- Description
- Diagnosis in children
- When and how to test in children
- Adapted WHO clinical staging of HIV and AIDS for infants and children
DESCRIPTION
HIV is a retrovirus affecting immune cells, especially CD4 T-lymphocytes. In advanced HIV disease the body loses its ability to fight infections and this is characterised by organ damage, opportunistic infections, malignancies and very low CD4 counts.
In infants and children, most infection is transmitted from mother to child.
In adolescents and adults sexual spread is the usual cause.
Infants born of HIV-infected mothers may be:
- HIV-infected,
- HIV-exposed uninfected, or
- HIV-exposed, unknown infection status (at risk of becoming HIV-infected).
To exclude HIV infection in HIV-exposed infants/children, an HIV PCR test (if ≥ 18 months of age: an HIV rapid or ELISA test) performed ≥ 6 weeks following cessation of breastfeeding should be negative and the infant should be ≥ 6 weeks of age.
If an HIV test result is indeterminate, or if the positive HIV status of a child already initiated on ART is disputed, consult with the closest referral centre for additional HIV testing.
For the purpose of the ART guidelines:
- Children < 10 years of age: follow the paediatric antiretroviral therapy (ART) guidelines.
- Adolescents (10–19 years of age): follow the adult ART guidelines.
DIAGNOSIS IN CHILDREN
Testing must be done with counselling of parent/legal guardian/primary caregiver and, where appropriate, the child. The appropriate consent/assent should be obtained.
WHEN AND HOW TO TEST IN CHILDREN
Which Test
Child < 18 months of age
HIV PCR test: Always confirm with 2nd HIV PCR test if the first test is positive. This should not delay ART initiation, which should be done with the first positive result.
Child ≥ 18 months of age
HIV rapid or ELISA test: If 1st rapid test is positive, confirm the result with:
- A HIV PCR test if infant between 18-24 months
- A second rapid test using a kit of a different manufacturer, and preferably on a different blood specimen if infant is > 24 months.
- HIV 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 HIV ELISA testing. If HIV status is still unclear, do an HIV PCR test
When to test HIV-exposed children
(See HIV-exposed infant).
- Birth (HIV PCR).
- Repeat at 10-week visit (HIV PCR).
- Repeat at 6-month visit (HIV PCR)
- At any time when clinical signs indicate possible HIV infection.
- 6 weeks after breastfeeding has stopped.
- Do Universal HIV rapid/ELISA test at 18 months (HIV rapid test for ALL children regardless of HIV exposure, except in those who previously tested HIV positive and are on ART).
Also perform PCR testing AT BIRTH on:
- Infants born to mothers who were on TB treatment for active TB during their pregnancy.
- Infants with congenital pneumonia.
- Infants with clinical features suggestive of HIV infection.
- High risk infants requiring urgent HIV diagnosis.
If the HIV PCR result is not available at discharge, the mother should return within 1 week for the result.
- If the HIV PCR result is negative, repeat at 10 weeks:
- If HIV PCR result at 10-18 weeks, or an age-appropriate test 6 weeks after breastfeeding has stopped, is still negative, perform HIV rapid test at 18 months of age.
- If positive at any time, start infant ART.
Note:
- Negative tests do not exclude infection until 10-18 weeks after birth and 6 weeks after exposure to other risk of HIV infection (including cessation of breastfeeding).
- Children with discordant HIV test results must be discussed with an expert.
- Do not repeat HIV rapid/ELISA tests in children on established ART.
Also perform age-appropriate testing at any time on:
- Parental request to test the child.
- HIV-infected father or sibling.
- Death of mother, father or sibling.
- Mother’s HIV status and her whereabouts are unknown.
- Clinical features suggest HIV infection.
- Infant has acute severe illness.
- Breastfed infant of newly diagnosed HIV-infected breastfeeding mother.
- IMCI classification of SUSPECTED SYMPTOMATIC HIV INFECTION or POSSIBLE HIV INFECTION.
- TB diagnosis, history of TB treatment or new TB exposure.
- Suspicion of sexual assault.
- Wet-nursed/breastfed infant fed by a woman of unknown or HIV-infected status (and repeat age-appropriate test 6 weeks later).
- Children considered for adoption or fostering.
Newborn child whose mother is of unknown HIV status, has died or is not available due to abandonment or other reasons:
- Perform both infant HIV PCR and HIV rapid tests. Initiate PMTCT as for high risk exposure.
- Perform age-appropriate HIV testing in an HIV-uninfected child at any other time if clinical symptoms suggest HIV infection.
Clinical indications that HIV infection should be considered in a child are:
- If the mother is HIV-infected or if the mother’s HIV status is not known.
- If the child was HIV PCR-negative but was subsequently breastfed.
- If a child has any of the following features:
- Rapid breathing or chest indrawing now (“Pneumonia”).
- Persistent diarrhoea now or in the past.
- Ear discharge now or in the past.
- Low weight for age/height or unsatisfactory weight gain.
- ≥ 2 enlarged glands of: neck, axilla or groin.
- Oral thrush.
- Parotid enlargement.
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 retested.
Where mothers tested negative in pregnancy, maternal HIV status should be determined 3-monthly whilst breastfeeding.
WHO clinical staging of HIV and AIDs for infants and children
https://www.who.int/hiv/pub/guidelines/arv2013/annexes/WHO_CG_annex_1.pdf