EML

B20–24

Description
Diagnostic criteria

Comprehensive guidelines are available for ART and the care of children with HIV infection in the National consolidated guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults

DESCRIPTION

Human Immunodeficiency Virus (HIV) is a retrovirus infecting immune cells, especially CD4 T lymphocytes. In advanced HIV disease the body loses its ability to fight infections and this stage is characterised by severe damage to organs, opportunistic infections, malignancies and very low CD4 counts.

In infants most infections are transmitted from mother to child, while in adolescents and adults, sexual transmission is the usual route for new infections. Infants born to HIV infected mothers may be:

HIV infected,
“HIV exposed”:
- At risk of being/becoming HIV infected,
- HIV uninfected (no further exposure e.g. not breastfed/ breast-feeding discontinued).

For the purposed of the ART guidelines:

Children and Adolescents <15yrs: follow the Paediatric antiretroviral therapy (ART) Guidelines.
Late Adolescence (15yrs – 19yrs): follow the Adult ART Guidelines.

DIAGNOSTIC CRITERIA

Suspect HIV infection in the following situations:

Mother HIV infected.
Sexual abuse.
Adolescents having unprotected sexual encounters.
Parents with tuberculosis or HIV.
Any child with tuberculosis.
Clinical features of symptomatic HIV infection.
Unexplained severe dermatoses.
Persistent/recurrent ear discharge.
Severe progressive pneumonia especially in the first 6 months of life.
Confirmed Pneumocystis jiroveci (carinii) and/or Cytomegalovirus pneumonia.
Low weight for age, unsatisfactory weight gain or stunting.
Persistent or recurrent diarrhoea in the past three months.
Enlarged lymph nodes in two or more of the following sites: neck, axilla or groin.
Oral thrush outside the neonatal period.
Parotid gland swelling.
Liver enlargement.
Spleen enlargement.
Recurrent infections including pneumonia, ear infections, sinusitis, osteitis and arthritis.
Digital clubbing.
Progressive developmental delay.
The combination of multiple problems.

All infants/children accessing care should have their HIV exposure status (recent maternal HIV status) and/or HIV status determined.

Women who previously tested HIV positive should not be re-tested.
Where mothers tested negative in pregnancy, maternal HIV status should be determined 3 monthly whilst breastfeeding.

Confirmation of HIV infection

Children < 18 months of age:

Birth: Do HIV PCR at birth in ALL HIV exposed infants
10 Weeks: Do HIV PCR at 10 weeks of age in all HIV exposed infants.
18 weeks: Do HIV PCR at 18 weeks in HIV exposed infants receiving 12 weeks of infant prophylaxis.
Post cessation of breastfeeding: If the child is breastfed and the birth and 10-week HIV PCR are negative, repeat testing 6 weeks after complete cessation of breastfeeding. (If the child is 18 months or older, do an ELISA or rapid test).
Symptomatic child/infant: If at any time the child has evidence suggesting HIV infection, even if the child has had a previous negative PCR test, the child should be tested for HIV infection.
If HIV PCR is positive at any time-point:
- Confirm with a repeat HIV PCR test.
- Initiate treatment while awaiting the second HIV PCR test result.

In children ≥ 18 months of age:

Do HIV rapid/ELISA test.
If 1ˢᵗ test is positive, confirm the result with a second test using a kit of a different manufacturer, and preferably on a different blood specimen.

Note:

Rapid tests may be less reliable in children with advanced disease. If clinical findings suggest HIV infection but the rapid test is negative, send a further specimen of blood to the laboratory for formal ELISA testing. If test results are still equivocal do an HIV PCR test.

Note:

A child cannot be confirmed as HIV negative until at least 6 weeks after birth and 6 weeks after other potential HIV exposure (including cessation of breastfeeding). Also, exposure to ART through prophylaxis (NVP) or maternal ART may delay the diagnosis of HIV even further.
Children with discordant or indeterminate HIV test results must be discussed with an expert.

Adapted WHO clinical staging of HIV and AIDS for infants and children

For persons aged under 15 years with confirmed laboratory evidence of HIV infection

Clinical Stage 1

asymptomatic
persistent generalised lymphadenopathy (PGL)

Clinical Stage 2

unexplained persistent weight loss
hepatosplenomegaly
papular pruritic eruptions
extensive human papilloma virus infection
extensive molluscum contagiosum
fungal nail infections
recurrent oral ulcerations
lineal gingival erythema (LGE)
unexplained persistent parotid enlargement
herpes zoster
recurrent or chronic RTIs, i.e.
- otitis media
- otorrhoea
- sinusitis

Clinical Stage 3

moderate unexplained malnutrition (not adequately responding to standard therapy)
unexplained persistent diarrhoea (14 days or more)
unexplained persistent fever (above 37.5°C, intermittent or constant, for longer than one month)
persistent oral candidiasis (after first 6-8 weeks of life)
oral hairy leukoplakia
acute necrotising ulcerative gingivitis/periodontitis
lymph node TB
pulmonary TB
severe recurrent bacterial pneumonia
chronic HIV-associated lung disease including bronchiectasis
symptomatic lymphoid interstitial pneumonitis (LIP)
unexplained anaemia (< 8 g/dL), and or neutropaenia (< 500/mm³) and/or thrombocytopenia (<50000/mm³ ) for more than one month

Clinical Stage 4