What is the Risk for the Family of HIV-Positive Children?
ABSTRACT & COMMENTARY
Synopsis: HIV-infected infants and children should be allowed full access to out-of-home care, and continuing attention should be paid to universal precautions when handling blood and body fluids in all childcare facilities, regardless of whether children are identified to be carriers of HIV, hepatitis B, or other bloodborne infections.
Source: Courville TM, et al. Lack of evidence of transmission of HIV-1 to family contacts of HIV-1 infected children. Clin Pediatr 1998;37:175-178.
In this study, household contacts of nine children with transfusion-associated HIV infection tested negatively for antibodies to HIV after a total of 174 person-years of contact with the index cases. Because 76 of the person-years of contact occurred prior to the discovery of the HIV infection status of the index children, no infection control precautions were taken. Over these years of contact, there was sharing of dishes, glasses, and even toothbrushes. Household contacts hugged, kissed, bathed, and slept with the index cases. They also took care of nosebleeds, sustained toddler bites, and were scratched by the infected children.
COMMENT BY WARREN A. ANDIMAN, MD, FAAP
The article by Courville and associates at the Oakland Children's Hospital, although limited in scope and study design, is one of the latest in a long line of studies of HIV transmission that have put to rest many of the anxieties regarding casual transmission of HIV. For healthcare workers who were not directly involved in AIDS care in the late 1980s, it is difficult to convey in words the swirl of anxiety, controversy, and inflammatory rhetoric that characterized discussions of horizontal transmission of HIV-1. Early on, it had been clearly shown that the virus was present in blood, semen, and the female genital tract. Soon thereafter, it was proven that transmission from mother to child could occur transplacentally or at the time of delivery. Breast-milk was then identified as another vehicle responsible for vertical transmission. Oddly enough though, it was discovery of the virus in saliva, tears, and urine, albeit in minuscule amounts, that incited the greatest fear. For years, there was great concern that the virus might spread from person-to-person in the course of normal daily activity. Households, day care centers, and schools, especially nursery schools, seemed to be logical places where the virus might spread. Contamination of the environment with saliva, urine, small amounts of blood, and tears were all regarded with suspicion. Such suspicions were further fueled by the publication of a small number of case reports (unusual ones, to be sure) that provided evidence to support transmission of the virus by way of blood or bodily secretion to relatives and other caregivers through significant breaks in the skin (e.g., eczema), by multiple bites, or by intensive nursing care provided at home without precautions.
The encouraging results of the Courville report are similar to those found in the landmark study by Friedland and associates.1 In that study, it was shown that household contacts who are not sexual partners of, or born to, patients with AIDS are at minimal or no risk of infection with HIV. Most of the families observed were "poor and lived in crowded conditions, which would have been expected to facilitate horizontal transmission of infection." Also, "substantial sharing of household facilities and items likely to be soiled with body secretions took place . . . as did the close personal interaction and affectionate behavior expected among family members." Despite this, horizontal transmission of infection could not be demonstrated.
Thus, based on a firm foundation of evidence, the conclusions reached by Courville et al are sound: HIV-infected infants and children should be allowed full access to out-of-home care; however, continuing attention should be paid to universal precautions when handling blood and body fluids in all childcare facilities, regardless of whether children identified to be carriers of HIV, hepatitis B, or other bloodborne infections are present. (Dr. Andiman is Professor of Pediatrics and Epidemiology and Public Health and Director of the Pediatric HIV Service at Yale-New Haven Hospital.)
Reference
1. Friedland GH, et al. Lack of transmission of HTLV-III, LAV infection transmission to household contacts of patients with AIDS or AIDS related complex with oral candidiasis. N Engl J Med 1986;314:344-349.
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