Aim: To know diagnostic criterions of HIV/AIDS in children, how to examine the chil with HIV infection and prove the diagnosis, differentiate, give individual treatment an prophylaxis.

HIV/AIDS

Aim: To know diagnostic criterions of HIV/AIDS in children, how to examine the chil with HIV infection and prove the diagnosis, differentiate, give individual treatment an prophylaxis.

Professional motivation: HIV is a viral disease of human, which is passed mainl by sexual and parenteral ways and is characterized by long-term persistence. Defeat c the thymus gland, immunity causes clinically expressed form - syndrome of acquire immune deficiency (AIDS) with lymphadenopathy, intoxication, spreading of infectioi diseases and oncology processes. HIV infection is widely spread alloverthe world. Numbi of infected people grew in all regions. Mortality in case of AIDS is very high because < the opportunistic infections in those people. All this requires from the doctors of differei specialities to know diagnostic criteria, duration, treatment and prophylaxis of this patholog

Basic level:

1. To know how to ask complaints, disease history, life history in children (Propedeut pediatrics)

2. To perform the clinical examination of the child (Propedeutic pediatrics).

3. To know microbiology, pathophysiology, pathomorphology, of HIV/AIE (microbiology, pathophysiology, pathomorphology).

4. To diagnose HIV/AIDS after clinical and laboratory examination (infectk diseases, propedeutic pediatrics, microbiology, pathophysiolog biochemistry).

5. To give etiologic, pathogenetic, symptomatic treatment (pharmacology).

Students' Independent Study Program

Objectives for students' independent studies

You should prepare for the practical class using existing text books and lectures, spec attention should be paid to the following:

1. Etiology, epidemiology, pathogenesis of HIV/AIDS.

2. Clinical diagnostic features of HIV/AIDS.

3. Laboratory examination of patients with HIV/AIDS.

4. Differential diagnosis of HIV/AIDS.

5. Main treatment of HIV/AIDS.

6. Prevention of HIV/AIDS.

HIV infection is a chronic infectious disease that develops because of infection w human immune deficiency virus (HIV) and is characterized by progressive immune syst< damage.

AIDS is a terminal (final) 4^th stage of the HIV infection course as the result of 1 human immune system destruction by the virus (HIV), and loss of human capacity to res infections and diseases.

Etiology

• HIV - T- lymphotropic retrovirus of 3^rd type RNA-containing

• Cells-targets - DNA-containing (T-lymphocytes helpers)

• Enzymes: reverse transcriptase (revйrtase), protease

• Specific markers - p24, gp41, gpl20, gpl60

• Genom of the virus includes 3 structure genes (as all retroviruses) and 6 regulatory

genes (increase replication, activate of virus protein structure synthesis)

There are 2 types of HIV: HIV-1 and HIV-2. According to the nomenclature in 1999 HIV-lis based on phylogenetic analysis of genomes and produce 3 independent groups of viruses: group M - "main", group O - "outlier" and the group N - "non-M, non-O". Group M includes the most common worldwide isolates of HIV-1, which define a pandemic disease. This group of viruses is divided into 9 subtypes (A, B, C, D, F, G, H, J and K). In group O, according to the phylogenetic analysis, were allocated 5 separate subtypes: I, II, III, IV, V. In group N HIV-1 specific subtype have not identified. The highest prevalence of infection with group O and N recorded in Africa, particularly in Cameroon.

In addition to "pure" subtypes within group M HIV-1 there are "circulating recombinant forms", which have a mosaic genome structure. Spreading of HIV-1 group M subtypes:

• A: Western and Eastern Africa, Central Asia, Eastern Europe

• B: North America, Europe, East Asia, Latin America

• C: SouthAfrica,Asia, Ethiopia

• D: East Africa

• E: South-Eastern Asia.

HIV BIOLOGICAL CHARACTERISTICS

• HIGH genetic variability (up to 10⁴-10⁵ mutations / gene / every replication cycle,

predominantly in the gene gpl20)

• Resistance of HIV in an infected organism

- Rapid development of drug resistance

- Modified tropism of HIV at different stages of disease

- Difficulty in creating an effective vaccine

Stability of the virus in the Environment

• Drying the cell cultures will kill the virus at t° +23 +27 °C in 3-7 days.

• In fluid at a temperature of +23-27 °C - within 15 days.

• In the blood for transfusion it is alive through the years, and in the frozen serum -

activity persists up to 10 years.

• HIV dies quickly when using disinfectants, UV radiation, when heated above

56 °C loses activity in 30 minutes.

• HIV loses activity under the influence of protective enzymes of saliva and sweat.

Epidemiology

Source - sick and carrier (contagious during all life) Mechanism of transmission - contact (wound), vertical

Ways of transmission:

• natural: sexual (homosexuals - 1-3 %, females - 0.6 %, males - 0.09 %)

• vertical (transplacentar - 15-20 %, childbirth - 50-70 %, during breast feeding -

20-30 %)

• artificial: parenteral manipulations and drug using - 30 %, blood recipients -100 %,

transplantation of organs and tissues, artificial abortion - 100 % -

• professional: infection of medical personal - 0.1-0.4 %. Intrahospital outbreaks.

Estimated risk of transmission HIV from mother to child

(in the absence of any interventions)

• During pregnancy, 5-10 %

• During childbirth 10-20 %

• When breastfed 5-20 %

HIV is not transmitted:

• When insect bites (mosquitoes, fleas, lice, beetles, flies, etc.)

• With saliva, sweat, urine, feces, sputum, discharge from the nose, tears, vomitus (if

there is no visible admixture of blood)

• Household contact

Transmission has not been proved during puncture

• Cerebrospinal

• Synovial

• Pleural

• Peritoneal

• Pericardial •Amniotic

Biological fluids, which contacted you may be infected HIV:

• Blood and any liquid with a visible admixture of blood

• Sperm

• Vaginal Secretions

• Culture containing HIV

Contacts associated with the risk of infection:

• Trans-dermal contact

needlesticks

cut with a sharp object

• Contact with biological materials on mucosa or damagen skin

• Contact of the intact skin with blood, biological tissues or fluids for a long time or

over a large area

Pathogenesis of HIV infection in humans

• Infection occurs through close contact with blood or other body fluids containing the

virus in sufficient quantities for infection (semen, vaginal secretions, breast milk)

• When penetration of the virus to the body mucosal dendrite cells are involved

• The virus rapidly infects activated CD4 lymphocytes near the atrium and reaches

with them the regional lymph nodes

• Following this, HIV is spread through the body with blood and lymph

• The virus is detected in the blood and lymph nodes, in long-living lymphocytes it is

contained in a latent form, which makes it impossible to completely eliminate.

• Persistent failure of the lymphatic system occurs within 48 hours

- In contact with infected blood or other body fluids should be as soon as

possible to take preventive measures (optimal in the first hours after contact)

• For some groups of patients it is characterized by depression of the immune system

and a more rapid progression of infection. These include:

- Infants

- Individuals with defects in the immune system

HIV and the immune system

• HIV uses mostly CD 4 cells to reproduce

• CD 4 cells - contain CD 4 receptors on their surface

• CD 4 receptors are located on the surface of many cells, but mainly on the T 4

lymphocytes (T helper)

• The shell of the virus contains a molecule that helps it connect to the CD4 receptor

and to penetrate into the cell

"Window" Period - This is the time needed to accumulate in the body a sufficient number of antibodies to HIV, which is determined by laboratory tests (3 months - in 99 %).

DEVELOPMENT OF HIV INFECTION (2004 WHO Classification)

Stages:

• Acute viral infection

• The latent period of asymptomatic carriers

• HIV infection (4^th stage - AIDS)

Characteristic of the HIV infection clinical stages

The first clinical stage is characterized by the absence of clinical manifestations of the disease and requires observation of the child. Presence in patient persistent generalized lymphadenopathy is driven to deep examination and timely installation of other possible manifestations of HIV infection.

Second clinical stage is characterized by the mild clinical manifestations. Typically, these patients require outpatient pediatric support. There is an opinion about possible consolidation of patients with first and second clinical stage in one group among experts.

The third clinical stage corresponds to the moderate and severe clinical manifestations, which require specialized research. Examination and treatment of such patients require hospitalization.

The fourth clinical stage of the disease (AIDS) is accompanied by severe diseases of internal organs and requires immediate intensive treatment.

Clinical classification of HIV infection in children (WHO, 2005)

Clinical stage 1

• Asymptomatic

• Persistent generalized lymphadenopathy (PGL)

Clinical stage 2

• Hepatosplenomegaly

• Papular skin lesions accompanied by itching

• Seborrhoeic dermatitis

• Disseminated disease, caused by human papilloma virus

• Disseminated contagious mollusk

• Fungal infection of nails

• Recurrent oral ulcers

• Linear erythema of gums •Angular cheilitis

• Increased parotid glands

• Shingles (herpes zoster)

• Recurrent or chronic respiratory tract infection (otitis media, otorrhoea, sinusitis)

Clinical stage 3

1. Conditions, the preliminary diagnosis in which can be put on the basis of clinical signs
and simple investigations:

• Moderate malnutrition, which is difficult to explain and it is not adequately responding

to standard therapy

• Unexplained persistent diarrhea (14 days or more)

• Unexplained persistent fever (intermittent or permanent, lasting more than one month)

• Oropharyngeal Candidiasis (except newborns)

• Oral hairy leucoplakia

• Acute necrotizing ulcerative gingivitis / periodontitis

• Pulmonary tuberculosis

• Severe recurrent probably bacterial pneumonia

2. Conditions which require the diagnostic investigation:

• Chronic lung diseases associated with HIV infection, including bronchiectasis

• Lymphoid interstitial pneumonitis

• Anemia (HB < 80 g/1), and / or neutropenia (<1000/mcl) and / or thrombocytopenia

(<50000/mcl), which is lasted more than 1 month

Clinical stage 4

1. Conditions, the preliminary diagnosis in which can be put on the basis of clinical signs and simple investigations:

• Marasmus or severe malnutrition which is not responding to standard treatment

• Pneumocystics pneumonia (PCP)

• Severe recurrent probably bacterial infections (empyema, pyomyozitis, bone and

joint infections, meningitis, except pneumonia)

• Chronic infection caused by HSV (orolabial or skin, lasting over one month)

• Extrapulmonary TB (tuberculosis)

• Kaposi's sarcoma

• Esophageal candidiasis

• CNS toxoplasmosis (which arose after the newborn period)

• HIV encephalopathy

2. Conditions which require the diagnostic investigation:

• CMV infection (CMV retinitis, internal organs infection except liver, spleen or

lymph nodes, which have started in a child aged one month or older)

• Extrapulmonary cryptococcosis including meningitis

• Any disseminated mycosis (ie extra pulmonary histoplasmosis, coccydioidomycosis,

penicyllinosis)

• Cryptosporidiosis

• Isosporosis

• Disseminated infection caused by not tuberculosis mycobacterium

• Trachea, bronchi or lungs Candidiasis

• Visceral lesions caused by herpes simplex virus

• Lymphoma of the brain or not Hodjkin's B-cell lymphoma

• Multifocal progressive leukoencephalopathy

• HIV-associated cardiomyopathy or nephropathy

Indicators that determine the stage of HIV infection:

Clinical (Opportunistic infections and AIDS - Indicator diseases)

Immunologic (Number and % CD4/8, total number of lymphocytes)

Virologie (Virus load)

Immunological categories of HIV infection in children

Immune status	Age
12 months	13-59 months	5 years or older
Significant immunosuppression is absent	> 35 %	> 25 %	> 500/mm^3
Mild immunosuppression	25-34 %	20-24 %	350-499/mm^3
Moderate immunosuppression	20-24 %	15-19%	200-349/mm^3
Severe immunosuppression	< 20 %	< 15 %	< 200/mm ^3

The presence of any pathological condition that is included to the list specified in the classification is returning to test for HIV / AIDS.

Determining the degree of immunosuppression, specified in the classification, is an additional criterion for the disease progression.

Examples of the diagnosis by WHO classification:

• HIV infection, the second clinical stage, without significant immunosuppression.

• HIV infection, the fourth clinical stage, severe immunosuppression.

Opportunistic infections

HIV slowly destroys CD 4 cells during many years of infection

When the number of CD 4 cells decreases agents of infectious diseases can easily penetrate into the body, causing the development of opportunistic infections (agents that do not cause pathological process in people with normal immunity).

Laboratory studies

Serological methods for diagnosis of HIV infection

1. ELIS A (routine serological test).

2. Immune blot method (Western blot).

3. Determination of P24-antigen. Determination of P24-antigen in serum implies the presence of HIV in the body. It appears in the blood, as in the early stages, and in progression of HIV infection.

Molecular genetic and virologie research methods

1. HIVDNA PCR

2. HIVRNAPCR

3. Getting HIV culture

Characteristics and significance of the standard methods of diagnosis in HIV-infection in children

Serological diagnostic methods	Methods for determining the virus
ELISA, immune blot diagnostic in children after 18 months	Determine the infection status of children aged 1-4 months
Reflective monitoring of maternal antibodies	Allow time to begin HIV treatment
The main methods for take the child of the observation after 18 months	Allows to carry out rational PCP primary prevention in children

Diagnosis of HIV-infected child under 18 months:

• age - under 18 months +

• antibodies to HIV are determined in serum (ELISA and immune blot) or a child

was born by HIV-infected women +

• child has two positive results, done by one of the following methods:

- PCR DNA

- a culture of HIV

- definition of P24-antigen.

Diagnosis of HIV-infected child older than 18 months:

• age - 18 months and older +

• antibodies to HIV are determined in serum (ELISA and immune blot) +

• a child was born by HIV-infected women or the child was a blood recepient or

the child was infected by other way (including sexually).

Diagnosis of HIV perinatal contact (status is uncertain):

• age - under 18 months +

• antibodies to HIV are determined in serum (ELISA and immune blot) or a child

was born by HIV-infected women.

HAART: Highly active Antiretroviral Therapy (or triple combination therapy)

The only effective way to suppress the virus is HAART

Use one or two drugs leads to the fact that the virus becomes resistant.

The purpose of ARV therapy:

• Improve the quality of life

• Prolong life

• ARVs do not cure people of HIV infection

• Lifetime administration of drugs

• Commitment (attitude and punctuality admission)

Problems associated with ARV drugs

• Limited access to ARV drugs

• Long-term (life), which requires strict regime of time reception (commitment) -

necessity of uninterrupted supply of ARV drugs

• The presence of side effects that reduce quality of life of the patient

• Difficulties with the quality monitoring of the patient and his viral load

• Fear of disclosure HIV status Antiretroviral therapy Benefits

• Ability to reduce viral load

• Ability to reduce the risk of vertical transmission of HIV from mother to child

• Ability to extend the life of a person with AIDS

Effects of AR V therapy

• HIV infection ceases to be a death sentence for people and becomes a "chronic" disease.

• Which - subject to constant use of the drugs - you can live, learn, work, create a

family, having children.

Recommendations for early ART in patients with HIV infection

Clinical stage by WHO classification	The level of CD4 cells	Recommendation
I	<200 mcl •'	Treat
	200 mcl ^1 - 350 mcl^_I	Consider treatment
II	<200 mcl ^1	Treat
	200 mcl ^1 -350 mcl	Consider treatment
III	<350 mcl ■'	Treat
IV	independantly of the CD4 level	Treat

Markers of ART scheme failure

	Virologie failure	Immunologic failure	Clinical failure
Tag	BH	Level of CD4	HIV-associated Infection
Time from the ART beginning	24 weeks	48 weeks	48 weeks
Score	> 50 copies/ml	Increased less than 50 cells/mcl	Opportunistic infection

Schemes based on NRTI: 1 NNRTI + 2 NRT1
Preference is recommended to: EFV + AZT / ZTS EFV + TDF [1] + FTC [2] (or ZTS)	Possible use, but not a full-fledged alternative: NVP + AZT/ZTS
Schemes based on IP: 1 IP + 2 NRTI
Preference is recommended to: LPV/rtv + AZT/ZTS LPV / rtv + TDF + FTC (or ZTS)	Possible use in case intolerance to LPV / rtv, but not a full-fledged alternative: NFV + AZT/ZTS

Recommended schemes of second ART series for adults and adolescents in case of the first ART series schemes failure

The first ART series schemes based on PI	Second ART series schemes in case of treatment failure
LPV/rtv + AZT + ZTS	LPV/rtv + AZT + ZTS or LPV / rtv + AZT + ddl or LPV / rtv + ddl + ABC or LPV / rtv + TDF + ABC or LPV / rtv + TDF + (ZTS + AZT)
LPV / rtv + TDF + FTC	LPV / rtv + TDF + FTC or LPV / rtv + ddl + ABC or LPV / rtv + ddl + AZT
NFV + AZT + ZTS	LPV/rtv + AZT + ZTS or LPV / rtv + AZT + ddl or LPV / rtv + ddl + ZTS or LPV / rtv + ddl + ABC or LPV / rtv + TDF + ABC or LPV / rtv + TDF + (ZTS + AZT) or LPV/rtv + EFV
NFV + TDF + FTC	LPV / rtv + ddl + ABC or LPV/rtv + EFV

Other treatment

• Immune correction - interleukin-2 (roncoleukin), tactivin, timalin, inerferons,

immunofan, splenin, galavit, specific (monoclonal) antibodies, transplantation of thymus and bone marrow

• Treatment of opportunistic infections

- protozoal -Trymetoprim/sulfametoxazolum,

- pirimethamin/sulfamethoxazolum, metronidazolum, pentamedinum;

- mycosis - amphotericin B, ketokonazolum, flukonazolum;

- herpetic infection - acyclovir, valtrex, zovirax, interferon, laferon;

- CMV-infection - gancyclovir, foskarnet;

- bacterial-antibiotics-macrolids, fluorqinolons, karbapenems, cephalosporins,

aminoglycosides)

• Anti tumor remedies

• Pathogenetic and symptomatic therapy

Prevention of infectious diseases in children with HIV / AIDS

Pneumocystis pneumonia (PCP) prevention

Indications	The first row scheme	Alternative scheme
Children with an uncertain status from 6 weeks to 12 months of life	Trymetoprim / sulfametoxazolum: daily dose - 150 / 750 mg / m^2 per os in 2 intakes x 3 times a week or Trymetoprim / sulfametoxazolum: daily dose - 150 / 750 mg / m^2 per os 1 time per day x 3 times a week, every second day.	Dapson 2mg/kg per os daily (maximum dose 100 mg)or 4 mg/kg per os 1 time per week (maximum dose 200 mg).
HIV-infected children, regardless of CD4 + from 6 weeks to 12 months of life
HIV-infected children aged 1-5 years the number of CD4 + < 500 cells (<15 %)
HIV-infected children aged 6-12 years, the number of CD4 + < 200 cells (<15 %)

Preventive measures aimed at preventing the development of histoplasmosis, cytomegalovirus infection, cryptococcus infection is applied in case of severe immunosuppression

• Cryptococcus neoformans - Fluconazole is a drug of choice, 3-6 mg/kg orally,

daily, an alternative scheme - Itraconazole, 2-5mg/kg every 12-24 hours orally (in cases of severe immunodeficiency in children)

• Toxoplasma gondii - TMP/SC is the drug of choice, daily dose - 150/ 750 mg/m2

per os in 2 receptions, daily (if anti-Tox-IgG antibodies present and in cases of severe immunodeficiency in children).

• Histoplasma capsulatum - Itraconazole is the drug of choice, 2-5mg/kg every

12-24 hours per os (if the child is living in endemic area and in cases of severe immunodeficiency in children)

• CMV- Gancyclovir is the drug of choice 30 mg/kg 3 times per day per os (in the

presence of antiviral antibodies and in case of severe immunodeficiency in children).

Rabies	After contact	After contact	After contact	After contact	Only postcontact prevention
Influenza	+	+	+	+	Every autumn, repeated annually

Calendar of vaccination against influenza to HIV-infected children

Child age	Type of vaccine	Dose, ml	Number of doses
6-35 months	Split vaccine	0.25	1-2
3-8 years	Split vaccine	0.5	1-2
9-12 years	Split vaccine	0.5
Over 12 years	Split or complete vaccine	0.5

Passive immunization

It is used in cases of direct contact of HIV-infected child with agents of infectious diseases to which immune prophylaxis should be used.

Vaccination don't perform for child's with AIDS, passive immune prophylaxis with immune globulins only.

Passive immunization against hepatitis A

It is used once, in a dose - 0.02 ml/kg body weight, IM immediately after contact, but not later than 2 weeks in the following cases:

• home contact with hepatitis A patients

• contact with hepatitis A patients in an organized children's groups: group, class

• hospital contact

Passive immunization against hepatitis B

It is designed for children born by HIV-infected and hepatitis B infected women, in a dose of 0.5 ml IM within 12 hours after birth at the same time with the first vaccine against hepatitis B in different parts of the body.

Passive immunization against measles.

It is used immediately after contact, but no later than 6 days after contact in the following cases:

• home contact with measles patients

• contact with measles patients in an organized children's groups: group, class

• hospital contact Dosing regimens:

HIV-infected child with clinical manifestations of HIV infection - 0.5 ml/kg body weight, IM (maximum dose is 15 ml).

HIV-infected children without clinical signs of HIV infection - 0.25 ml/kg body weight, IM (maximum dose is 15 ml).

In cases where HIV-infected child received IV immunoglobulin within 3 weeks before contact with measles patient, passive immunization is not recommended.

Passive immunization against Varicella-Zoster.

It is used immediately after contact, but no later than 96 hours after contact in the following cases:

• home contact with varicella patients;

• contact with varicella patients in an organized children's groups: group, class;

• hospital contact. Dosing regimens:

1.25 ml /10 kg body weight, IM (minimum dose is 125IU, the maximum dose is 6251U).

In cases where HIV-infected child received IV immunoglobulin within 3 weeks before contact with varicella patients, passive immunization is not recommended. A child who was in contact with patients and received passive immunization against varicella zoster, is potentially infectious 8-28 days after contact and need to be isolated.

Passive immunization against rabies and tetanus

HIV-infected children are immunized under the general rules of these infections passive immunization.

HIV-infection prophylaxis

Methods of parenteral infection prevention

• Mandatory testing of blood and special processing of blood products

• Prevention of infection in health care and beauty parlors (tools for injection and

manipulation by contact with blood)

• Prevention of occupational infection with HIV (medical personnel, etc.)

Fighting HIV infection in health care

• Use the disposable instruments

• Handwashing

«Use of personal protective equipment: gloves, goggles, apron, and shoe covers

• Organization of activities in case of emergency

• When drawing blood and conducting laboratory and diagnostic studies of blood

and other body fluids of any patient should be treated as potentially dangerous in terms of HIV infection Guidelines reduce the risk of HIV transmission from mother to child

• Antiretroviral prophylaxis for mother and child

• Planned (elective) Caesarean section •Artificial feeding

• Also recommended:

- Prevention or treatment by STDs

- Noninvasive procedures

First aid for exposure to HIV through injury

• Immediately!

• Wash the damaged area with soap and water

• Rinse it under running water

• Wash the surface by disinfectant or gel for hand washing

• NOT!

- alcochol

- iodine

- squeezing or rubbing

- suck blood

First aid for exposure to HIV through spraying

• Immediately!

• Wash the damaged area with soap and water

• Wash the surface by disinfectant or gel for hand washing

• 2-4 % chlorhexedin gluconate solution

• Rinse eyes with water

• NOT!

- alcochol

- iodine

- bandage

PEP (Post Exposure Prevention)

If the result of HIV testing in an employee-negative, and the patient's positive:

A. Beginning in the early hours after exposure (Required no later than the first 72
hours).

B. Assign triple ART course for 4 weeks:

Two drugs - a combination of zidovudine and lamivudine:

- zidovudine - 300 mg every 12 hours, and

- lamivudine - 150 mg orally every 12 hours The third drug - from Class PI:

- lopinavir / ritonavir - 400/100 mg orally every 12 hours (the drug of first choice) Alternative PI, but less preferred:

- saquinavir / ritonavir - 1000/100 mg orally 2 times a day.

Kev words and phrases: HIV, AIDS, T- lymphotropic retrovirus of III type, reverse transcriptase (revйrtase), Specific markers - p24, gp41, gpl20, gpl60, CD4 cells, Opportunistic infections and AIDS - Indicator diseases, oropharyngeal Candidiasis, oral hairy leucoplakia, Pneumocystic pneumonia, Kaposi's sarcoma, Cryptococcosis, Cryptosporidiosis, Coccidioidomycosis, Isosporosis, Lymphoma of the brain or not Hodjkin's B-cell lymphoma, Multifocal progressive leucoencephalopathy, HIV-associated cardiomyopathy or nephropathy, ELISA (routine serological test), Immune blot method (Western blot), Highly active Antiretroviral Therapy, Nucleoside/nucleotide reverse transcriptase inhibitors (NRTI), Nonnucleoside reverse transcriptase inhibitors (NNRTI), Protease inhibitors (PI).

Test and assignments for self assessment

Multiple choices: choose the correct answer / statement:

1. What is the most common way of HIV transmission?

A. Parenteral

B. Perinatal

C. Sexual D.Oral E. Contact

2. What is the average incubation period of AIDS?

A. One year

B. Five years

C. Ten years

D. Fifteen years

E. Twenty years

3. Which cells are the most often infected by HIV?

A. CD4+ T lymphocytes

B. CD8+ T lymphocytes
C.NK cells

D. B cells

E. Macrophages

4. Which opportunistic bacterial infection the most often occurs in case of HIV infection?

A. Yersinia pseudotubercullosis infection

B. Salmonella infection

C. Gardnerella infection

D. Klebsiella infection

E. Mycobacterium infection

5. Which of these antiviral drugs most commonly are used to inhibit HIV replication?

A. Zintevir

B. Nevirapine

C. Indinavir

D. Azidothymidine

E. Retonavir

6. Antigenic structure of HIV:

A. Changes slowly jB. Is variable

C. Depends on the immunity

D. Does not change

E. Changes every 5 years

7. Virological method sometimes is used for the diagnosis of HIV infection. Where HIV
cultivated?

A. In chicken embryos

B. In white mice organism

C. In normal lymphocytes

D. In cell culture He-La

E. In cell culture Vero

8. A protein gp 120 was found in a test of serum by western blot method. What disease does it tell
us about?

A. Viral hepatitis B B.fflV infection

C. Tuberculosis

D. Syphilis

E. Poliomyelitis

9. What method should be used to confirm HIV infection?

A. Electrophoresis of blood proteins in polyacrylamide gel

B. The ELISA test

C. Radioimmune analysis

D. Coagglutination reaction

E. Immune blot

10. Pneumocystis carinii were revealed in the analysis of patient's sputum. At which infection
could develop pneumonia of this etiology?

A. Plague

B. HIV infection

C. Ornitosis

D. Legionellosis

E. Candidiasis

Algorithm of practical students work

Complaints and anamnesis taking in newborns and infants

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Tactful and calm conversation with the parents of sick child.

5. Explanation of future steps concerning the child (hospitalization, some methods of examination, etc).

Complaints and anamnesis taking in toddlers and preschoolers (children aged from 1 to 6 years)

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. By means of game playing find a contact with a child.

5. Tactful and calm conversation with the parents of sick child.

6. Explanation of future steps concerning the child (hospitalization, some methods of examination, etc).

Complaints and anamnesis taking in school age children

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Tactful and calm conversation with sick child his/her parents.

5. Explanation of further steps to child and his/her parents (hospitalization, some methods of examination, etc.).

6. To collect complaints: fever, head ache, general weakness, cold, cough, pain in joints, excessive weight loss, nausea, vomiting, unpleasant taste, skin, nails and mucosa lesions, recurrent or chronic respiratory tract infection, persistent diarrhea, persistent fever, lymph nodes enlargement, different neoplasms.

7. To ask anamnesis of the disease, epidemiological anamnesis:

• gradual beginning of the disease from lymphadenorpathy, than other symptoms appear;

• a child was born or breastfeeding by HIV infected mother;

• parenteral manipulations and drug using, blood recipients, transplantation of organs and

tissues, artificial abortion;

• sexual contacts with HIV infected partners.

• Conversation accomplishment

3. To inspect a patient:

Physical methods of examination of newborns and infants

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to the parents what examination should be performed and obtain there informed consent.

5. Prepare for examination(clean and warm hands, warm phonendoscope, etc).
Physical methods of examination of toddlers and preschoolers

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to the parents what examination should be performed and obtain there informed consent.

5. Find a contact with a child; try to gain his/her confidence.

6. Prepare for examination(clean and warm hands, warm phonendoscope, etc).
Physical methods of examination of school age children

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to the parents what examination should be performed and obtain there informed consent.

5. Find a contact with a child; try to gain his/her confidence.

6. Prepare for examination (clean and warm hands, warm phonendoscope, use the screen if necessary etc.).

A. Examination: excessive weight loss, marasmus, papular skin lesions accompanied by itching,
seborrhoeic dermatitis, disseminated contagious mollusk, fungal infection of nails, recurrent oral
ulcers, linear erythema of gums, angular cheilitis, Kaposi's sarcoma, increased parotid glands,
shingles, persistent generalized lymphadenopathy, different neoplasms, hemorrhages, bleeding,
focal neurological signs.

B. Palpation: persistent generalized lymphadenopathy, hepatosplenomegaly, different neoplasms,
meningeal signs, bone and joint infections.

C. Percussion, auscultation: signs of pneumonia, tuberculosis, pneumonitis or chronic
bronchopulmonary diseases, cardiomyopathy, meningoencephalitis.

Conversation accomplishment.

Informing about the results of examination

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to a child and his/her parents what examinations should be performed and obtain their informed consent.

5. Involve adolescent and his/her relatives in to the conversation (compare present examination results with previous ones, clarify whether your expectations are clear for them or not).

6. Conversation accomplishment.

4. To estimate the results of additional investigations

• Complete blood analysis: anemia (HB < 80 g/1), neutropenia (<1000/mcl), thrombocytopenia

(<50000/mcl), which is lasted more than 1 month.

• Analysis of urine: nephropathy, bacterial infection of urinary tract.

• Biochemic blood test: nephropathy, hepatitis signs.

• Serologic methods for diagnosis of HIV infection:

-ELISA.

- Immune blot method.

- Determination of antigen-P24.

- Serological methods for diagnosis of opportunistic infections.

• Molecular genetic and virologie methods for diagnosis of HIV:

-HIVDNAPCR. -fflVRNAPCR. -Getting HIV culture.

• Bactйriologie and virologie methods for diagnosis of opportunistic infections.

• Explaining the results of examination to child's parents.

• Conversation accomplishment.

5. To substantiate the diagnosis

Planning and prediction of conservative treatment results

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing

4. Explain to child's parents the necessity of further treatment directions correctly and accessibly.

5. Discuss with parents and their child the peculiarities of drug intake, duration of usage.

6. Side effects and find out whether they understand your explanations.

7. Conversation accomplishment.

6. To prescribe the treatment:

Basic therapy: regime, diet, HAART combinations: 2 specimens NRTI + 1 specimen PI, or 2 specimens NRTI + 1 specimen NNRTI, or 3 specimens NRTI; immune correction, treatment of opportunistic infections, anti tumors remedies, pathogenetic and symptomatic therapy.

Informing about treatment prognosis

1. Friendly facial expression and smile.

2. Gentle tone of speech

3. Greeting and introducing

4. Correct and clear explanation of expected results of treatment.

5. Discuss with the parents and their child the importance of continuous treatment, following the treatment scheme; make sure that your explanations are properly understood.

6. Conversation accomplishment

Step

1.14-years old teenager has HIV/AIDS, which is characterized by low number of CD4 cells and high concentration of virus. Highly active antiretroviral therapy was appointed to him. One of the products is nucleoside analog that inhibits viral reverse transcriptase, and is effective for HIV and Hepatitis B. This drug is:

A. Acyclovir

B. Amantadine

C. Ribavirine

D. Sacvumavir

E. Lamivudine

2. In patient of 7 years submandibular, axillary and inguinal lymph nodes are increased. Lymph
node biopsy reveal marked follicular hyperplasia. HIV infection was diagnosed by PCR method.
What period of HIV infection is characterized by such clinical symptoms?

A. Incubation

B. The latent infection

C. The period of persistent generalized lymphadenopathy
D.Pre-AIDS

E.AIDS

3. A combination of drugs that suppress HIV reproduction were assigned to patient in the
specialized clinic. What group drugs that are obvious for the complex antiviral treatment belong to?

A. Interleukins

B. Broad-spectrum antibiotics

C. Nucleoside analogs

D. Antimicotic drugs

E. Trimethoprim/sulfamethoxasolum

Real situation to be solved:

1. A child of HIV-infected mother was born with a weight 2750 g, length 48 cm. During the first 3-
month he had pneumonia with cardiovascular and meningo-encephalic syndrome. Second episode
of severe pneumonia was 2 months later. Bloating, liquid, undigested feces 3-4 times per day in
addition to typical signs of pneumonia then were observed.

1. Indicate the most likely etiologic factor of recurrent pneumonia in this child.

2. Name medicine and its dose, for pneumonia prevention in this child.

2. Child of 1.5 years has entered the hospital in severe condition. During his examination were
found signs of pneumonia, lack in physical and motor development, hepatosplenomegaly, seborrheic
dermatitis. His parents are healthy. The child was born with hemolytic disease of newborns. He
received replacement blood transfusion for three times. Up to 6 months he has developed normally:

began to hold the head in 2 months, sit in 6 months. From that age his psychomotor development delayed. Twice he suffered from the severe pneumonia. Periodically unexplained prolonged diarrhea occurs. Now, the deficit of body weight is 22 %, the child is not sitting, not walking.

1. What disease should be suspected in this child, name its clinical stage?

2. What vaccinations should be planned to him after recovery from pneumonia, if previous vaccinations he received in time?

Answer for the self-control

Test: l.C;2.C; 3.A;4.E; 5.D; 6.B; 7.C; 8.B;9.E; 10.B. Step: l.E:2.C:3.C

Real - life situation 1:

1. Pneumocystis pneumonia

2. Trymetoprim / sulfametoxazolum: daily dose - 150 / 750 mg/m² per os in 2 intakes x 3 times a week

Real - life situation 2:

1. HIV-infection, 3^rd clinical stage 2DTP,Hib₎IPV

Aids and material tools: charts "HIV/AIDS", photo, video.

Result level

Students must know:

1. Etiology, epidemiology, pathogenesis of HIV infection.

2. Clinical diagnostic features of HIV infection.

3. Laboratory examination of patients with HIV infection.

4. Differential diagnosis of HIV infection.

5. Main treatment of HIV infection.

6. Prophylaxis of HIV infection. Students should be able to do:

1. Separate anamnesis data, which told us about HIV infection.

2. Find diagnostic criteria of HIV infection, while examining the patient.

3. To perform differential diagnosis among diseases, which have the similar clinical features.

4. To learn main tendentions of HIV infection treatment.

5. To perform prophylaxis of HIV infection, and opportunistic infections.

Дата добавления: 2015-11-05