bai Jerbai Wadia Hospital for Children Nowrosjee Wadia Maternity Hospital
Mumbai, Maharashtra, India
Rashid H Merchant
Former Dean and Professor of Pediatrics Former Director of Pediatric/Perinatal HIV Program Bai Jerbai Wadia Hospital for Children
Mumbai, Maharashtra, India
Consultant Pediatrician Dr Balabhai Nanavati Hospital
Mumbai, Maharashtra, India
Forewords Hoosen Coovadia
Ishwar S Gilada
Janak K Maniar
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Principles of Perinatal and Pediatric HIV/AIDS
First Edition: 2011
9789350251973
Printed at
All the children who have lost their lives to the HIV epidemic and to those who continue to fight bravely in the face of this disease…….
In doing so, they not only inspire us to become better clinicians, but more importantly, teach us to smile and not to give up hope in spite of all adversities……
In memory of Dr SM Merchant, who ignited the lamp of knowledge and inspired us to do the same and spread the light
7Contributors
- Abdulkadeer Jetpurwala mds
- Assistant Professor, Department of Pediatric and Preventive Dentistry
- Nair Hospital Dental College
- Mumbai, Maharashtra, India
- Alay Banker ms (ophthalmology)
- Banker's Retina Clinic and Laser Center, Ahmedabad, Gujarat, India
- Amisha Malhotra md
- Assistant Professor, Department of Pediatrics, University of Medicine and Dentistry of New Jersey
- Robert Wood Johnson
- Medical School, New Jersey, USA
- Angelika Mohn md
- Department of Pediatrics
- University of Chieti
- Chieti, Italy
- Anisa Mosam mbchb fc derm (sa) mmed (natal) phd
- Department of Dermatology
- Nelson R Mandela School of Medicine
- University of KwaZulu-Natal
- Durban, South Africa
- Anna Coutsoudis phd
- Professor, Department of Pediatrics and Child Health, Nelson R Mandela
- School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Antoni Noguera-Julian md phd
- Infectious Diseases Unit
- Department of Pediatrics
- Hospital Sant Joan de Déu
- Universitat de Barcelona
- Barcelona, Spain
- Asmita Mhaskar md
- Clinical and Translational Science Institute
- Division and Center for Evidence-based
- Medicine, Department of Internal Medicine, College of Medicine
- University of South Florida, USA
- Beata Casanas do
- Executive Medical Officer
- Hillsborough Health Department
- Assistant Professor, Internal Medicine
- University of South Florida
- Tampa, Florida, USA
- Bonaventura Clotet md phd
- Director, HIV Unit and Retrovirology
- Laboratory “irsiCaixa”
- Hospital Universitari Germans
- Trias i Pujol, Universitat Autònoma de Barcelona, Catalonia, Spain
- Brian Eley mbchb fcp (sa) (ped) bsc (hons)
- Pediatric Infectious Diseases Unit
- Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
- Brie-Anne Kohrt ma
- Cancer Research Training Fellow
- National Cancer Institute
- National Institutes of Health
- Bethesda, USA
- Cherie-Ann Pereira bsc (hons) msw
- Project Officer–Ashray
- Committed Communities Development Trust (CCDT)
- Mumbai, Maharashtra, India
- Chiriboga Daniella md
- Medical Officer
- Pediatric Infectious Diseases
- Polk County, Florida, USA
- Clàudia Fortuny-Guasch md phd
- Chief-Infectious Diseases Unit
- Department of Pediatrics
- Hospital Sant Joan de Déu
- Universitat de Barcelona
- Barcelona, Spain
- Deepa A Banker md
- Associate Professor of Pediatrics
- Smt NHL Municipal Medical College
- Ahmedabad, Gujarat, India
- Dorothy M Myridakis md
- Staff Cardiologist
- St Joeseph's Medical Center
- Paterson, New Jersey, USA
- Douglas Watson md
- Assistant Professor
- Division of Pediatric Immunology
- Department of Pediatrics
- University of Maryland School of Medicine, Baltimore, Maryland, USA
- Edna Siima Majaliwa md
- Muhimbili National Hospital
- Dar-es-Salam, Tanzania
- Eknath Naik md phd
- Co-Director, USF–India AITRP Program
- Staff Physician and Assistant Professor
- Pediatrics, Internal Medicine and Global Health, University of South Florida
- Tampa, Florida, USA
- Francesco Chiarelli md phd
- Department of Pediatrics
- University of Chieti, Chieti, Italy
- Fuad Kiblawi md
- Staff Cardiologist
- St Joesephs Medical Center
- Paterson, New Jersey, USA
- Gail Burack phd
- Clinical Assistant Professor of Pediatrics
- Robert Wood Johnson AIDS Program
- Department of Pediatrics, University of Medicine and Dentistry of New Jersey
- Robert Wood Johnson Medical School
- New Jersey, USA
- Graham Taylor mbchb frcp
- Reader in Communicable Diseases and Honorary Consultant Physician
- Imperial College, Norfolk Place
- London, UK
- Gurpreet Kindra mbbs dip epi (lshtm)
- Senior Research Medical Officer
- Department of Pediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
- Durban, South Africa
- Jacquie Flynn bsc (n)
- HIV Clinical Nurse Specialist
- Great Ormond Street Hospital for Children, UK
- Jaideep A Gogtay md (pharmacology)
- Medical Services Department
- James Nuttal mbchb dch (sa) dip obstet (sa) fcp (sa) (ped)
- Pediatric Infectious Diseases Unit
- Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
- Janak Patel md
- Professor, Department of Pediatrics
- Director, Pediatric Infectious Disease and Immunology and Maternal-Child
- HIV Program, University of Texas
- Medical Branch, Galveston, Texas, USA
- Jayanta Kumar Basu msc (statistics) pg diploma (population studies)
- Ex-Director, Research, Committed Communities Development Trust (CCDT)
- Mumbai, Maharashtra, India
- John Farley md mph
- Clinical Associate Professor
- Department of Pediatrics
- University of Maryland School of Medicine, Baltimore, Maryland
- Office of Antimicrobial Products
- US Food and Drug Administration USA
- Jose T Ramos md phd
- Chairman and Head
- Pediatrics Infectious Disease Unit
- University Hospital Getafe
- Madrid, Spain
- Josep M Llibre md
- HIV Unit and Retrovirology
- Laboratory “iris Caixa”, Hospital
- Universitari Germans Trias i Pujol
- Universitat Autònoma de Barcelona
- Catalonia, Spain
- Jyoti Dhar mbbs md frcp dtm&h
- Consultant Physician
- University Hospitals of Leicester, UK
- Kaizad R Damania md dnb fcps dgo dfp
- Professor, Obstetrics and Gynecology
- Nowrosjee Wadia Maternity Hospital
- Mumbai, Maharashtra, India
- Lori Wiener phd
- Director, Pediatric Psychosocial
- Support and Research Program
- National Cancer Institute
- National Institutes of Health
- Bethesda, USA
- Luise V Marino bsc (hons) pg diploma diet mmed sci rd
- Pediatric Research Dietitian
- Imperial College London, UK
- M Archary mbchb fcped dch Cert ID (ped)
- Pediatric Infectious Disease and HIV Specialist, Department of Pediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
- Durban, South Africa
- Madhavi Sathe bsc msc (food and nutrition)
- Lecturer, Smt Maniben MP Shah
- Women's College of Arts and Commerce
- SNDT Women's University Mumbai, Maharashtra, India
- Mamatha M Lala mbbs dnb (ped) dch
- Medical Advisor and Consultant
- Pediatrician, Committed Communities Development Trust, Medecins Sans Frontieres (MSF), Society for Human and Environmental Development
- Other attachments:
- Wadia Group of Hospitals, Mumbai
- Maharashtra, India
- Margaret Clapson bsc msc (n)
- Senior Clinical Nurse Specialist
- Department of Infectious Diseases
- Great Ormond Street Hospital for Children, UK
- Maria Isabel González Tome md
- Attending Pediatrician
- Immunodeficiency Unit
- University Hospital, Madrid, Spain
- Maryland Pao md
- Clinical Director
- National Institute of Mental Health
- National Institutes of Health
- Bethesda, USA
- Michael Breglia md
- Staff Physician, James A Haley VA
- Hospital and Assistant Professor
- University of South Florida
- Tampa, Florida, USA
- Mirium Adhikari mbchb fcp (ped)
- Head, Pediatrics
- Nelson R Mandela School of Medicine
- Durban, South Africa
- Mritunjay Kumar md
- Department of Pediatrics
- Patna Medical College
- Patna, Bihar, India
- Mukesh Agrawal md
- Professor, Department of Pediatrics
- Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
- Mumtaz Sharif md
- Lecturer, Pediatrics
- Dr DY Patil Medical College
- Navi Mumbai, Maharashtra, India
- N Poorana Ganga Devi mbbs pg dph
- Tuberculosis Research Center
- ICMR, Chennai, Tamil Nadu, India
- Niel Constantine phd
- Professor, Department of Pathology and Institute of Human Virology
- University of Maryland School of Medicine, Baltimore, Maryland, USA
- Nigam Prakash Narain md dch phd mrcp
- Associate Professor, Department of Pediatrics, Patna Medical College
- Patna, Bihar, India
- Ninad Desai md
- Associate Professor, Pediatrics
- Kings County Hospital Center and State University of NY-Downstate
- Medical College, Brooklyn
- New York, USA
- Paramita Ghosh ma sociology
- Research Officer, Committed Communities Development Trust (CCDT), Mumbai, Maharashtra, India
- Patricia Emmanuel md
- Clinical and Translational Science Institute, Department of Pediatrics
- College of Medicine
- University of South Florida, USA
- Patricia Whitney Williams md
- Professor of Pediatrics and Interim
- Chair, Department of Pediatrics
- University of Medicine and Dentistry
- Robert Wood Johnson Medical School
- New Jersey, USA
- Pensi Tripti md
- Associate Professor
- Department of Pediatrics and Neonatology, PGIMER and Dr Ram Manohar Lohia Hospital
- New Delhi, India
- Priti S Jain mds
- Assistant Professor
- Department of Pediatrics and Preventive Dentistry
- Nair Hospital Dental College, Mumbai
- Maharashtra, India
- Radhika Singh mbbs fcpeads cert neonatology
- Senior Specialist/ Lecturer
- Nelson R Mandela School of Medicine
- University of Kwazulu-Natal
- Rahul Mhaskar md
- Clinical and Translational Science Institute, Division and Center for Evidence-based Medicine, Department of Internal Medicine, College of Medicine, University of South Florida, USA
- Rajendra Thejpal mbchb fc paed(sa)
- Pediatric Clinical Hematologist
- University of KwaZulu-Natal
- Durban, South Africa
- Rashid H Merchant md dch
- Former Dean and Professor of Pediatrics, Former Director of Pediatric/Perinatal HIV Program, BJ Wadia Hospital for Children
- Consultant Pediatrician
- Dr Balabhai Nanavati Hospital
- Mumbai, Maharashtra, India
- Razia Bobat mbchb fc ped md cert id (ped)
- Associate Professor/Principal Specialist Head, Pediatric Infectious Diseases and HIV, Department of Pediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Rewari BB md frcp ficp
- Associate Professor
- Department of Medicine
- PGIMER and Dr Ram Manohar Lohia Hospital, National Program Officer
- ART, NACO, New Delhi, India
- Roger Paredes md phd
- HIV Unit and Retrovirology
- Laboratory “iris Caixa”,
- Hospital Universitari Germans
- Trias i Pujol, Universitat Autònoma de
- Barcelona, Catalonia, Spain
- Rohan Chauhan do
- Banker's Retina Clinic and Laser Center, Ahmedabad, Gujarat, India
- Roseann Marone mph bsn rn
- Assistant Professor of Pediatrics
- Program Coordinator-Robert Wood
- Johnson AIDS Program, University of Medicine and Dentistry of New Jersey,
- Robert Wood Johnson Medical School,
- New Jersey, USA
- SN Mothi md
- Founder Trustee, Consultant
- Pediatrician, Ashakirana Hospital
- Mysore, Karnataka, India
- Sandra Gompf md
- Chief, Infectious Diseases
- James A Haley VA Hospital and Associate Professor
- University of South Florida, Tampa Florida, USA
- Sanjiv Lewin md dnb
- Professor, Department of Pediatrics
- St John's Medical College Hospital
- Bengaluru, Karnataka, India
- Savita Pahwa md
- Professor, Microbiology and Immunology, Department of Pediatrics and Medicine, University of Miami
- Miller School of Medicine, Miami,
- Florida, USA
- Shelleye-Anne Bailey md
- Assistant Professor, Pediatrics
- Kings County Hospital, Center and State University of NY-Downstate
- Medical College, Brooklyn
- New York, USA
- Shubhika Srivastava mbbs faap facc
- Associate Professor, Pediatrics
- Director, Pediatric and Fetal
- Echocardiography Laboratory
- Division of Pediatric Cardiology
- Mount Sinai Medical Center
- New York, USA
- Soumya Swaminathan md mnams
- Scientist F, Tuberculosis Research
- Center (ICMR), Chetput
- Chennai, Tamil Nadu, India
- Steven Welch mbbs mrcp (uk) mrcpch ba (hons) msc
- Consultant, Pediatric Infectious
- Diseases, Heartlands Hospital
- Birmingham, UK
- Suganthi Iyer mbbs dha llb pgdmle pdcr
- Medicolegal Consultant
- PD Hinduja National Hospital and Research Center, Mumbai
- Maharashtra, India
- Sunanda Gaur md
- Professor of Pediatrics
- University of Medicine and Dentistry and Robert Wood Johnson Medical School, New Jersey, USA
- T Jacob John mbbs dch frcp (e) msc phd dsc fna
- Retired Professor and Head
- Department of Clinical Virology
- Christian Medical College, Vellore
- Tamil Nadu, India
- Tammy Meyers mbbch fcpaed (sa) mmed dtm&h
- Senior Consultant, Harriet Shezi Children's Clinic, Department of Pediatrics, Chris Hani Baragwanath Hospital and University of Witwatersrand, Johannesburg
- South Africa
- VV Banurekha mbbs pgdph
- Tuberculosis Research Center (ICMR)
- Chennai, Tamil Nadu, India
- Valentina Chiavaroli md
- Department of Pediatrics
- University of Chieti
- Chieti, Italy
- Vikram Kumar md
- Department of Pediatrics
- St John's Medical College Hospital
- Bengaluru, Karnataka, India
- Viraj B Mehta msc (life sciences)
- Medical Services Department
- Cipla, India
I am extremely pleased to see this textbook appear in India where the epidemic of HIV in children has not attracted the attention it deserves. The comprehensive coverage in this textbook makes it a reliable guide to the management of HIV in children. Many health workers are intimidated by the prospect of caring for children with HIV and AIDS.
Dr Mamatha M Lala, Dr Rashid H Merchant and their wide range of authors have succeeded in providing sufficient details to reassure those who are familiar with pediatric HIV and introduce those unfamiliar with prevention and treatment of this grave disease. In many developing countries, the clinical and epidemiological burden of childhood HIV are often unappreciated, but the global burden and broad ramifications of this unprecedented epidemic demand recognition and are of universal concern.
HIV has introduced all of us, who care for children, wherever we may be, to profound issues about the future of infected children on lifelong drugs and the unpredictable long-term outcomes of those born in HIV positive households but who remain uninfected. Entire families are at risk when HIV emerges even in a single member. For clinicians, there is an enormous amount of work to be done to keep abreast with developments in this disease which is as much a social, economic and ethical challenge as it is, a biomedical disorder. This excellent textbook will meet the requirements of most who read through its pages.
The book is aimed at a rather wide audience and should be of value to practising physicians, pediatricians, obstetricians, family doctors, postgraduate students and many others who have the interests of children at heart. Globally in regions which are most affected by HIV, such as sub-Saharan Africa, there is an increasing recognition that medically trained doctors will not easily fill the gap in provision of health services created by the serious epidemics of the modern world. “Task-Shifting” allows other well-trained health professionals to deal with many problems conventionally dealt with by doctors; to such cadres of health workers, the chapters in this book will be extremely useful and may serve as a reference to simpler guides.
The dimensions of HIV are often misunderstood or ignored in countries in which it is not a major cause of infant and child death, but it is a major cause of child morbidity and death, mainly in HIV affected regions: In 2008, there were 2.1 million infected children under 15 years of age in the world; 430, 000 of whom had become newly infected and 280, 000 had died of AIDS related diseases in that year. Ninety-one percent of the new HIV infections in children were in sub-Saharan Africa. Ninety-five percent of these infections were probably due to mother-to-child-transmission. There was about 18 percent decrease in these numbers from 2001. It is estimated that about 200, 000 new HIV infections in children had been prevented in the past 12 years. Of the total of 33.4 million persons infected with HIV in 2008, 15.7 million were women. HIV in pregnancy can worsen outcomes for both infants and mothers. There were an estimated one million HIV infected women who were pregnant in 2008 and who required PMTCT services. About 45 percent received these services in 2007. The antenatal months are pivotal in MTCT for the pregnant woman's and infant's health. Interventions to indirectly reduce vertical transmissions are well described in the book. Counseling on a range of issues is central to management. This includes advice on the use of antiretrovirals (ARVs) for either her own health or for PMTCT programs. By December 2008, coverage of adults and children for ARVs was 42 percent and more than 4 million adults and children were on treatment with ARVs, the number of children in need, receiving treatment was 275, 700.
There are two key issues on treatment of children with HIV which are extensively addressed in this book: Early diagnosis and early treatment. Maternal antibodies obscure detection of HIV and other more elaborate tests are required. Knowledge of the mother's HIV status or her exposure to risky sexual encounters can alert the health professional to the need for testing both mother and infant. Shortages of skilled personnel and unavailability of technology very often account for the difficulties faced by clinicians in making a firm diagnosis of HIV in children. 12Simpler and affordable tests for infant HIV diagnosis are an urgent need as clinical criteria for diagnosis are insensitive. Children have more rapidly advancing disease than do adults and delay in diagnosis result in high mortality rate. This is especially important for diagnosis of newborns and infants because, without appropriate ARV treatment, as many as a third of infected babies will die within a year, and most of these within a few months of birth. New WHO recommendations concerning treatment of children have recently been developed and provide practical guidance.
The richness of the text, the clear presentations from experts from all over the world—India, South Africa, the United Kingdom, the United States of America and Spain and the huge body of information within its 47 Chapters, ensures a wide readership and establishes this as a medical contribution which will be bought and consulted for many years to come.
Hoosen Coovadia
Emeritus Professor, Pediatrics and Child Health
Emeritus Victor Daitz Professor, HIV/AIDS Research
University of KwaZulu-Natal
Director—HIV Management
Maternal Adolescent and Child Health Unit
University of the Witwatersrand, South Africa
13Foreword
It is my proud privilege to write a foreword for one of the first books on Pediatric HIV/AIDS— Principles of Perinatal and Pediatric HIV/AIDS from the Indian subcontinent. I have known Dr Rashid H Merchant for two decades and Dr Mamatha M Lala for more than a decade for their dedicated passion and single-minded pursuit, especially in the field of Pediatric HIV, wherein not many pediatricians dared to get involved even for fashion!
In a country like India where HIV is largely a heterosexual epidemic, Mother-to-Child Transmission (MTCT) of HIV-1 has a great significance afflicting thousands of children each year. Situation in sub-Saharan Africa is worse, where HIV prevalence is high and resources are scarce. Moved by this tragedy few researchers across Africa and Asia got involved in getting safe, efficient, innovative and inexpensive strategies that could reduce the risk of perinatal HIV transmission and increase uneventful survival of HIV positive children. In 1993, an NGO known as a torch-bearer in the fight against AIDS—the Peoples Health Organization, India (formerly Indian Health Organization) and Wadia Maternity Hospital in Mumbai had launched a self-funded low-cost project to look at these issues, when many countries had no affordable, easy-to-emulate options. Over the years, it became the country's (possibly the world's) first and longest running Prevention of Mother-to-Child Transmission (PMTCT) project. The project used a four pronged approach: Zidovudine to mothers in their pregnancy, Zidovudine to the infants, elective cesarean section for delivery and avoiding breastfeeding, simple innovations like group counseling and pool-testing were some by-products. A major offshoot of this project was emergence of India's first Pediatric HIV set-up as also emergence of these two authors as Pediatric HIV experts!
The fact that pediatric HIV and its repercussions will be with us for several years emphasizes the need for a sustainable response and the book on this topic is one such significant effort. This is indeed an elaborate and comprehensive textbook with as many as 47 Chapters dealing with Perinatal HIV and Pediatric HIV, contributed by a wholesome combination of several national and international experts, many belonging to centers of excellence in Africa, US and Europe. From Immunology, Virology, Natural History, Diagnosis, Pharmacotherapy to Clinical Manifestations and Management, all chapters have been eloquently dealt with, by the Who's Who in the respective fields. Chapters like Nutrition, Growth/ Development/ Puberty in HIV Positive Children, Malignancies and Immune Reconstitution Inflammatory Syndrome have been lucidly addressed. HIV-TB, HIV-Hepatitis and HIV-Malaria co-infections find a prominent place in the book. PMTCT has been elaborately dealt with and a guide is provided for care of HIV positive pregnant women. As children with HIV have started living longer, reaching adolescence and even marriageable age, the tackling of psychosocial issues related to growing up with HIV, which is the need of the hour, has been very sensitively portrayed. The ever-so-important areas Antiretroviral Therapy, Toxicities, Adherence and Drug Resistance have been discussed in detail, as also the practical issues pertaining to Nursing Care of an HIV-positive Child in day-to-day life and Professional, Ethical and Legal issues have been very pragmatically presented.
The global HIV epidemic seems to be a permanent challenge to human existence, integrity and solidarity. Given the scale of suffering of children, given the proven effectiveness of several approaches in making them long-term survivors, and given the prospect of furthering other goals of the fight against HIV/AIDS, a sustained response makes practical sense. I have no doubt that this book—a collection of immense knowledge and experience from the global experts—is readily available to HIV care-givers and will certainly enhance the quality of care that the children will receive to further make their lives as meaningful as possible. It is a ‘must read treatise’ for postgraduates/physicians/obstetricians/primary medical practitioners/pediatricians as also all care providers for children with HIV. I wish the authors a grand success in this endeavor and hope each reader will admire the book, as much as me, if not more.
Ishwar S Gilada
Secretary General
Peoples Health Organization (India) and AIDS Society of India, Consultant in HIV/STDs
Unison Medicare and Research Center (India's first comprehensive HIV care center in private sector since 1994)
Mumbai, Maharashtra, India
15Foreword
This comprehensive book on Principles of Perinatal and Pediatric HIV/AIDS has wide range of coverage of relevant topics compiled by both eminent national and international authors. There shall be need for periodical revision of the edition to update about rapidly changing views on HIV medicine. The scientific standard of topics is very satisfactory.
I recommend this book should be read by postgraduate medical students and by all health care providers involved in the management of pediatric AIDS and perinatal HIV intervention. I anticipate that this book shall succeed in sensitizing pediatricians at large, and increasing number of new children/adolescents with HIV shall be identified and managed appropriately. The text in the book should be made available on Internet for easy and instant access. I sincerely appreciate the grand efforts made by editors and contributors at large.
Janak K Maniar
Consultant in HIV Medicine
Jaslok Hospital and Research Center
Saifee Hospital, Bhatia Hospital and HN Hospital
Mumbai, Maharashtra, India
President—AIDS Society of India
Formerly Professor—Dermatovenereology and HIV Medicine
Grant Medical College
Mumbai, Maharashtra, India
17Preface
The United Nations International Children's Emergency Fund (UNICEF) was founded in December 1946 in the wake of the World War II, when the international community recognized that children had special needs. Although the health of children has improved significantly over the last 60 years, much still remains to be done. The scourge of AIDS came upon the world in the last three decades. The developed world has succeeded in almost eliminating perinatal HIV transmission and has effectively given their already infected children a new lease of life. Health providers from developing nations need to shift emphasis towards priorities for improving child health care, and in doing so must pay special attention to preventing mother-to-child transmission of HIV and to the welfare of the HIV infected child. We believe that with adequate and appropriate support this challenge can and will be met in the future.
Pediatric HIV/AIDS is a vital discipline of modern pediatrics and in nearly three decades, researchers and clinicians have accumulated an abundance of scientific knowledge in this field. Unfortunately, little of this information is available in pediatric textbooks for clinical application. Although one of the major accomplishments in the management of HIV is the reduced incidence of mother-to-child transmission, even today a child is infected with HIV every minute, and about 1000 children die of AIDS everyday, claiming roughly half a million young lives every year. It is estimated that about 1300 infected children are born each day in Africa, 150 in India, and 1 in Europe or the US. Over the last two decades, therapeutic strategies for the treatment of pediatric patients with HIV have expanded dramatically from treatment with a single medication to combination therapy that includes up to five different classes of antiretroviral agents. The wealth of new information and experience available regarding rapidly emerging and changing pathogens, newer therapeutic agents and treatment regimens with renewed approaches to management, have made this specialized field more intricate and added to the complexity in management of what is now a chronic life-limiting illness. Effective management of the diverse needs of HIV infected infants, children, adolescents and their families requires attention to areas beyond antiretroviral therapy by a multidisciplinary team approach. It is important to remember that the long-term health of these vulnerable children depends on the sound judgment that we, as care providers, must exercise in their management.
This book, the first of its kind from the Indian subcontinent is directed to postgraduates, practicing pediatricians, physicians, obstetricians, general practitioners, non-governmental organizations, and all care providers of children with HIV, solely with a view to share knowledge for the benefit of patients, with no financial gains intended. It is aimed to provide a comprehensive, reliable, up-to-date reference focused on evidence-based, practical information that is required not only to prevent transmission of HIV to children, but also provide holistic care for the infected child.
Keeping in mind that children are our future, we are publishing this compilation of collective knowledge and experience of experts from across the globe. We hope that the information and insight it provides will take us one step closer to achieving our goal of enhancing the quality of care of HIV infected children and thereby provide them a chance for a better future.
Mamatha M Lala
Rashid H Merchant
19Acknowledgements
As this book evolved to emerge in this final form, a number of people have directly and indirectly contributed in various ways:
- We are grateful for the encouragement and support of our families without which a book of this scope could not have been completed.
- We learnt a great deal from all our patients and thank them for being a constant source of inspiration. We also wish to thank their caretakers who provided an insight into the practical challenges of their management.
- We gratefully acknowledge all our teachers for their encouragement, criticism and motivation. We wish to thank our colleagues and students who have encouraged us in this endeavor.
- Our special thanks to all authors, an outstanding faculty of experts in the field of Perinatal and Pediatric HIV/ AIDS, who willingly shared new knowledge and insights and provided chapters for our book.
- We are indebted to our team of reviewers, especially Dr. Steven Welch, Consultant in Pediatric Infectious Diseases, Birmingham Heartlands Hospital, UK; Dr. Rajendra Thejpal, Principal Specialist, Pediatric Hematologist, University of KwaZulu-Natal, South Africa, for providing excellent clinical pictures, in addition; Dr. Tammy Meyers, Senior Consultant, Department of Pediatrics, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa; Dr. Heather Zar, Dr. Diane Gray from the Division of Pediatric Pulmonology; Dr. Priya Gajjar and Dr. Peter Nourse from the Division of Pediatric Nephrology, Red Cross War Memorial Children's Hospital, South Africa; Dr. PR Donald from Tygerberg Hospital and the University of Stellenbosch, Cape Town, South Africa; Ms. Sara D'Mello, Director, Committed Communities Development Trust, Mumbai, Maharashtra, India, and many other anonymous reviewers for the care with which they reviewed the original manuscript. Their friendship and professional collaboration mean a great deal to us.
- We acknowledge the inputs from our students Dr. Shashank Ganatra and Ms. Noor Ahmad for their help and valuable suggestions.
- We would like to thank our esteemed colleague and friend Commander Asad Farhaat for all his help onboard " MV Ivan Papanin" en route to Antarctica, where the final proof-reading of the book was done despite stormy seas and extreme weather conditions. Our sincere thanks to Dr. Rajesh Asthana, Team Leader—XXX Indian Scientific Expedition to Antarctica, for his unflinching support and encouragement.
- The entire team at Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, approached this assignment with enthusiasm, and dealt with suggestions and comments with promptness and proficiency. We thank them cordially for all their efforts.
- While every effort has been made to acknowledge data from published research sources, we offer our apologies to any source/ copyright holders whose rights we have unwittingly infringed.