1. M W E B A Z
A
VICTOR.J
MBchB 5th Yr Africa Uganda
mwebazavictor1997@gmail.com
Kampala international university western
campus Uganda under the care of Jinja
Regional Referral Hospital Children hospital
(Naluffenya)
H I V / A I D S I N C H I L D R E N
P R E S E N TAT I O N
2 0 2 2 / O C T O B E R
Supervised by;
DR. TAGOOLA
(peadiatric senior consultant at JRRHosp)
DR. WILLIAM .W
(peadiatric consultant /paediatric JRRHosp site
2. Make your voice a potential weapon to create beautiful earth,
one without HIV/AIDS for our children(Mwebaza Victor
@webinar invitation celebrations of AIDS day 2021)
Give a child love, laughter and peace, not AIDS(president
Nelson Mandela 2001)
Heal the world by making it a better place for you and for me
3. OUT LINE
1. History on HIV/AIDS
2. Introduction
3. Definitions
4. Pathophysiology
5. Transmission
6. Epidemiology
7. Clinical presentations in HIV/AIDS
8. Testing and diagnosis of HIV in
9. children
10. Pediatric Clinical staging
11. Ant retro viral therapy
12. Supportive care for HIV positive children
13. Management of HIV related
14. IRIS
15. PMTCT/EMTCT
4. HISTORY ON HIV/AIDS
Studies show that HIV may have jumped
from chimpanzees to humans as far back
as the late 1800s. The chimpanzee
version of the virus is called simian
immunodeficiency virus. It was probably
passed to humans when humans
hunted these chimpanzees for meat
and came in contact with their infected
blood.
5. Luc Montagnier—Discoverer of the AIDS Virus
Mayo Clinic Proceedings
https://www.mayoclinicproceedings.org › article
› fulltext
Luc Montagnier—Discoverer of the AIDS Virus
on May 20, 1983,
6. HIV first diagnosed in Uganda in Rakai in 1985
and the first specialised pediatrics clinic was
started in 1988.
1973: Ugandan children
From 1972 to 1973, researchers drew blood from 75
children in Uganda to serve as controls for a study
of Burkitt's lymphoma. In 1985, retroactive testing
of the frozen blood serum indicated that antibodies
to a virus related to HIV were present in 50 (67%) of
the children.
Hematology : basic principles and practice. Ronald Hoffman, Edward J.,
Jr. Benz, Leslie E. Silberstein, Helen Heslop, Jeffrey I. Weitz, John
Anastasi (7th ed.). Philadelphia, PA. 2018. pp. 1187–1203. ISBN 978-
0-323-50939-8. OCLC 1001961209.
7. Introduction
HIV/AIDS is a major cause of infant and
childhood mortality and morbidity in Africa. In
children under five years of age, HIV/AIDS now
accounts for 7.7% of mortality worldwide.
AIDS already accounts for a rise of more than
19% in infant mortality and a 36% rise in
under-five mortality. Together with factors
such as declining immunization, HIV/ AIDS is
threatening recent gains in infant and child
survival and health.
8. The transmission risk for a child born to an HIV-
infected mother in an African setting without
interventions for (PMTCT) is about 30–40%.
The other 60–70% of children, although not
HIV-infected, still have a 2- to 5-fold risk of
mortality as a direct consequence of the
mother’s HIV disease, when compared to
children born to uninfected mothers.
W.H.O 1st/dec/2019
9. DEFINITION
Human immunodeficiency virus (HIV) is an
infection that attacks the body's immune
system, specifically the white blood cells called
CD4 cells.
HIV/AIDS - World Health Organization (WHO)
10. The most advanced stage of HIV infection is
acquired immunodeficiency syndrome (AIDS),
which can take many years to develop if not
treated, depending on the individual. AIDS is
defined by the development of certain
cancers, infections or other severe long-term
clinical manifestations.
27 Jul 2022 WHO
11.
12. Pathophysiology
Goldman, DL et al. Pediatrics (2001) 107:E66; Abadi, J et al JID (1999) 180:915; Davis, J Pediatrics
Infect Dis J (2007) 26:549
13.
14. Mechanism for Decline in CD4 Count
o CD4 T-cell depletion through single-cell killing
caused by accumulation of HIV DNA in the cell
or by inhibition of cell function.
o Cell membranes of infected cells fusing with
cell membranes of uninfected cells (syncytium
induction) , resulting in giant multi-nucleated
cells that are readily destroyed by the immune
system.
15. o Programmed death (apoptosis) also contributes
to T-cell depletion.
o HIV infection induces neutralizing antibodies
against regions of the HIV envelope; these
antibodies may play a role in mediating
antibody-dependent cellular toxicity after
binding to natural killer (cell killing) cells.
o HIV specific cytotoxic T-cells (CD8 cells) also
play a role in killing HIV-infected cells.
16. Transmission
90% of paediatric HIV by MTCT.
In utero 30-40%
Intrapartum 50-70%
Breast feeding 14-29%
Others: sexual abuse, therapeutic scarifications,
sharing of sharps, etc.
Atwiine, et al (2013): 98% of HIV positive children had
been presumably infected thru the MTC route.
17. Factors Affecting MTCT
(Maternal)
1. Severe maternal disease (low CD4 count,
high viral load, severe clinical stage and
malnutrition)
2. Co exciting sexually transmitted disease
3. Sero-conversion during pregnancy or b/f.
4. Ante-partum hemorrhage
5. Vaginal delivery
6. Prolonged membrane rupture
7. Episiotomy
18. Epidemiology
Global prevalence of HIV
Of the estimated 38.4 million [confidence bounds:
33.9–43.8 million] people living with HIV
worldwide in 2021, 2.73 million [2.06–3.47
million] were children aged 0–19.
HIV Statistics - Global and Regional Trends - UNICEF
DATA
https://data.unicef.org › HIV and AIDS Reports
Search for: Global prevalence of HIV
19. In 2021, around 160,000 [110,000–230,000]
children aged 0–9 were newly infected with
HIV, bringing the total number of children
aged 0–9 living with HIV to 1.02 million
[820,000–1.26 million].
HIV Statistics - Global and Regional Trends -
UNICEF DATA
20. The UN Joint Program on HIV/AIDS (UNAIDS)
estimates that 85% of the 2.6 million children with
HIV infection are from sub-Saharan Africa. About
650,000 children are living with HIV/AIDS
and approximately 1000 infected infants
are born every day in Africa.
21. The prevalence of HIV among children aged 0-14
is 0.5% which corresponds to approximately 95,000
children living with HIV in Uganda.
The prevalence of VLS Virologic suppression in
children aged 0-14 is 39.3%.
In the entire UPHIA 2020 survey sample of adults
aged 15 years and older, HIV prevalence was 5.8
percent (7.2 percent among women and 4.3
percent among men) corresponding to
approximately 1.3 million adults living with HIV in
Uganda. 10 Feb 2022
22. Clinical experience indicates that
children infected with HIV
perinatally who are not on ART fit
into one of these three categories:
o Those with rapid progress (25-30%)most of whom
die before their first birthday
o Children who develop symptoms early in life the
follow a down hill course and die at age 3-5yrs (50-
60%)
23. o Long term survivors who lived beyond 8yrs of age
(5-25%) they tend to have lymphoid interstitial
pneumonitis and stunting with low weight and
height for age.
24. Signs that may indicate possible
HIV infection in children:-
o Recurrent infections, three or more severe
episodes of a bacterial infections such as
pneumonia, meningitis, sepsis, cellulitis in the
past 12month
o Oral thrust, erythema and white-beige pseudo
membranous plaques on the plate, gums and
buccal mucosa. After the neonatal period , the
presence of oral thrust is highly suggestive of HIV
infection when it last >30days despite antibiotic
treatment
25. o Chronic parotitis , unilateral or bilateral parotid swelling for
>=14days with or with out associated pain or fever.
o Generalized lymphadenopathy
o Hepatomegaly with no apparent cause.
o Persistent and or recurrent fever (>38 degrees c) lasting
>=7days or occurring more than once over 7days.
o Neurological dysfunction, progressive neurological
impairment, microcephaly, delayed developmental
milestone, hypertonia, or mental confusion.
o Herpes zoster(shingle), painful rash with blister confined to
one dermatome on one side
o HIV dermatitis, erythematous popular rash, typical skin rash
i include extensive fungal infection of the skin, nail, and
scalp and extensive molluscum contagiosum
o Chronic supportive lung disease.
26. Signs common in HIV-infected children,
but also common in ill non-HIV infected
children
1. Chronic otitis media: ear discharge
lasting ≥14 days.
2. Persistent diarrhea: diarrhea lasting
≥14 days.
3. Moderate or severe malnutrition:
27. Signs or conditions very specific
to HIV-infected children
1. pneumocystis pneumonia (PCP),
2. esophageal candidiasis,
3. lymphoid interstitial pneumonia (LIP)
4. Kaposi’s sarcoma.
5. Acquired recto-vaginal fistula in girls is also
very specific but rare.
These conditions are very specific to HIV
infected children.
28. Neurodevelopment abnormalities
1. Developmental delay
2. Developmental regression
3. Spasticity, hyperreflexia
4. Impaired cognitive function
5. CT scan brain: generalized
cortical atrophy with
ventricular enlargement and
calcified basal ganglia (arrow)
(Ref. D. Carli C et al, Ann Neurol
34(2): 198-205, 1993.)
33. Bacterial infections of skin
Staph. aureus and
Strep. pneumoninae.
Impetigo, folliculitis,
abscesses, infected
wounds, cellulitis.
More frequent than
non-infected children
Hepatosplenomegaly
34. Symptomatic HIV seropositive infant <18
months with 2 or more of the following; -
1. oral thrush,
2. severe pneumonia,
3. failure to thrive,
4. severe sepsis
35. Testing and diagnosis of HIV
infection in children
The diagnosis of HIV infection in perinatally exposed
infants and young children is d i f f i c u l t
b e c a u s e p a s s i v e l y a c q u i r e d
m a t e r n a l H I V a n t i b o d i e s m a y b e
p r e s e n t i n t h e c h i l d ’s b l o o d u n t i l
t h e c h i l d i s 1 8 m o n t h s o f a g e .
Additional diagnostic challenges arise if the child is
still breastfeeding or has been breastfed.
Although HIV infection cannot be ruled out until 18
months for some children, many children will have
lost HIV antibodies between 9 and 18 months.
36. Virological testing or DNA-PCR
Virological testing for HIV-specific RNA or
DNA is the most reliable method for
diagnosing HIV infection in children <18
months of age.
1. The 1st DNA/PCR test should be done at six weeks
2. Another PCR test has been introduced to be done at 9
months of age as the second test for all infants
irrespective of breastfeeding status.
3. The 3rd PCR should be done 6 weeks after cessation of
breastfeeding.
37. POSITIVE DNA/PCR test result indicates that the child is
HIV-infected. All infants with a positive DNA/PCR test result
should be initiated on ART and another blood sample should
be collected on the day of ART initiation to confirm the
positive DNA/PCR HIV test result.
NEGATIVE FIRST DNA/PCR test result means that child is not
infected but could become infected if they are still
breastfeeding. Infants testing HIV negative on first DNA/PCR
should be re-tested using DNA/PCR at 9 months of age
irrespective of breastfeeding status and six weeks after
cessation of breastfeeding. Infants with negative third
DNA/PCR test should have a final rapid antibody
test performed at 18 months
38.
39. HIV antibody test (ELISA or rapid tests)
reliable for diagnosing HIV infection in children from
the age of 18 months and above.
You can use rapid HIV tests to exclude HIV infection in
a child presenting with malnutrition or other serious
clinical events in high HIV-prevalence areas.
40.
41. Diagnosis: older children >18
months
Rapid test: DETERMINE → STATPAK →UNIGOLD;
If positive, start HAART
NB: The above rapid test is also applicable to
the mother
42. The WHO pediatric clinical staging
system
STAGE 1
o Asymptomatic
o Persistent generalized lymphadenopathy (PGL)
STAGE 2
o Hepatosplenomegaly
o Parotid enlargement
o Papular pruritic eruptions
o Seborrhoeic dermatitis
o Fungal nail infection
43. o Angular cheilitis
o Lineal gingival erythema (LGE)
o Extensive human papilloma virus infection or
o molluscum infection (>5% body area)
o Recurrent oral ulcerations (2 or more episodes
in 6 months)
o Herpes zoster Recurrent
o Chronic upper respiratory tract infections
(otitis media, otorrhoea, sinusitis, 2 or more
episodes in any 6 month period
44. STAGE 3
o Unexplained moderate malnutrition not responding to
standard therapy
o Unexplained persistent diarrhoea (>14 days) Unexplained
o persistent fever (intermittent or constant, for longer than 1
month)
o Oral candidiasis (outside neonatal period)
o Oral hairy leukoplakia
o Pulmonary tuberculosis
o Severe recurrent presumed bacterial pneumonia (2 or more
episodes in 6 months)
o Acute necrotizing ulcerative gingivitis/periodontitis
o LIP (lymphoid interstitial pneumonia)
o Unexplained anaemia (<8 gm/dl), neutropenia (<500/mm3) or
thrombocytopenia (<30,000/mm3) for >1 month.
45. STAGE 4
o HIV/AIDS Unexplained severe wasting or severe
malnutrition not responding to standard therapy
o Pneumocystis pneumonia
o Recurrent severe presumed bacterial infections (2
or more episodes within one year, e.g. empyema,
o pyomyositis, bone or joint infection, meningitis,
but excluding pneumonia )
o Chronic orolabial or cutaneous herpes simplex
infection (of >1 month duration)
o Disseminated or extrapulmonary tuberculosis
o Kaposi sarcoma
o Oesophageal candida
46. NOTE
1. TB may occur at any CD4 count and CD4 %
should be considered where available.
2. Presumptive diagnosis of stage 4 disease in
seropositive children <18 months requires
confirmation with HIV virological tests or
using HIV antibody test after 18 months of
age.
49. The 2020 version of the guidelines CGFPT HIV and
AIDS Ug
recommend using Dolutegravir-based regimens as
preferred first- and second-line ART for all eligible
PHLIV including pregnant and breastfeeding women.
❖ These guidelines emphasize the importance of
Pharmacovigilance (PV) and describe the procedures
for identifying, investigating, reporting and
management of adverse effects of ART, anti-TB and
other medications.
50. FIRST-LINE ART REGIMENS FOR
PATIENTS INITIATING ART
The first-line ART regimens for treating HIV infection in
Uganda were selected based on the universal principles:
1. Toxicity: regimens with less toxicity are preferred.
2. Palatability and pill burden; better palatability and lower pill
burden preferred.
3. Increased durability and efficacy.
4. Sequencing: spares other available formulations for use in
the 2nd line regimen.
5. Harmonization of regimen across age and population.
6. Lower cost
51. DOLUTEGRAVIR (DTG) is an integrase inhibitor
and is recommended for use as the anchor ARV
in the preferred first and second-line treatment
regimens for all HIV infected clients; children,
adolescents, men, women (including pregnant
women, breastfeeding women, adolescent girls
and women of child bearing potential).
Think about this Qn. What is the
rationale for using dolutegravir
(DTG)
52. RECOMMENDED FIRSTLINE REGIMEN
FOR INITIATING ART IN CHILDREN
WEIGHING BETWEEN 20Kg TO LESS
THAN 30KG (≥20Kg to <30Kg).
All HIV-infected children weighing between 20kg
to less than 30kg should be initiated on
Abacavir + Lamivudine+ Dolutegravir
(ABC+3TC+DTG)
When to use ABC+3TC+LPV/r
Children who weigh between 20kg to <30kg
should only be initiated on ABC+3TC+LPV/r if
DTG is contraindicated or not tolerated
53. When to use TAF/3TC/DTG
Patients will be given TAF/3TC/DTG if ABC and
AZT are contraindicated. TAF (when available)
should be given to children who are older
than 6 years and weigh ≥ 25kg.
54. RECOMMENDED FIRSTLINE REGIMEN
FOR INITIATING ART IN CHILDREN
LESS THAN 20KG
recommended firstline regimen: ABC+3TC+DTG
o In the absence of DTG formulations initiate on
Abacavir + Lamivudine+ Ritonavir-boosted
Lopinavir (ABC+3TC+LPV/r).
LPV/r syrup, pellets or tablets should be
prescribed/dispensed on the basis of the
individual child’s ABILITY to CORRECTLY take
the specific formulation.
55.
56. Side-effects of antiretroviral therapy and
monitoring
General, long-term side-effects of
antiretroviral therapy include lipodystrophy
. Specific side effects of individual
antiretroviral drugs are summarized in
Table next slide.
57.
58.
59. Monitoring response after ARV
initiation:
Clinical monitoring involves taking a medical history and
doing a physical exam also VL
HIV/AIDS The response to antiretroviral
treatment and side-effects of treatment
need to be monitored.
Where CD4 cell count is available, this should be done
every 3-6 months and can inform on the successful
response to treatment or its failure and therefore guide
changes in treatment. Where this is not possible,
clinical parameters, including clinical staging events,
need to be used
60. After ARV initiation or ARV change:
— See the child at 2 and 4 weeks after the start/
change.
Child should be seen if there are any problems
Viral load monitoring
A patient who has been on ART for more than 6
months and is responding to ART should have
viral suppression (VL <1000 copies/ml)
irrespective of the sample type (either DBS or
plasma).
61. Frequency of viral load monitoring
1. Children and adolescents under 19 years of age: the first VL test
should be done at 6 and 12 months after initiating ART, if it is
suppressed, every 6 months thereafter. If not suppressed.
2. HIV positive pregnant and breastfeeding women: If newly
initiated on ART at ANC, conduct a VL test at 6 months on ART. If
VL <1000 copies/ml repeat VL every 6 months throughout
pregnancy and until cessation of breastfeeding. If not
suppressed.
3. HIV positive pregnant and breastfeeding women already on ART
at ANC1 or MBCP: If HIV+ woman is already on ART at ANC1 or
enrolled at MBCP, conduct a VL test at first ANC or MBCP visit. If
VL <1000 copies/ml, repeat VL every 6 months throughout
pregnancy until cessation of breastfeeding. If not suppressed
4. After every switch in treatment (after failure): The VL test should
be done at 6 months after a switch to second- and third-line ART.
62. Long-term follow-up
1. A clinician should see the child at least every
3 months.
2. A non-clinician (ideally, the provider of ARV
medication, such as pharmacist, who would
assess Adherence and provide adherence
counselling) should see the child monthly.
3. Child should be seen more frequently,
preferably by a clinician, if clinically unstable.
63. follow-up care
1. Weight and height (monthly)
2. Neurodevelopment (monthly)
3. Adherence (monthly)
4. CD4 (%) if available (then every 3–6 months) •
5. Baseline Hb or Hct (if on ZDV/AZT), ALT if
available.
6. Symptom-related determination: Hb or Hct or
full blood count, ALT
64. When to change treatment
o Treatment limiting toxicity, such as:-
— Stevens Johnson Syndrome (SJS)
— Severe liver toxicity
— Severe hematologic findings
o Drug interaction (e.g. tuberculosis treatment
with rifampicin interfering with NVP or PI)
o Potential lack of adherence by the patient if he/
she cannot tolerate the regimen.
65. Supportive care for HIV
positive children
1. Immunization
Children who have, or are suspected to have, HIV
infection but are not yet symptomatic should be given
all appropriate vaccines including BCG and, where
relevant, yellow fever vaccine.
Do not give BCG and yellow fever vaccines to
childrenwith symptomatic HIV infection.
Give all children with HIV infection an extra dose of the
measles vaccine at the age of 6 months, as well as the
standard dose at 9 months.
79. 1. HIV/TB Co infection
After diagnosis of HIV/TB Co-infection before
you iniate ARVs , start with antiTBs for 2 weeks
then introduce the ARVs this helps to prevent IRIS
But if IRIS occurs then just continue with ARVS and
antiTBs on addition to glucocorticoids
recommended firstline regimen: ABC+3TC+DTG
o In the absence of DTG formulations initiate on
Abacavir + Lamivudine+ Ritonavir-boosted Lopinavir
(ABC+3TC+LPV/r).
80. 2. Pneumocystis jiroveci (formerly carinii)
pneumonia (PCP)
Make a presumptive diagnosis of pneumocystis
pneumonia in a child who has severe or very severe
pneumonia and bilateral interstitial infiltrates on
chest X-ray
Pneumocystis pneumonia occurs most frequently in
infants and is often associated with hypoxia. Fast
breathing is the most common presenting sign,
respiratory distress is out of proportion with chest
findings, fever is often mild. Peak age is 4–6 months.
81. Promptly give oral or preferably
1. IV high-dose cotrimoxazole (trimethoprim (TMP) 8
mg/kg/dose. OR
2. sulfamethoxazole (SMX) 40 mg/kg/dose) 3 times a
day for 3 weeks.
If the child has a severe drug reaction, change to
pentamidine (4 mg/kg once per day) by IV infusion
for 3 weeks.
83. Give a trial of antibiotic treatment for bacterial
pneumonia before starting treatment with
Give oral prednisone, 1–2 mg/kg daily for 2
weeks. Then decrease the dose over 2–4
weeks depending on treatment response.
88. C a s e s t u d y
Mwebaza victor is a 10 yr Male who is admitted at
JRRHosp with severe headache, fatigue and weight
loss over the last 2 months. His mother reports that
he has never been tested for HIV before. His exam is
notable for meningismus and a sixth nerve palsy An
LP is done. Opening pressure is not measured but
fluid is noted to be “under pressure” His labs are
notable for a Na 128, a WBC of 1.8, Hgb7g/dl,
Plt152 His CSF is notable for a cell count of
3cells/mm3, total protein 85g/dL, glucose nl. India
ink and CSF CrAg are positive. He is commenced on
antifungal therapy
89. K e y C l i n i c a l Q u e s t i o n s
1. What is the best way to diagnose
cryptococcaldisease?
2. What is the most appropriate antifungal therapy?
3. When should antiretroviral therapy be initiated?
Pulmonary cryptococcosis
Cryptococcal meningoencephalitis in child with AIDS who became
progressively obtunded.
Smith A B et al. Radiographics 2008;28:2033-2058
91. Cryptococcoma in a 13-year-old HIV-
infected patient who presented with
increasing headache, nausea, and
vomiting.
Smith A B et al. Radiographics
2008;28:2033-2058
92.
93. Immune reconstituti on
inflammator y syndrome
Immune reconstitution inflammatory syndrome (IRIS)
is a condition seen in some cases of AIDS or
immunosuppression, in which the immune system
begins to recover, but then responds to a previously
acquired opportunistic infection with an
overwhelming inflammatory response that
paradoxically makes the symptoms of infection
worse.
94. Persons living with AIDS are more at risk for
IRIS if they are starting HAART for the first
time, or if they have recently been treated for
an opportunistic infection
95. There are two common IRIS scenarios. The first is the
“unmasking” of an occult opportunistic infection. The
second is the “paradoxical” symptomatic relapse of a
prior infection despite microbiologic treatment
success. Often in paradoxical IRIS, microbiologic
cultures are sterile
. https://en.wiktionary.org/wiki/occult#Adj1
Bolognia, Jean; Schaffer, Julie V; Cerroni, Lorenzo, eds. (2018). "Immune Reconstitution
Inflammatory Syndrome (IRIS)". Dermatology. p. 1378. ISBN 978-0-7020-6342-8.
OCLC 1016978099. Archived from the original on 2022-08-19. Retrieved 2021-04-27
96. Preve ntion of m othe r - to - child
transm ission.
Phionah Nakyeyune`s
story
97. 4 prong approach
Prong 1: Primary prevention of HIV infection
among women of reproductive age
Prong 2: Prevent unwanted pregnancies among
women living with HIV
Prong 3: Prevent HIV transmission from HIV
positive mothers to their infants
Prong 4: Provide appropriate treatment, care
and support to mothers living with HIV and
their children and families
98. PMTCT OPTION B+
Screen all pregnant mothers for HIV during
pregnancy
Start ART for all HIV+ mothers regardless of CD4
count, viral load and clinical stage
Encourage all HIV+ pregnant mothers to deliver at
a health facility
Modified obstetric care at delivery
Start infant on Nevirapine syrup for 6 weeks
1.5ml OD for 6 weeks(less than 2.5kg) and 2.0ml
OD for 6 weeks(more than 3.0kg)
99. At 6 weeks, do first DNA-PCR and stop NVP syrup
Start contrimoxazole prophylaxis at 6 weeks
If test positive, child HIV infected, start HAART
If test negative, continue contrimoxazole
Continue exclusive breastfeeding up to 6 months
and start complimentary feeing Complimentary
feeding goes on up to 12 months and stopped
Repeat DNA PCR test 4 weeks after ceasation of
breastfeeding
If positive, child HIV positive, start HAART and do
rapid HIV test at 18 months
If negative, child is confirmed HIV negative, stop
septrin
100.
101. "If I can stop one heart from breaking I shall not live in
vain; if I can stop one life the aching or cool one pain, or
help one fainting robin unto its nest again, I shall not
live in vain.
- M W E B A Z A V I C T O R . J
