HIV and Children

OVERVEIW
 Diagnosis of HIV/AIDS in infants
children.
 Initiation and monitoring of ART
 Preferred regimen ARVs and follow
up.
 Exposed infants prophylaxis
Diagnosis of HIV infection in
children

 Because of the passive transfer of maternal

antibodies, HIV antibody tests cannot be
reliably used for diagnosis of HIV infection in
children aged less than 18 months.
 Thus a definitive diagnosis of infection will need to
wait until the child reaches the age of 18 months.
• However, a negative test will rule out maternally
acquired infection.
 HIV infection in these children can only be
confirmed by tests (for example, viral culture
and PCR ) that detect the virus.
• However these tests are expensive .
:Groups of children born to HIV-infected women

 Group 1: children with negative tests

 Group 2 : children with positive test but not
infected
 Group 3: children with a positive test and
infected.

The infants and children who are infected need chronic

HIV care including antiretroviral therapy (ART) and
follow-up .
recommendations on methods for establishing the presence of HIV
infection in infants and children
To diagnose HIV infection in mother or identify HIV-
exposure of infant

To diagnose HIV infection in children aged 18 months or

more
HIV
To identify HIV-antibody positive children aged under 18
months and support the presumptive clinical diagnosis . Antibody
testing
To exclude HIV infection where HIV antibody negative in
children aged under 18 months who are HIV-exposed and
never breastfed.
To exclude HIV infection where HIV antibody negative in
children aged under 18 months who are HIV-exposed and
discontinued breast feeding for more than 6 weeks
Care of HIV exposed Child
Immunization and HIV

HIV-exposed children should be

immunized according to the routine
national Expanded Programme on
Immunization (EPI) schedule with
:the following modifications
Cotrimoxazole (CTX) prophylaxis for all HIV
exposed infants

 Cotrimoxazole prophylaxis protects the

infant from PCP, toxoplasmosis and other
bacterial diseases. It is the standard
component of HIV care to reduce the
morbidity and mortality of children less
than five years of age:
 All HIV-exposed infants should get CTX
prophylaxis from age of 4–6 weeks.
 The recommended dose is 5mg/kg/day as
a single daily dose.
?When to suspect HIV
?When to suspect HIV
 Recurrent infections like pneumonia, sepsis, and
meningitis.
 Oral thrush. After the neonatal period, without antibiotic
treatment, or persisting or recurring after treatment
 Chronic parotitis (unilateral or bilateral parotid swelling
> 2 weeks)
 Generalized lymphadenopathy
 Persistent or recurrent fever, without any apparent
cause.
 Unexplained neurological abnormalities: hypertonia,
delay in developmental milestones, microcephaly and
progressive neurological impairment.
 Herpes zoster
 HIV dermatitis: a non-specific erythamatous papular
rash.
 Suspected or confirmed maternal HIV infection.
Signs very specific for HIV

 Pneumocystis carinii pneumonia (PCP)

 Oesophageal candidiasis
 Lymphoid interstitial pneumonia (LIP)
 Herpes zoster across several dermatomes
 Progressive encephalopathy
 Kaposi sarcoma
 Extra-pulmonary cryptococcosis
 Invasive salmonella infection
 Lymphoma
Oral Kaposi’s Sarcoma (KS)
Staging
WHO Paediatric Staging of HIV/AIDS Disease

Asymptomatic
WHO
 Persistent Generalized Paediatric
Stage 1
Lymphadenopathy
(PGL)
 WHO Paediatric Staging of HIV/AIDS Disease

Unexplained persistent hepatosplenomegaly

Papular pruritic eruptions
Seborrheic dermatitis
Fungal nail infections
Angular chelitis
Lineal gingival erythema
WHO
 Extensive HPV or molluscum
infection(>5% of bodyarea/face) Paediatric
Extensive wart virus infection Stage 2
Recurrent oral ulcerations
(>2episodes/6mos)
Unexplained persistent Parotid enlargement
Herpes zoster(>1episode/12mos)
Recurrent or chronic upper respiratory
infection: otitis media, otorrhea, sinusitis(>2
episodes/6mos)
 WHO Paediatric Staging of HIV/AIDS Disease
Unexplained moderate malnutrition not responding to
standard therapy
 Unexplained persistent diarrhoea (>14days)
 Unexplained persistent fever (above 37.5oC intermittent or
constant, >1mo)
 Persistent oral candidaisis (after first 6-8 weeks of life)
Oral hairy leukoplakia WHO
Lymph node tuberculosis Paediatric
Pulmonary tuberculosis Stage 3
Severe recurrent presumed bacterial pneumonia (2episodes/
12 mo )
Acute necrotizing ulcerative gingivitis/periodinitis
 Symptomatic lymphoid interstitial pneumonitis (LIP)
Chronic HIV-associated lung disease including bronchiectasis
Unexplained anaemia(<8gm/dl), neutropenia (1000/mm3),or

Thrombocytopenia (<30000/mm3) for >1mo

WHO Paediatric Staging of HIV/AIDS Disease

Symptomatic HIV-antibody positive

infant age <18mos*
Two or more of the following
 Oral candidiasis/thrush
 Severe pneumonia WHO
 Failure to thrive Paediatric
 Sepsis Stage 4
*Presumptive diagnosis of stage 4
disease in HIV-antibody positive
infant <18mos requires confirmation
with HIV virologic tests when
possible, or by antibody tests after
age 18mos
WHO Paediatric Staging of HIV/AIDS Disease

Unexplained severe wasting, stunting or severe

malnutrition not responding to standard therapy
Pneumocystis pneumonia
Recurrent severe bacterial
infections(>2episodes/12mos, e.g. empyema,
pyomyositis, bone or joint infection, meningitis, but
excluding pneumonia)
Chronic herpes simplex infection; (orolabial or WHO
cutaneous of more than one month’s duration or Paediatric
visceral at any site) Stage 4
Extrapulmonary tuberculosis )Any Age(
Kaposi’s Sarcoma
Oesophageal candidiasis (or candidiasis of
trachea, bronchi or lungs)
Cytomegalovirus infection: retinitis or CMV
infection affecting another organ, with onset at age
over 1 month.
 WHO Paediatric Staging of HIV/AIDS Disease

CNS toxoplasmosis(after the neonatal period)

HIV encephalopathy
Extrapulmonary cryptococcosis (including
Cruptococcal meningitis) WHO
Disseminated endemic mycosis (Extrapulmonary Paediatric
histoplasmosis, coccidiomycosis Stage 4
Disseminated non-tuberculous mycobacteria )Any Age(
infection
Chronic isosporiasis
Acquired recto –vesico fistula
Cerebral or B cell non Hodgkins lymphoma
Progressive multifocal leukoencephalopathy (PML)
Symptomatic HIV-associated nephropathy
 Symptomatic HIV-associated cardiomyopathy
Oral Hairy Leukoplakia (OHL)
 Commonly seen as
fixed white plaques on
the sides of the tongue

Oral Candidiasis
Why to Start ART
 By one year of age, approximately 30% of
untreated HIV-infected infants die.
 By 2 years of age, 50% of untreated infants
die
 Children are at risk for the regular child-
hood illness as well as opportunistic
infections.
 HAART improves the child’s ability to
respond to infection and increases survival
with many living through adolescence and
beyond.
Standardised national ART regimens for
Infants and Children
First Line Regimen

All infants and children under 3 years ABC + 3TC + NVP

AZT+3TC+NVP

Children 3-9 years ABC + 3TC + EFV (preferred)

AZT+3TC+ EFV/NVP or
TDF+3TC+EFV/NVP

Adolescents (10-19 years, >35kg) Adult regimens TDF+3TC+EFV

Second-Line Regimens

ABC + 3TC + EFV (or NVP) AZT + 3TC + LPV/r

Monitoring: success

 Growth is geting better

 Reduced frequency of OI
 VL
Infant prophylaxis
Infant born to HIV-infected women

 daily AZT and NVP for the first 6

weeks of life, whether they are
breastfed or formula-fed.
 NVP and ZDV prophylaxis should
begin as soon as possible after
delivery.
 Good practice statement

 ART should be initiated urgently in all

pregnant and breastfeeding women,
even if they are identified late in
pregnancy or postpartum, because
the most effective way to prevent
mother-to-child HIV transmission is to
reduce maternal viral load.
HIV and Infant feeding
 Breastfeeding is normally the best way to feed an
infant.
 A woman infected with HIV ,however can transmit the
virus to her child during pregnancy(5-10%), labour
delivery (10-15%) or through breastfeeding(5-
20%).
 It is a health public responsibility to prevent HIV
infection to infant &young children.
 It is a health public responsibility to support optimal
breastfeeding ,to prevent mortality &illness due to
diarrhoea &respiratory infections.
To Breastfed or Not
 Breast Formula

The same population

HIV Mortality
MORTALITY THROUGH
HIV INFECTIONS THROUGH AVOIDANCE OF
BREASTFEEDING BREASTFEEDING
300,000 per annum 1,500,000 per annum
(UNAIDS) (UNICEF)
HIV and Infant feeding
The UN guidance stated that ‘when
replacement feeding is acceptable,
feasible, affordable, sustainable and
safe, avoidance of all breastfeeding
by HIV-infected mothers is
recommended. Otherwise , exclusive
breastfeeding is recommending
during the 1st months of life.”
Thank You