HIV Encephalopathy

"More than 50% of children with HIV have neurological abnormalities including delayed motor development, loss of milestones, seizures or encephalopathy with a lack of growth and a decline in head circumference." page 233 Principles of Medicine in Africa.

Sarah watches other children play outside

Sixteen month old Sarah was much smaller than she should have been, weighing in at a mere 14 pounds. An incomplete antibiotic course had recently been given at an outside health center for presumed sepsis so I was concerned about partially treated meningitis/encephalitis. Yet, her wasting was so marked that it was clear she had a chronic not an acute condition.  Six months earlier she had had an HIV test done elsewhere but the result was not known by her parents. They reported it had never come back. Since birth she had been breastfed and her mother was not known to be HIV positive. The chief complaint on admission was "She no longer lifts her head or speaks." She was extremely thin, apathetic and anorectic, showing no interest in the world not even crying with the placement of an IV or the threat of an exam. Her mother held her head propped up. Although her head circumference was small for age, her head appeared large compared to her body. It lolled like a mushroom cap a top the stem of her neck. Her parents walked about with her draped over one shoulder, head dangling. Neurologically she seemed shockingly distant; failing to follow with her eyes, grasp a toy, sit up or make any vocalizations. The history that she had said words, smiled, and even walked seemed totally at odds with her presentation. An LP was surprisingly unremarkable for such a dramatically abnormal neurological presentation, but her HIV test was positive. ARV's and Cotrimoxazole were started. Additionally due to recurrent fevers, following a week of Ceftriaxone, our best antibiotic she was started on TB medications. After about ten days of ARV's her mother reported one day, "She smiled." No one else had seen it but Frank, the medical student, and I were pleased at some improvement, any improvement, even imaginary. By the end of two weeks, amazingly she was holding her head up and watching other children play in the courtyard. Is this the way HIV encephalopathy responds to ARV's in children? I have had no other experience to compare with this.

I recently learned in Zambia ( and I suspect elsewhere) if you don't breast feed your baby people will ask you why and suspect you have HIV/AIDS. The stigma is great and choosing not to expose your baby to HIV through breast feeding is therefor not really an option. Child survival continues to be significantly better in breast-fed infants in places where water sources are unclean and infectious diseases and malnutrition pose a significant risk of death.Yet breast-feeding contributes greatly to mother to child transmission. Strategies to reduce transmission include treating mothers and infants with ARV's during the period of breast feeding.