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CHAPTER 24

HIV/AIDS and the Paediatric Surgeon

Lary Hadley
Kokila Lakhoo

Introduction
Three of every four HIV-positive people in the world live in sub-
1
Saharan Africa. This disease dominates our every activity as doctors,
and intrudes into the practice of paediatric surgery in Africa as much as
into every other sphere of human endeavour.
AIDS became recognised as a disease entity in the early 1980s,
when an increase in the incidence of opportunistic infections was seen
in Kinshasa and there were clusters of affected homosexuals in Los
2
Angeles and San Francisco. In Africa, HIV/AIDS has nothing to do
3
with homosexuality, but may be related to heterosexual promiscuity.
HIV-1 was defined as the cause of the clinical syndrome called AIDS
by French workers in 1983. In 1985, a new human retrovirus, HIV-2,
4
5
was identified in AIDS patients in West Africa.
It is likely that HIV infection originated in tropical Africa in the
1930s, making the transition from a simian infection to a human
+
pathogen. It is a retrovirus that infects the CD4 lymphocyte and
6
monocyte, destroying them, reducing their absolute numbers and global Source: Reproduced by permission from UNAID.
function, thereby exposing the patient to the risks of impaired cellular Figure 24.1: HIV prevalence in Southern Africa. 20
immunity. There is no cure for the infection, but antiviral therapy has
the potential to suppress the virus and restore immune function.
Demographics and History
By 2001, 20 million HIV-infected people lived in sub-Saharan Africa, of
whom only a trivial number were receiving effective treatment. In 2007,
1.6 million people in Africa died of AIDS; more than 11 million children
have been orphaned by the disease. Figures 24.1 and 24.2 show the
7
prevalence of HIV in Southern Africa and in West and Central Africa,

respectively. Effective treatment against these retroviruses was known in
the last decade, but proved to be too expensive for developing countries
that were struggling with other important health issues and lacked the
infrastructure to deliver the treatment in a sustainable fashion. 8
In the face of these difficulties, the South African government
9
initially denied any association between HIV and AIDS, but later
sought to parallel import generic antiviral drugs. Drug manufacturers
were keen to protect their profits and intellectual capital, but the scale Source: Reproduced by permission from UNAID.
of the humanitarian disaster precluded the continuation of this precept, Figure 24.2: HIV prevalence in West and Central Africa. 20
and at the World Trade Organisation (WTO) meeting in Doha in 2001,
10
a resolution of the impasse was negotiated. It should be emphasized that whilst some aspects of HIV/AIDS,
In 2001, the Global Fund to Fight AIDS, Tuberculosis and Malaria was such as the prevention of vertical transmission and the impact of
established, and in 2003, President Bush’s President’s Emergency Plan for breast-feeding, have been well studied, 15,16 and entire libraries of reports
AIDS Relief (PEPFAR), as well as private agencies such as the Bill and have been compiled on epidemiological studies and papers attempting
Melinda Gates Foundation, increased the money available to counter the to define and alter African sexual traditions, 3,17,18 paediatric surgeons
8
scourge and to support necessary infrastructure development. In 2004, have been slow to formally study the impact of this disease on their
antiretroviral drugs became available in South Africa, and currently, about practices. Much is not known.
19
7
28% of the patients in need are on treatment. Prior to 2004, there was
little point in testing for HIV, as all that could be offered was symptomatic Route of Infection
treatment, and such palliation did not require formal diagnosis. Most children become infected during gestation or delivery. The rate of
11
Concomitant with the HIV pandemic are the TB pandemic , the transmission can be reduced from around 35% to less than 10% by offering
14
13
12
lymphoma pandemic , the Kaposi pandemic, the orphan pandemic, perinatal nevirapine to the mother and child and may be further reduced by
21
and myriad evil social, ethical, and economic consequences, all of which dual therapy with zidovudine and nevirapine. .Elective Caesarean section
complicate management decisions. may even further reduce the transmission rate to around 2%. 21,22