PC1173: HIV Transmission Through Pre-mastication—opportunities for Provider and Caregiver Education

Introduction: Premastication is a potential route of HIV transmission from caregiver to child if one or more unique factors are also present. We report the case of a 13 month old Alaska Native child from rural Alaska who presented to medical care with failure to thrive, recurrent pneumonias, and dysphagia. Additionally, this child was noted to have severe dental decay and pharyngeal pillar ulcerative lesions. The child’s grandparent, who is HIV positive with inconsistent medication use and high viral load, was revealed to be a primary caregiver to the child and to have premasticated food for the child. The patient’s mother, however, was HIV negative. This case illustrates the importance of physicians’ complete understanding of a child’s caregiving situation for accurate and timely diagnosis and caregiver education.

Case Description: Diagnosis in toddlerhood of HIV-1 infection with initial HIV-1 quantitative RNA PCR of 2,620,000 copies/mL via premastication in setting of severe toddler dental caries with aphthous ulcer and caregiver tobacco use

Discussion: After a prolonged stay outside of Alaska for stabilization of medical issues and gastrostomy-tube placement, the child returned to Alaska for ongoing care. Additional questioning revealed the grandparent had not been taking antiretroviral therapy at the time they had been caring for the patient, and their last known HIV-1 viral load was >100,000 copies/mL. During detailed nutritional assessments, it was determined that both the biological mother as well as the grandparent routinely premasticated.

Conclusion: This case presentation highlights the need for clinicians to fully evaluate the home living situation and primary caretakers for children. Although the patient’s mother was known to be HIV negative, the grandparent had assumed the primary caretaker roll. As the grandparent’s viral load was high during the period before the child’s presentation to medical care with recurrent pneumonias and failure to thrive, the child was at risk for contracting HIV. In addition, both the patient and grandparent had reduced quality dentition, which also could have enabled this outcome. Premastication may be situational or in response to immediate circumstances as well as an inability to provide infant food or formula. Therefore, prevention messages might be effective among this population, particularly those with situational or immediate reasons for premastication to determine helpful, realistic alternatives for caregivers experiencing HIV-infection.