Pediatric HIV/AIDS

Objectives
• Explain component of care for HIV
infected and exposed child
• Identify EID
• Explain cotrimoxazole preventive
therapy(CPT)
• Describe INH Prophylactic Therapy(IPT)
• Describe follow up of patient
 Components of Routine Care for
the HIV-Exposed/Infected Child
1. History (past, interim, parental concerns)
2. Nutrition evaluation
3. Developmental assessment
4. Physical examination
5. Laboratory evaluation
6. Staging/classification
7. Preventing Opportunistic infections
8. ARV eligibility
9. Assessment & plan
10. Follow up schedule 3
 1. History
• Why is history important?
– Develop clinical profile for older children entering
the program
– Identify changes in health status since last visit
– Identify changes in home setting that may affect
child’s health
• PAST HISTORY
– Newly enrolled older children
• HIV-related illnesses
• Hospitalizations
• Medications (ARV, OI prophylaxis, PMTCT)
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 1. History (2)
Interim History
• New health problems
– Signs & symptoms checklist
– HIV-related illness
• Current Medications
– antiTB medications
– Medications for OI prophylaxis e.g. Cotrimoxazole
– Other alternative medications (herbal
preparations)
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 2. Nutritional Evaluation
 At every visit:

– Nutrition and feeding history – exclusive

breastfeeding or formula feeding?
– Weigh, measure height/length and HC and
examine child
– Use growth curves to monitor growth pattern.

 Any child who is not thriving needs extensive

nutritional history. 6
 Feeding recommendation
Exclusive Breast Feeding
-Definition
-Advantage
Formula feeding
-Definition
-Advantage
AFASS = Affordability, Feasibility, Accessibility,
Safe, Sustainability
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 Failure-to-Thrive
• The failure to sustain a normal velocity of
weight and/or height growth during the first 3
years of life – downward crossing of 2
percentiles over time..
• Can be quantified using growth curves.
• May be indication:
Of HIV disease in exposed infant
For ARV treatment in infected infant/child
Of ARV treatment failure in child on therapy
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 3. Developmental Assessment
• At every visit
– Ask about the infant’s development
– Simple questions should focus on four critical
developmental domains; cognitive, motor, language, and
social
– This can be done through observation during the physical
exam or asking the parent
• The developmental checklist may be helpful
• Ask about school performance for school aged kids
• Delayed acquisition of developmental milestones or loss of
previously acquired skills can be the first sign of HIV
encephalopathy
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 3.Developmental Assessment (2)
• Developmental Checklist
– 1 month: raises head, crawling
movement, alerts to sound
– 2 months: head midline, lifts
chest off table, smiles socially
– 4 months: rolls front to back,
laughs
– 6 months: sits unsupported,
babbles
– 9 months: pulls to stand, says
“mama”
– 12 months: walks alone, two
words

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 Red Flags!
AGE WARNING SIGNS
1 month
Does not regard face , no eye contact, no smile, poor suck, floppy
2 months Does not look at you with both eyes at least for a few moments, and does not follow with eyes if you
move your face slowly from side to side

3months Does not respond to sound by quieting

4months Does not hold head steady for a few moments when you sit him up, does not grasp rattle that you
put into his palm

5months Does not raise head and support weight on arms when in prone position

6 months Cannot reach for objects with both hands, Floppy, no response to sound, Poor social response to
people

9 months Unable to sit unsupported , hand preference, fisting, persistence of primitive reflexes

12months Unable to bear weight on legs

15 months Does not walk alone, is not using at least one word meaningfully

18 months Does not use at least 3 words, and does not point to what he wants 11
 4. Physical Examination
• Perform careful physical examination at every
visit
• Initial exam should be comprehensive including
examination of all organ systems
– Identify any HIV related physical findings; thrush,
lymphadenopathy, organomegaly,dermatitis,
encephalopathy etc
• Subsequent exams can be guided by findings
on the symptom/sign checklist
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 5. Laboratory Evaluation
• Which Laboratory Tests Need To Be Done?
– Confirmation of HIV infection ASAP
– Complete Blood Count with DC
– CXR if clinically indicated
– CD4 number and percent

When infant is determined to be HIV-infected

Upon enrollment for older children
Every six months there after

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 EID=>Complexities of Infant Diagnosis
• HIV infection is difficult to diagnosis in infants:
– Routine HIV antibody tests cannot be used
– Specialized virologic tests are necessary
– Clinical diagnosis requires frequent and close follow-
up of the infant
• HIV infection is difficult to exclude in infants:
– Infants who breastfeed continue to be at risk for
acquiring HIV infection
• Risk of infection continues throughout duration of breast feeding
• Diagnosis of infants is an ongoing process and depends on good
clinical reasoning as well as laboratory results

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Complexities of HIV Diagnosis: Antibody Testing
• All infants born to HIV+ mothers will test HIV antibody
positive in the first several months of life
– Maternal HIV antibody (IgG) is transferred across the placenta during
pregnancy

• A positive HIV antibody test in infants <18 months of age will

not distinguish whether or not the infant is HIV-infected;
rather it shows that:
– Mother is HIV-infected
– Infant is at risk for HIV infection (exposed to HIV)

• If the child is not infected the HIV antibody fades during first 6
- 18 months of life
– Most uninfected infants test negative by 12 months of age
– All uninfected infants test negative
15 by 18 months of age
 Antibody Detection in 77 HIV-Exposed,
Uninfected Infants in South Africa

Rapid Ab can be used

to exclude infection
around 9-18 months of
age

Moodley D, PIDJ 1995;14:850

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 Virologic Tests
• Specialized virologic tests must be used for
early Infant HIV diagnosis
– HIV DNA PCR
– HIV RNA PCR
– Ultra sensitive p24 Antigen
– Viral Culture
• Two positive virologic tests = HIV infection
• One positive virologic test = Presumed HIV
infection
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 HIV DNA PCR
• HIV DNA PCR is a special laboratory test that
detects pieces of the viral gene that are
incorporated in the human blood cell

• Sensitivity of HIV DNA PCR increases with time

during the first month of life
– The infant may have HIV infection but there may
not be enough virus in the blood to detect it at
birth
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 DNA PCR for Infant Diagnosis

At 4-6 weeks of age

sensitivity of
DNA PCR is 96-
98%

Dunn D, AIDS 1995, 9:F7

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 When to do Virologic Testing
• Every HIV-exposed baby should have a DNA PCR test
At 4-6 weeks of life
or
At first visit* (if >6 weeks of age)
or
*If the child presents at 9-18 months of age
screen with a rapid antibody first
– If antibody positive, virologic testing is indicated
– If antibody negative, no virologic testing is necessary
• If breastfeeding, repeat antibody testing >6 weeks after
cessation of breastfeeding
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Interpretation of virologic test results in Breastfed
infants

• Breastfed infants
– Remain at risk for acquiring HIV infection
throughout the duration of breastfeeding
– Most are infected in utero, intrapartum and early
postpartum (by 6 weeks of age)
– A negative virologic test cannot reliably exclude
HIV if the infant is still breastfeeding
– Infant must always be tested again 6 weeks after
complete cessation of breastfeeding

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 What if the DNA PCR is
Positive?
• Initiate ART according to the national guideline
• Infants with an initial + viral test should start ART
without delay according to the national guidelines
BUT a 2nd specimen should be collected to confirm
the initial + test(antibody at 1year
• Start or continue cotrimoxazole
• Continue exclusive breastfeeding (EBF) through 6
months of age
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 What should you tell the care giver if the initial
PCR test is Negative?
• We did not find the HIV virus in your baby’s blood at present
• Since you are breastfeeding, your baby there is a small
chance of getting the virus from the breast milk
• We will have to keep monitoring him/her for signs of
infection
• If s/he stays well, we will not test again until at least 6 weeks
after you wean the baby from the breast
• If your baby gets sick, we will repeat the special test again to
check for the virus
• You need to keep bringing your child for check ups and
continue cotrimoxazole and breastfeeding
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Presumptive Diagnosis of Severe HIV Disease in Children
<18 months

• HIV antibody positive and

– Diagnosis of Stage 4 or AIDS-indicator condition (s)
OR
– Symptomatic with ≥ 2 of the following:
• Oral thrush
• Severe pneumonia
• Severe sepsis
• Supporting factors
– Recent maternal death
– Advanced HIV disease in the mother
– CD4% < 25% in infant
• The diagnosis should be confirmed with HIV antibody when
the child reaches 18 months
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 Diagnosing HIV in the Child >18
Months
• HIV antibody should be used to diagnose HIV
infection in children > 18 months of age
• Children >18 months with positive antibody
test have HIV infection
• A negative antibody test in children > 18
months excludes HIV infection
– Except in cases of continued breast feeding.
Antibody should be repeated 6 weeks post
cessation of breast feeding
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 When should you use HIV Antibody Tests?

• Children < 18 months of age

– Determine HIV exposure in infants born to women
of unknown HIV status
– Exclude infection in an infant who is not breastfed
or > 6 weeks post-weaning
– Exclude HIV infection in children > 9 months of
age
• Children > 18 months of age
– Confirm HIV infection

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 6. Clinical Staging of Pediatric HIV/AIDS

• Old WHO clinical stages:

– Three stages
– Didn’t capture many disease manifestations
– Didn’t include measures of immunologic status
• New WHO clinical staging:
– Four clinical disease categories; asymptomatic, mild,
advance and severe
– Expanded comprehensive list of associated
conditions based on prognosis
– Standardized criteria for presumptive and definitive
diagnosis 27
WHO Staging for <15 Years Old

Clinical Stage 1 (Asymptomatic)

Asymptomatic
PGL

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WHO Staging for <15 Years Old
Clinical Stage 2 (Mild)
Hepatosplenomeagly
Papular pruritic eruptions,
Extensive wart virus infection
Extensive molluscum contagiousum
Fungal nail infections,
Recurrent oral ulcerations
Linear gingival erythema (LGE)
Angular cheilitis
Parotid enlargement
Herpes zoster
Recurrent or Chronic URTI (otitis media, otorrhea,
sinusitis)
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 WHO staging for <15 Years Old
Clinical Stage 3 (Advanced)
Moderate unexplained malnutrition not adequately responding to
standard therapy
Unexplained persistent diarrhea (14 days or more)
Unexplained persistent fever (intermittent or constant for longer than
one month)
Oral Candidiasis (outside neonatal period),
Oral hairy leucoplakia
Acute necrotizing ulcerative gingivitis/periodontitis
Pulmonary TB

Severe recurrent bacterial pneumonia

Unexplained anemia (<8mg/dl),and/or neutropenia (<500/mm3) and/or
thrombocytopenia, (<50,000/mm3) for >1 month

Chronic HIV associated lung disease including bronchiectasis

Symptomatic lymphoid interstitial
30 pneumonitis (LIP)
 WHO staging for <15 Years Old
Clinical Stage 4 (Severe)
Unexplained severe wasting or severe malnutrition not
adequately responding to standard therapy
Pneumocystis pneumonia
Recurrent severe bacterial infections (empyema,
pyomyositis, bone or joint infection, meningitis, but
excluding pneumonia)
Chronic herpes simplex infection (orolabial or cutanoeus >
1 month, visceral of any duration)
Kaposi’s sarcoma, esophageal candidiasis, CNS
toxoplasmosis, HIV encephalopathy

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 WHO Staging for <15 Years Old
(Stage 4 continued)
CMV infection (retinitis or infection of organs other than
liver, spleen or lymph nodes; onset at the age of 1 month or
more)
Extrapulmonary cryptococcosis including meningitis
Any disseminated mycosis (e.g. extrapulmonary
histoplasmmosis, coccidiomycosis, penicillosis)
Cryptosporidiosis, isosporiasis
Disseminated non-tuberculous mycobacteria infection
Candida of the trachea, bronchi or lungs
Acquired HIV associated rectal fistula, cerebral or B-cell
lymphoma
Progressive multifocal leucoencephalopathy (PML)
HIV associated cardiomyopathy or HIV associated
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nephropathy
 WHO Classification of
Immunodeficiency
Age related CD4 values

Immunological <12 months 12-35 months 36-59 months > 5 years

Classification (CD4 %) (CD4 %) (CD4 %) (CD4
cells/mm3)
Not significant > 35% > 30% > 25% > 500

Mild 30-35% 25-30% 20-25% 350-499

Advanced 25-30% 20-25% 15-20% 200-349

Severe < 25% < 20% < 15% < 200 or 15%

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 7.Preventing Opportunistic
Infections
• Occurs with severe immune suppression
• Young children have primary infection rather
than reactivation as in adults
• Immature immune system of the infant leads
to more fulminant course than in adults
• Prophylaxis prevents disease progression and
morbidity and mortality!

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 Cotrimoxazole Prophylactic
Therapy
• Cotrimoxazole Prophylactic Therapy (CPT) is
one of the most important interventions for
HIV-exposed infants and HIV-infected infants
and children
• It prevents
– Pneumocystis jiroveci (formerly Pneumocystis carinii), most common
opportunistic infections in infants and young children, with a very high
mortality rate
– Prevents diarrheal infections
– Prevents malaria

• Without prophylaxis, 40% of infants and

children with AIDS experience PCP 35
 Which HIV-infected children should get
Cotrimoxazole Prophylactic Therapy?

• All HIV-infected infants < 5yrs

• All HIV-infected children > 5 years with:

– Clinical stage 2, 3 or 4 disease or
– CD4 < 350
• All HIV-infected infants and children with
prior Pneumocystis pneumonia

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 Dosing Recommendations for
Cotrimoxazole
• Cotrimoxazole suspension
Trimethoprim/sulfamethoxazole
– Use weight band chart for dosing CTX/SMZ, Cotrimoxazole, Septrim®, Bactrim®
Suspension Single-Strength
– Administer once daily Age 40mg TMP/200mg Tablet
SMZ per 5ml 80mgTMP/400mg
• Toxicities are rare in children and SMZ

include ¼ tablet
< 6 months 2.5 ml daily
– Rash
– Fever
6 months - 5 5 ml daily ½ tab daily
– Bone marrow suppression years
(neutropenia)
6 - 14 years 10 ml daily 1 tab daily
• Use Dapsone (2mg/kg/day, max
100mg) for severe allergy to
> 14yrs 2 single-strength or
cotrimoxazole one double-strength
tab daily

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 TB Prevention in HIV Patients
• BCG?
– Definitely not; shown to be both ineffective and dangerous
– Overall rate of disseminated BCG in HIV + South African infants:992
(95% CI: 567–1495) per 100 000.
• Hesseling et al. Bull World Health Organ 2009;87:505–511
– In Vitro evidence suggests little or no efficacy of BCG in the HIV-
infected .
• Avoid Exposure?
– Not practical in most cases, with the exception of health care
workers
• ART
– Of course!
• Chemoprophylaxis?
‒ IPT  progression to active disease by 90 % in HIV -ve
people and 37-70 % in HIV infected people.
 Indication for IPT
There are groups that are at increased risk to disease
progression from primary infection:
43% of infants (<1yr)
25% 0f 1-5 yrs
15 % of adolescents
Immune compromised people irrespective of age
(HIV)
Malnutrition
The vast majority of children progress to disease within
1 year of primary infection.
 TB screening in children
Symptom based screening
(Any of the following)
• Cough any duration(Current cough)
• Fever >two weeks( fever of > 38oC) after
exclusion of common causes like malaria and
pneumonia
• Documented weight loss or failure to gain
weight
• Close contact with active TB case
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 Positive Screening….
Exclude active TB as per local and national
Guidelines
Laboratory investigations
• Sputum for AFB in children above five years of
age
• Gastric aspirate in children below five years of
age
• Radiologic examination
• Mantoux test if available
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 Outcome of the screening

1. TB unlikely= INH prophylaxis

2. TB possible= follow up

3. TB highly likely= Treat for TB

 Who should take IPT
• Only children at high risk of disease
progression shall receive preventive therapy.

–All HIV infected children irrespective of their age

and have no symptoms and signs of active TB

disease.
• Dose of INH 5 – 10mg/kg p.o for 6
months & Pyridoxine 25mg daily

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 Child over 12 months of age and living with
HIV*
Screen for TB with any one of the
following:
•Poor weight gain**
•Fever
•Current cough
•Contact history with TB patient
No Yes

Assess for contraindications to ITP **** Investigate for TB and other diseases****

No Yes Other diagnosis Not TB TB

Give IPT Defer IPT Give

Follow up Treat for
appropriate
treatment and
and TB
consider ITP consider ITP

Screen regularly for TB

 Follow up IPT

• Monthly follow up
• Check adherence and check for toxicity(
hepatitis )
• Evaluate for development of active TB
• Check for drug- drug interactions
• Check for eligibility for ART
 Contraindication IPT

• Active TB

• Symptoms Compatible with TB, Even

Though Diagnosis cannot be confirmed
• Active Hepatitis [Clinical or Lab]
• Peripheral neuropathy
• Prior Allergy or Intolerance to INH
 Summary

• Early diagnosis is critical for survival

• Systems for following children need to be
established in the clinical setting
• Prophylactic therapies and nutritional support
are critical interventions to decrease HIV
morbidity