PAEDIATRIC HIV

 Screening
o Babies of HIV positive mothers
o Abandoned babies / street children
o Babies of mothers with high risk behavior
o Sexually abused children
o Children with STD
o Children receiving regular blood products

 Deliveries and infant nursing

o Standard precautions observed at all times
o Protective barriers – arm length gloves, mask, goggles, and gown with waterproof sleeves
(use using deliveries, handling the placenta, during handling babies)
o All equipment need to be sterilised
o Home deliveries – batteries operated suction device should be used
o For parents and relatives – gloves are given to handle the placenta
 The placenta should be soaked in formalin solution before disposal or
 Sealed in plastic bag or leak proof container

 Immunisation
o All routine vaccines can be given according to schedule, special precaution for live vaccines
– BCG, MMR
o BCG – safe is child is asymptomatic and not immunosuppressed.
o MMR – safe, omit in child with severe immunosuppression (CD4<15%)
o Recommended vaccines
 Pneumococcal – after 2 years old, booster 3-5 years later
 Varicella zoster vaccine, 2 doses with 2 months interval. Omit if immunosuppressed

 Intervention to limit transmission

o Breastfeeding is contraindicated
o ELLSCS
o Antiretroviral prophylaxis

 Factors associated with higher transmission rate

Maternal Foetal

Low CD4 counts Premature

High viral load Delivery and procedures
Advanced disease Invasive procedure -
Seroconversion during episiotomy
pregnancy Foetal scalp electrodes
Vaginal delivery
Rupture of membrane >4
hours
 Management of babies born to HIV infected mothers
o Children born to HIV mothers are usually asymptomatic
o During pregnancy, counsel mother regarding
 Transmission rate – 25-30%
 ARV prophylaxis +/- ELLSCS reduces transmission to ~2%
 Breastfeeding doubles the risk of transmission
 Difficulty in making early diagnosis because of presence of maternal antibody in
babies
o Neonatal period
 Admit ward
 Examine for evidence of congenital infections, symptoms of withdrawal
 Most babies are asymptomatic and only require routine perinatal care
 Start on prophylaxis ARV as soon as possible
 Sample blood for
 HIV DNA / RNA PCR
 FBC
 LFT, RP, HbsAg, Hep C, CMV, Syphillis

 Management of HIV in children

o Clinical features
 Lymphadenopathy
 Hepatosplenomegaly
 FTT
 Recurrent infections
 Developmental delay, regression
o Diagnosis of HIV infection
 In children > 18 months age : 2 consecutive positive HIV antibody tests
 In children < 18 months age : 2 positive HIV DNA / RNA PCR tests
o Monitoring
 Clinical, immunological (CD4) and viral load status
 CD4+ and viral load done at diagnosis
 2-3 months after initiation or change of combination ART and every 3-4 months
thereafter
 Management of HIV exposed infants
o Initiate HIV prophylaxis immediately after delivery
o Investigation : HIV DNA/RNA PCR at 0-2week, FBC at birth and 6 weeks
o Start PCP prophylaxis at 6 weeks, until HIV status determined
 Co-trimoxazole or trimethoprim
o If HIV DNA/RNA PCR positive, repeat another one. If positive, INFECTED
o If HIV DNA/PCR negative, repeat in another 6 weeks. If still negative, to repeat at 4-6
months. If negative, NOT INFECTED. Stop co-trimoxazole. Tca until 18 months. Ensure baby
negative by 18 months.
 When to start ART?
 NRTI NNRTI Protease inhibitor PI

zidovudine ZDV nevirapine NVP ritonavir

stavudine d4T efavirenz EFZ lopinavir/ritonavir
lamivudine 3TC Etravirine ETV Kaletra
abacavir ABC Rilpivirine RPV darunavir
tenofovir TDF
emtricitabine FTC

 Which drug to use?

o Always use combination of at least 3 drugs
o 2 NRTI + 1 NNRTI
o 2 NRTI + 1 PI
o NNRTI – efavirenz > 3years, nevirapine < 3 years
o Recommended NRTI combination
 Zidovudine + lamivudine
 Abacavir + lamivudine
 Tenofovir + emtricitabine > 12 years
o For infant exposed to maternal or infant NVP or other NNRTI used for maternal
treatment/prevention of mother to child transmission
 Start ART with protease inhibitor (lopinavir) with 2 NRTI
o When to change?
 Treatment failure – clinical, virologic and immunological parameters
 Deterioration of condition, rebound/unsuppressed viral load or
dropping CD4
 Toxicity or intolerance
 Follow up
o Aim of ART is to achieve an undetectable VL (<50 copies/ml) and CD4 reconstitution
o Follow up 3-4 months
o Ask about adherence and side effects
o Examine growth, head circumference, pallor, jaundice, oral thrush, lipodystrophy syndrome
(on PI)
o FBC, CD4, viral load 3-4 monthly. RP, LFT, Ca, P04 every 6 months. On PI, FSL & RBS yearly.
PAEDIATRIC QUESTIONS
Online
1. A 2-month-old female infant is brought in for a follow-up visit. She was born via spontaneous
vaginal delivery at 38 weeks gestation to a mother with HIV who had limited prenatal care and was
not taking antiretroviral therapy. The infant received 6 weeks of zidovudine and 3 doses
of nevirapine. The infant had a negative HIV DNA test at birth and at 21 days after birth.

Which one of the following should be ordered for this 2-month old infant at this visit to
further evaluate possible HIV diagnosis in the infant?

A. A rapid HIV antibody test

B. A laboratory-based HIV enzyme immunoassay (EIA) antibody
C. A virologic test (HIV RNA PCR or HIV DNA PCR).
D. A HIV p24 antigen assay
E. An HIV-1/2 antigen antibody immunoassay

2. A 23-year-old woman with HIV gives birth to a healthy boy at week 38 of her pregnancy. The
mother received antiretroviral therapy throughout the pregnancy and had an undetectable HIV
RNA 1 week prior to delivery. The infant received 4 weeks of oral zidovudine. The mother did not
breastfeed the infant.
Which one of the following results would definitively exclude the diagnosis of HIV in this non-
breastfed infant?

A. Negative virologic tests at 6 weeks and at 5 months .

B. Negative HIV antibody tests at birth and at 6 weeks
C. Negative HIV-1/2 antigen-antibody tests at 6 weeks and 6 months
D. A negative HIV DNA PCR test at birth and at 2 weeks
E. A single negative HIV antibody test at 6 months

3. An 18-month-old girl with HIV infection returns to the clinic with her mother for ongoing care. She
has no HIV-related symptoms and the mother has regularly been giving her antiretroviral therapy
medications. Her weight and height have been at roughly the 50th percentile since birth. The child
has not had any HIV-related opportunistic illnesses. The physical examination is normal and
laboratory studies show a CD4 count of 942 cells/mm3, CD4 percentage 27%, and an HIV RNA level
below the limit of detection.

What would be the HIV classification for this 18-month-old girl?

A. Stage 0
B. Stage 1
C. Stage 2
D. Stage 3
E. Stage 4
4. A 10-week-old boy diagnosed with HIV is seen in clinic for follow-up evaluation after a diagnosis of
HIV was confirmed on the prior day. The child was born to a mother who was diagnosed with HIV at
the time of delivery and the mother’s initial HIV RNA level was 148,000 copies/mL. The infant
received three dose of nevirapine prophylaxis after birth and sporadic prophylactic zidovudine for 6
weeks. He was diagnosed with HIV based on positive HIV RNA tests at birth and at 9 weeks of age.
He has been gaining weight appropriately and his mother has not breastfed him. Laboratory studies
for the infant show a CD4 count of 1,238 cells/mm3, CD4 percentage of 31%, and an HIV RNA level
of 237,200 copies/mL. An HIV genotypic drug resistance test is ordered.
Which one of the following is the most appropriate management for the infant?

A. Initiate antiretroviral therapy urgently.

B. Initiate antiretroviral therapy if the CD4 count declines to less than 1,000 cells/mm 3
C. Initiate antiretroviral therapy if the CD4 count declines to less than 750 cells/mm 3
D. Initiate antiretroviral therapy if the CD4 percentage declines to less than 25%
E. Initiate antiretroviral therapy only if HIV-related clinical signs or symptoms develop

5. A 4-year-old female is brought to your clinic for evaluation. She was diagnosed with HIV at 7 months
of age based on two positive HIV nucleic acid tests (HIV DNA PCR and HIV RNA). She had taken
antiretroviral therapy from birth until about 6 months of age when at that time the parents
discontinued the antiretroviral medications because they were worried about medication safety.
Although she has remained asymptomatic, her CD4 count has declined and is now 550
cells/mm3 with a CD4 percentage of 22%. Her HIV RNA level is 93,100 copies/mL.

Which one of the following is recommended for this 4-year-old girl?

A. Wait until her CD4 count falls below 500 cells/mm3 before starting ART
B. Wait until her CD4 count falls below 350 cells/mm3 before starting ART
C. Wait until her CD4 count falls below 200 cells/mm3 or she has HIV-related symptoms before
starting ART
D. Start ART now.
E. Recheck HIV RNA and start ART if its greater than 100,000
 6. A 5-month-old male infant is brought to the office by his adoptive mother. He was diagnosed with
HIV based on two HIV DNA tests at birth and 14 and 21 days. Results from CD4 testing are pending.
At this visit, his mother expresses concern about the safety of giving her son vaccines because of
his potential immunocompromised state.

Which one of the following statements is most accurate regarding the administration of
vaccines in children with HIV?

A. Most recommended routine childhood vaccines are safe for children with HIV, with the
exception that children with severe immunosuppression (CD4 less than 200) should not receive
varicella or MMR.
B. Routine childhood vaccines can be given to children with HIV if they have undetectable HIV RNA
value
C. All recommended routine childhood vaccines are safe for children with HIV
D. All recommended routine childhood vaccines are safe for children with HIV, but should be
administered on a delayed schedule to optimize immune response to the vaccines
E. All recommended routine childhood vaccines are safe for children with HIV, but guidelines
suggest administering only live, attenuated vaccines to provide optimal immune response

7. An 11-week-old baby girl who was recently diagnosed with HIV infection is brought to the clinic for
initial evaluation. The infant had a positive HIV DNA at week 8 and a positive follow-up HIV RNA test
at week 9. She has been feeding well and gaining weight appropriately and her mother reports no
concerns. The infant’s CD4 count is 1,450 cells/mm3 and CD4 percentage is 30%; she is started on
combination antiretroviral therapy.

Which one of the following is TRUE regarding prophylaxis for Pneumocystis pneumonia in this

infant?

A. She does not need prophylaxis based on the absolute CD4 cell count
B. She does not need prophylaxis based on CD4 percentage
C. She should be started on trimethoprim-sulfamethoxazole for prophylaxis regardless of the
CD4 cell count.
D. She should be started on trimethoprim-sulfamethoxazole for prophylaxis beginning at age 6
months
E. She should be started on dapsone prophylaxis beginning at 1 year of age