VATICAN - HIV/AIDS among children: the HIV+ child becomes an adult By Dr. Castelli Gattinara, of the Bambino Gesù Children’s Hospital, President of the Paediatric Infectivology Society

Saturday, 3 April 2004

Vatican City (Fides Service) - The pandemic of the HIV virus which can cause AIDS, continues to spread all over the world. According to recent reports by the World Health Organisation, as many as 40 million people in the world suffer from AIDS and last year AIDS killed at least 2.6 people and there were 5 million new cases of infection among adults and 700,000 among children.
The fact that in Italy recently less attention is given to HIV/AIDS is probably due to unfounded optimism connected with the drop in the number of people infected with AIDS in this country in recent years. Rather than a decrease in the number of persons infected the figure indicates a slowing down in the progression of the disease thanks to ever more powerful and effective treatment. On the contrary it is estimated that the number of infected persons continues to rise and that in Italy every day there are 10 new cases of infection.
HIV is therefore still a serious problem even in Italy. Up to 2002, not counting HIV+ persons, 52,000 people had AIDS, the deadly stage of the disease and 1.4% of these were children. It is interesting to note that in the early 1990s in Italy the patients were all Italian in 2002 at least 15% were immigrants from Asia, Africa, Latin America, Eastern Europe. This reveals a concerning phenomena of migration of HIV+ persons, individuals and families, arriving in “rich” countries intending to stay simply to have access to treatment, only hope for survival, inaccessible in their own country.
HIV/AIDS effects children dramatically. For children the main channel of infection is mother/child transmission during pregnancy, childbirth or breast-feeding. It should be said that although these babies are HIV+ at birth (some of the mother’s anti-HIV antibodies pass through the placenta), only a small percentage are infected and in most cases the HIV+ value disappears rapidly in the first months of life. These children, the majority in our country, are absolutely normal because they have never come into contact with the virus.
Progress in science and the availability of effective therapy to treat HIV+ have obtained a drastic reduction in the rate of mother-child transmission of the virus from rates of about 13-18% to less than 1% today. The first encouraging results were obtained by a study ACTG 076 which revealed in 1994, that treating pregnant mothers with AZT reduced by about 70 % the rate of transmission. Later studies confirmed the effectiveness of antiretroviral treatment during pregnancy and the therapy was further improved with other preventative measures such as caesarean birth and mainly feeding with artificial milk.
With these measures of prevention, in the west of course, the rate of mother/child HIV infection has dropped to 1% as well as better life quality for HIV+ persons and the latter has led in recent years to more pregnancies among HIV+ women.
The development of the rate of children born HIV+ mothers is interesting. When the rate of infection and death due to AIDS in adults and children the rate dropped progressively and them in recent years showed a strong inversion of tendency with a clear reduction of abortions and increased birth rate above average. Various studies revealed that the recent increase in the number of children born to HIV+ mothers is mainly due to the use of antiretroviral combination therapy HAART (Highly Active Antiretroviral Treatment), which improves quality and length of life of women and reduces to a minimum level HIV mother/child transmission.
Unfortunately this is true only for a very small and rich part of the world and not developing countries where AIDS is often the main cause of death, but it is not possible to intervene adequately to prevent mother/child transmission and in fact HIV/AIDS infection among children has reached dramatic proportions: according to the WHO last year about 1,700 children were infected every day!
With regard to Italy a good picture of HIV/AIDS among children is given by the “Registro Italiano per l’Infezione da HIV in età Pediatrica” which so far has registered 1,300 infected babies out of 6,300 born of HIV+ mothers. At the start of the epidemic the babies were almost exclusively born to mothers with a problem of drug dependence mostly belonging to definite social categories characterised not only by infection and deaths for AIDS, but also a series of social, cultural and economic problems. Later as AIDS spread through heterosexual paths, categories not at risk, HIV became a problem for families of various economic, social and cultural levels, and the problems of marginalisation and exclusion, prevalent in the early years of the epidemic, appear less evident.
For paediatricians and infectivologists who treat HIV in children there are a variety of problems to face: prevent mother/child transmission and treatment for infected babies.
The natural story of paediatric infection, in the absence of treatment, is marked by an evolution more rapid compared to that of the adult in about 20-30% of the cases, with early appearance of symptoms present in most patients in the first 2 years of life. This explains the higher mortality rate among children, as WHO reports show with 38% death rate among adults infected with the HIV virus compared to 65% among children.
Since 1995 the natural story in HIV infection has changed also in the child thanks to new antiretroviral drugs and the ability to measure precisely the quantity of virus in the blood. We now use highly effective therapy consisting of the simultaneous use of more molecules belonging to different therapeutic classes able to control the viral replication of HIV, and to render indeterminable, with presently available methods, the number di virus circulating (<50 copie/mL). Progress in therapy rapidly provoked a changed in life expectancy of HIV+ children who today are becoming adolescents.
According to the Registro Italiano, more than 50% of HIV+ born babies today are over ten years old. Hence the need for a change in the type of assistance which from being purely medical is extended to psychological and social assistance.
One of the most complex aspects of how to deal with HIV/AIDS is relative to the communication of diagnosis and its impact in particular on adolescents. The truth has often been hidden for years because a parent had difficulty in admitting his or her responsibility, and hope the disease and death would eventually ‘speak’ for themselves. But death luckily does not come and communication of diagnosis is compulsory so it can be received less traumatically and at the same time with a more correct and constructive attitude.
This is not easy and calls for multidisciplinary intervention involving doctor, parents, nurses, psychologists and helpers: the aim is to avoid an attitude of rejection and to help adolescents achieve a responsible awareness of the disease to guarantee full adhesion to therapy, essential to avoid resistance on the part of the virus and therefore effectiveness of therapy) and limit the risk of the infection spreading with first experience of sexual activity.

In Rumania Italians launch successful programme to teach by example how to care for children with AIDS

“When we first went to Rumania in 1995, called in as consultant infectivologists for a new wing of a hospital in Bucharest, we were faced with a serious situation which we had never expected to find in Europe a short distance from Italy: hospitals and orphanages were filled with thousands of HIV+ children, dirty unkempt and underfed, often crowded into underground rooms with barred windows.
But what struck us even more was the medical personnel’s attitude: a feeling of complete helplessness, lack of medicines means, the size of the problem over the years had led them to assume an attitude of dark resignation, detachment, defensive cynicism which prevented any contact with the children. Doctors and nurses seem inhuman” Dr. Castelli told Fides.
Immediately the Bambino Gesù Hospital in collaboration with AVSI an Italian national association of volunteers launched a programme with lasted 6 years, with the aim of changing the culture of medical care. We were certain that without that change our intervention would not succeed. Besides offering medical support and means we undertook a series of interventions to give the staff new professional and human motivation. It was not easy and it took time but we succeeded. We helped to re-establish relations with government institutions, local NGOs; we organised formation courses locally and in at the hospital in Rome; we carried out health missions in all main hospitals in Rumania with medical and surgical interventions, (dermatological in particular), teaching local personnel methods and techniques, reassuring them that no risks were involved and convincing them with our own example.
In this way we trained new formators, and in a few years therapy for AIDS and its complications had become routine work for medical personnel in Rumania thanks also to availability of new drugs.
Today we can say that paediatric AIDS in Rumania is under control, but the same cannot be said for other countries and areas of the world, Africa for example where every thousands of children are infected and die of AIDS. In view of this Bambino Gesù Hospital is planning programmes to promote infant and child AIDS treatment and prevention of mother/child AIDS through medical therapy and vaccine research during labour and in the later more complicated period of feeding.

“Ionela is in our heart”: Testimony from a child in Rumania

“Ionela was 7 when we brought her from Rumania to Rome to the Bambino Gesù hospital for treatment. During the flight she was very frightened, but for the other passengers the sight of her was even more frightening and so we made her wear a mask. Her face was disfigured by a contagious mollusc and lot of purulent boils which made her whole face a blur with nose, eyes mouth all one…but you could see was that she was very frightened and very, very sad. Abandoned by her mother when she was four she was sent to an orphanage where she caught AIDS and in three years she had never had any treatment. She had lost her hair and very underweight and because of her aspect she was put in isolation and no one cared for her.
We obtained permission to bring her to Rome where we kept her for six months at the hospital and with a hosting family. In those six months she underwent several plastic surgery operations and received treatment for AIDS. The whole hospital turned out to say goodbye to Ionela the day she asked to return to Rumania. Now she is there and she is happy again. When we visit her she makes an effort to speak in Italian for us. She is a pretty girl of 16, long black hair and a lovely smile. With her orphanage companions she is studying and training for a job. She has lots of plans for the future when she leaves the Home and she is full of energy thanks to good treatment and regular AIDS therapy.”
(AP/CG) (3/4/2004 Agenzia Fides)