5. GAINS IN THE FIGHT AGAINST
HIV/AIDS
• The world has committed to ending the AIDS epidemic by 2030 - part of
the Sustainable Development Goals
• The extraordinary accomplishments of the last 15 years have inspired
global confidence that this target can be achieved.
• UNAIDS target of 90-90-90 by 2020
Challenges:
• Adolescent girls and young women aged 15–24 years are at high risk of
HIV infection - 20% of new HIV infections (2015)
• Gap between Adult and Paediatric treatment numbers
• Key populations are being left behind
6. ZAMBIA SITUATION
• Estimated number of Children Living with HIV: 89,000
(CI: 80,00-99,000; Spectrum 2015);
• Estimated number of CLHIV 95,000 (ZAMPHIA 2016)
• Estimated number of new infections 0 – 14, 8,900
(Spectrum 2015)
• Estimated HIV prevalence in children 1.3% (ZAMPHIA
2016)
• 6 weeks positivity rate 2.9% (PMTCT 2016)
• 12 months positivity rates 4.9% (PMTCT2016)
7. FACTORS CONTRIBUTING TO HIGH
HIV PREVALENCE IN CHILDREN
• High HIV prevalence (13.3%) in Zambia
• High prevalence of infection in women of childbearing age ( at 11.9%)
• HIV Prevalence among young women (15 – 24 yrs) 8% (ZDHS 2013/14)
• Low coverage of facility delivery 67% (ZDHS 2013/14)
• Lack of male partner involvement
• Late presentation at ANC
• Poor follow up testing during each trimester of pregnancy and
breastfeeding period
• Stigma
8. 94,352 84,917 76,425 46,060 30,365 68,783 20,267
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
CLHIV ZAMPHIA
Estimate
1st 90 National
Target
2nd 90 National
Target
Actual Q4 2017 Gap 3r 90 National
Target
estimated
REACHING 90-90-90
Coverage 60%
ZAMPHIA
Estimate: 44%
VLS among
Children < 15
9. IMPACT OF AIDS ON CHILDREN
• Increased infant and childhood mortality
• Increase in number of orphaned children
• Increased deprivations in various forms;
• Mental
• Psychological
• School dropouts
• Physical and sexual abuse
10. MODES OF HIV TRANSMISSION
IN CHILDREN
• 95% of infected infants
• Mother to child transmission (MTCT)
• 5% of infected infants
• Sexual transmission (adolescents/abuse)
• Unsterile injection procedures
• Scarification and other traditional practices
12. OBJECTIVES
At the end of this session the participant
should be able to describe:
• The classification of HIV
• The replication cycle of HIV
• The targets sites for antiretroviral drugs
13. CLASSIFICATION OF HIV
• HIV is a retrovirus with a long incubation
period from the Retroviridae family, genus
Lentivirus
• There are two types of HIV:
• HIV 1
o Found worldwide
o Main cause of the worldwide pandemic
14. CLASSIFICATION OF HIV CONT’D
• HIV 2
o Found in West Africa, Mozambique and
Angola (>1%).
o Causes a similar illness to HIV – 1
o Less efficiently transmissible
o Rarely causing vertical transmission
o Less aggressive with slower disease
progression
15. HIV-1 SUBTYPES
• HIV-1 has 3 major groups M, N and O.
• Group M has many subtypes: A-K,
• A: West Africa, E. Africa, Central Africa East
Europe & Middle East
• B: North America, Europe, Middle East, E. Asia,
Latin America
• C: Southern Africa, S. Asia, Ethiopia
• D: East Africa
16. HIV 1 SUB-TYPE C
Characteristics:
The HIV 1 found in Zambia is Group M sub-type C
• This is the most virulent (aggressive) subtype.
• It has a higher replication rate.
• Is associated with faster disease progression in adults.
• It is associated with higher MTCT rates than subtype A
• Increased risk of nevirapine resistance
17. STRUCTURE OF HIV
Has an outer double lipid
membrane (viral envelope)
The lipid membrane is
studded with the surface
glycoprotein gp120 and the
transmembrane glycoprotein
gp41.
These glycoprotein spikes
surround the cone-shaped
protein core (p24).
The protein core contains
genetic material (RNA) and
viral enzymes (protease and
reverse transcriptase)
18. ARV TARGET SITES: HIV LIFE CYCLE
Stages of the life
cycle
1. Binding, Fusion
and Entry
2. Reverse
Transcription
3. Integration &
Replication
4. Budding
5. Maturation
1
2
3
4
5
19. ARV TARGET SITES: PRIMARY
TARGET CELLS FOR HIV
• Cells with CD4 receptors or markers are
the primary target cells for HIV
• These receptors are found on:
• T-helper lymphocytes also known as CD4+
cells
• Macrophages which are found in:
oBrain
oKidneys and other organs
• Monocytes
20. MODE OF ACTION OF ANTIRETROVIRAL
DRUGS
• ARV drugs work at different stages of the
HIV replication cycle
• They interfere with the essential
enzymatic steps in the cycle thus
preventing the development of new
infectious HIV particles
• As a result further destruction of CD4
cells is prevented
21. ARV TARGET SITES
Point of action for
entry/ fusion
inhibitors
Point of action
for protease
inhibitors
Point of
action for
NRTIs,
NNRTIs
and NtRTIs
Point of
action for
Integrase
inhibitors
23. OBJECTIVES
• To describe the basic components of the
immune system.
• To describe the host immune response in
HIV infection.
• To describe the impact of HIV infection on
the host immune system
• To describe the disease progression in
children.
24. COMPONENTS OF THE IMMUNE
SYSTEM
• Non-specific immunity or
innate immunity
• Natural barriers to infection:
o Skin
o Nasal cilia
o Mucus
• Phagocytes:
o Neutrophils
o Macrophages
• Specific immune system
• Cellular immunity:
o T-lymphocytes
- CD4+
- CD8+
• Humoral immunity:
o B
-lymphocytes
• Antibodies
25. TYPES OF BLOOD CELLS
5 CONSOLIDATED TRAINING FOR MANAGEMENT AND PREVENTION OF HIV INFECTED ADULTS
CD8
CD4+
26. EFFECT OF HIV ON THE IMMUNE
SYSTEM
• HIV targets CD4+ T-lymphocytes and destroys them
• CD4+ T-lymphocytes coordinate immune function of:
• the non-specific immune cells
• the specific CD8+ and B-lymphocytes
• HIV causes profound immunodeficiency as a result of depletion of
CD4+ T-lymphocytes.
• This is the hallmark of HIV infection
• The CD4+ T-lymphocyte dysfunction is two fold:
• Reduction in numbers
• Impairment in function
27. IMMUNOLOGICAL DEFECTS CAUSED BY
HIV
Other defects caused by HIV on immune function
include:
• Lymphoid tissue destruction,
• CD8 cell dysfunction
• B Cell abnormalities
• Thymic dysfunction
• Autoimmune abnormalities
28. EFFECT OF HIV ON THE IMMUNE SYSTEM
• Reduction in the CD4 cell number and the
effects on their function reduces the
capacity of the body to fight infectious
diseases.
• Individuals with HIV infection are therefore
increasingly susceptible to many infections
especially at later stages of HIV infection
29. IMMUNOLOGIC PARAMETERS IN
CHILDREN
• Absolute CD4 count higher in healthy children than in adults.
• Absolute CD4 count varies with age
• Normal absolute CD4 counts slowly decline to adult levels by
age 5
• CD4 percentage does not change significantly with age.
• In children ≤5 yr CD4 percentage is the preferred immunological
parameter for monitoring disease progression.
32. NATURAL HISTORY: IMMUNOLOGIC
PARAMETERS
• CD4 count/percentage declines with
disease progression
• Rapid increases in risk of developing AIDS
or death as CD4+ cell percentage
decreases below 15–20%.
• Prognosis poorer in infants <12 months than
in older children
32
33. VIRAL LOAD (HIV RNA) IN CHILDREN
Definition: Viral load is the number of copies of HIV per ml
• Viral load in perinatally infected infants differs from
infected adults
In Infants:
• Viral load levels are low at birth.
• Increase to high levels > 100,000-millions of copies/ml by
2 months of age.
• Remain high throughout the first year of life.
• Decline slowly over the next few years to “set point”.
33
34. VIRAL LOAD (HIV RNA) IN CHILDREN
• This pattern is due to inability of the infant’s
immature immune system to contain viral
replication.
• There is also a greater number of HIV
susceptible cells.
• High RNA levels and low CD4 counts (<15%)
independently predictive of increased risk of
progression to AIDS and death.
34
36. HIV DISEASE PROGRESSION IN
CHILDREN WITHOUT TREATMENT-
CATEGORIES
Category 1 (25 – 30%): Rapid progressors
• Rapid disease progression; infants die within 1 year.
• Disease acquired in-utero or perinatally.
Category 2 (50 – 60%): Slow progressors
• Children who develop symptoms early in life.
• Deteriorate and die by 3 to 5 years.
Category 3 (5 – 25%): Long-term survivors
• Long-term survivors who live beyond 8 years of age.
37. DISEASE PROGRESSION OF HIV IN
CHILDREN
Factors related to disease progression are:
• Size of infecting viral dose which is dependent
on maternal disease status.
• The child’s immature immune system limits
ability to contain the virus.
• Low infant CD4+ cell counts/percentages.
• Infants with high peak viral load have more
rapid progression.
37
38. CLINICAL PRESENTATION OF RAPID
PROGRESSORS
Early Severe Form Characterised by
• LBW
• Early stunting
• Developmental delay
• Persistent oral candidiasis
• Recurrent/persistent diarrhoea
• Recurrent bacterial/fungal infections
• Hepato-splenomegaly
• Severe encephalopathy before 18 months
• High viral load at birth
• Rapidly decreasing CD4 counts
38
39. CLINICAL PRESENTATION OF SLOW
PROGRESSORS
• Opportunistic Infections after 2 - 10 years
• Growth stunting common
• Lymphoid interstitial pneumonitis (LIP)
• Parotitis
• Recurrent bacterial and fungal infections
• Skin problems
• AIDS related cancers
• Low viral loads at birth, stable CD4 counts for 2 - 10 years
then slow decline
39
40. CLINICAL PRESENTATION OF LONG-TERM
SURVIVORS
•Remain asymptomatic until 8-10 yrs
and thereafter, can present with
clinical symptoms suggestive of HIV
infection
41. TAKE HOME POINTS
• HIV 1 Group M sub-type C is predominant in
Zambia
• 95% of children are infected through MTCT
• High maternal viral load increases the risk of
infection to the child
• The child’s immature immune system limits ability to
contain the virus
• Infants with high peak viral load have more rapid
progression
• HIV progression is in 3 categories:
• Rapid
• Slow
• Long term
43. LEARNING OBJECTIVES
By the end of the module the participants will be able to:
• Describe the laboratory diagnosis of HIV in children
• Understand the current guidelines guiding the provision of EID and EPI
services.
• Know what should be done to Implement the guidelines
• Describe the common clinical presentation of HIV and AIDS in children
• Define the clinical staging of paediatric HIV disease using the WHO
staging system
• Outline a combined clinical and laboratory approach to diagnosis of HIV
in children
The Zambia Paediatric
•43
45. INTRODUCTION
• The identification and follow-up of infants born to women known to be
HIV infected is a necessary first step in infant diagnosis.
• It is recommended that provider initiated testing and counseling (PITC)
be offered to all children who come into contact with a healthcare worker.
46. INTRODUCTION (CONT’D)
• Maternal HIV antibodies are passively transferred to infant
across the placenta
• Maternal antibody wanes with time (over 6-24months)
• Antibody tests are positive at birth in MOST children born to
HIV infected women, including those children that are NOT
HIV infected
• Antibodies in an HIV infected child develop 6 to 12 weeks
from the time the child gets infected
• In an HIV positive child <24months the child COULD have
both its own and the maternal anti-bodies
47. INTRODUCTION (CONT’D)
• The definitive diagnosis of HIV infection in
children at any age requires diagnostic
testing that confirms the presence of HIV.
• Children ≥ 24 months: Antibody testing
(Shift to Test 1: Determine HIV 1/2; Test 2: SD Bioline HIV-1/2 )
• Children < 24 months: Virologic testing
The Zambia Paediatric ART Training Curriculum
47
48. TYPES OF LABORATORY TESTS
FOR HIV DIAGNOSIS
Serological tests (Antibody
tests)
Detect antibodies to HIV
proteins in blood and other
body fluids
• Determine
• SD Bioline
• Enzyme-linked
Immunosorbent
assay (ELISA)
Rapid Diagnostic Tests
o Blood
o Oral Fluid
• Western blot
Virologic tests
Detect HIV DNA or RNA by PCR
(polymerase
chain reaction). This test is also
called Nucleic Acid Test (NAT)
• P24 antigen
• Viral culture
We use DNA PCR, POC
testing in Zambia for early
infant diagnosis (EID)
The Zambia Paediatric ART Training Curriculum
48
49. TYPES OF LABORATORY
TESTS FOR HIV DIAGNOSIS
(CONT’D)
• New technologies: Nucleic Acid Testing (NAT) e.g. DNA
and RNA PCR
• The advantage of new NAT technologies is that they can
be done at the POC and offer same-day results
• NAT should be performed around the time of initiating
prophylaxis which would be at birth.
• Timely NAT minimizes the risk of development of
resistance due to extended prophylaxis in infected infants
and helps promote linkage to timely initiation of ART.
50. TIMING OF HIV TESTING SERVICES IN
CHILDREN LESS THAN 24 MONTHS
• HIV virologic testing should be concurrent with Expanded Program for
Immunization (EPI) visits and NAT should be done:
at birth/first week of life
at 6–8 weeks old and
at 6 months old
• Serologic tests should be done:
at 9 and 12 months old and If positive, follow up
with NAT. If negative, follow up with serologic test at
18 months old
at 18 months old and
at 24 months old
51. IMPLEMENTATION OF THE GUIDELINES ON HIV
SERVICE PROVISION AT THE EPI CLINIC:
• Each child's under five card should be checked to
identify the mothers HIV status and the child's
exposure to HIV with those coming for the 6
week’s visit treated as a priority.
• In the event the mothers status is either negative
or previously unknown, an HIV test should be
offered
• In the event an exposed child is identified based
on the mothers positive test, a DBS test should be
conducted on the child.
• The above services should be offered whenever
HIV rapid tests and DBS test kits available.
52. RISK OF TRANSMISSION OF HIV
30-40% HIV
exposed children
become infected
5% intrauterine
NAT +ve first week
of life
10-20% during
delivery
NAT +ve by age 6
weeks
10-20% via
breastfeeding
Do NAT at 6 wks
after stopping BF
52
53. ESTABLISHING AN HIV DIAGNOSIS IN
CHILDREN LESS THAN 24 MONTHS OF AGE
• Initial virological testing should occur at Birth. Test at first contact at
under five clinic visit, if missed at birth and at age 6 weeks.
• By the age of 4 weeks, virological testing approaches 98% sensitivity. Testing at 6
weeks of age will therefore identify the vast majority of infants infected in utero
and intrapartum
• Delaying testing beyond this time delays diagnosis and puts HIV-infected infants
at risk for disease progression and death
• Testing earlier than 4-6 weeks of age may be less sensitive for cases of
peripartum transmission
• Positive test results should be fast-tracked to the mother-baby pair as
soon as possible to enable prompt initiation of ART
54. WHEN TO DO NAT FOR HIV DIAGNOSIS IN
INFANTS
• Never breastfed
o a single negative NAT at > 6 weeks of age
rules out infection
oFollow up with antibody test at 24 months
54
55. PRESUMPTIVE CLINICAL DIAGNOSIS
OF HIV INFECTION
• Recommended in Infants and children < 24 months where there is no
access to virological testing, or reporting of results is delayed, but the
child has symptoms suggestive of HIV infection
• To permit decision making regarding initiation of potentially life saving
ART.
• Not indicated in children 24 months and above, because in this age
group it is recommended to use adult national protocols to confirm
HIV infection - antibody testing.
The Zambia Paediatric ART Training Curriculum
55
56. CRITERIA FOR PRESUMPTIVE DIAGNOSIS OF SEVERE
HIV DISEASE IN INFANTS AND CHILDREN <18 MONTHS
OF AGE
Presumptive diagnosis of severe HIV disease should be made if:
1. The child is confirmed as being HIV antibody-positive
2. a. The infant is symptomatic with two or more of the following:
• oral thrush
• severe pneumonia
• severe sepsis
b. A diagnosis of any AIDS-indicator condition(s) can be made
Confirm the diagnosis of HIV infection as soon as possible using age-
appropriate tests
* It is unclear how often CD4 is lowered in the above conditions in HIV-uninfected
children.
57. CRITERIA FOR PRESUMPTIVE DIAGNOSIS OF SEVERE
HIV DISEASE IN INFANTS AND CHILDREN < 24 MONTHS
OF AGE (CONT’D)
Other findings that support the diagnosis of severe HIV
disease in an HIV-seropositive infant include:
• Recent HIV-related maternal death or advanced HIV disease
• Child’s CD4% <25%*
Confirm the diagnosis of HIV infection as soon as possible
using age-appropriate tests
* It is unclear how often CD4 is lowered in the above conditions in HIV-uninfected
children.
58. PRESUMPTIVE SEVERE HIV
DISEASE
(NO VIROLOGY AVAILABLE, NEEDS HIV EXPERIENCED CONSULT)
Age < 18 mo
Symptomatic > 2 features
Oral Thrush Severe Pneumonia* Severe Sepsis*
AIDS indicator condition
diagnosed
The Zambia Paediatric ART Training Curriculum
58
Antibody Test (Rapid or ELISA) +ve
* Recent HIV related maternal death or advanced disease in mother or infant’s %CD4
<25% supports diagnosis. Confirm with a definitive test appropriate for age as soon as
possible.
59. DIAGNOSING HIV INFECTION WHERE
MOTHER OR INFANT HAS RECEIVED
ARV DRUGS FOR PMTCT
• Testing algorithms are the same for all infants, regardless of maternal
/ infant ARV exposure history
61. APPROACH TO CLINICAL DIAGNOSIS
• A rational approach requires high index of suspicion with
knowledge in skilled diagnosis and management of HIV
infection in children
• Paediatric HIV presents with conditions that are also found
in HIV- children
• These conditions are broken down as:
• Common in both HIV+ & HIV- children
• Common in HIV+ but less common in HIV- children
• Specific to HIV infection
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61
63. THE IMPORTANCE OF STAGING
• Provides a guide to prognosis and interventions needed at
the different stages
• Co-trimoxazole Prophylactic Treatment (CPT) in children
> 5 years
• When to ……
oSwitch ART
oStop ART
• Provides guidance in monitoring response to therapy
(treatment failure or improvement).
The Zambia Paediatric ART Training Curriculum
63
64. METHODS OF STAGING
• Clinical staging:
• WHO staging
• Immunological classification
• CD4 %
• CD4+ count
65. WHO CLASSIFICATION OF HIV-
ASSOCIATED CLINICAL DISEASE
CLASSIFICATION WHO STAGE
Asymptomatic 1
Mild 2
Advanced 3
Severe 4
65
WHO Staging is the classification of the severity of
patients’ clinical symptoms into Stages 1-4
66. WHO CLINICAL STAGING FOR INFANTS AND
CHILDREN
The Zambia Paediatric ART Training Curriculum
66
Clinical Stage 1
• Asymptomatic
• Persistent Generalised Lymphadenopathy (PGL)
67. WHO CLINICAL STAGING FOR
INFANTS AND CHILDREN (CONT’D)
• Unexplained persistent
hepatosplenomegaly
• Recurrent or chronic upper
respiratory infections (otitis
media, otorrhoea, sinusitis,
tonsillitis)
• Herpes zoster
• Lineal gingival erythema
• Extensive wart virus infection
• Recurrent oral ulcerations
• Unexplained persistent parotid
enlargement
• Papular pruritic eruptions (itchy
rash)
• Fungal nail infections
• Extensive molluscum
contagiosum
The Zambia Paediatric ART Training Curriculum
67
Clinical stage 2
68. WHO CLINICAL STAGING FOR INFANTS
AND CHILDREN
• Unexplained moderate
malnutrition not adequately
responding to standard therapy (-
2 SD)
• Unexplained persistent diarrhoea
(14 days or more )
• Unexplained persistent fever
(above 37.5 intermittent or
constant, for longer than one
month)
• Persistent oral candidiasis (after
first 6 weeks of life)
• Oral hairy leukoplakia
• Acute necrotising ulcerative
gingivitis/periodontitis
• Lymph node TB
• Pulmonary TB
• Severe recurrent presumed
bacterial pneumonia
• Symptomatic lymphoid interstitial
pneumonitis (LIP)
• Chronic HIV-associated lung
disease including bronchiectasis
• Unexplained anaemia (<8g/dl)
• neutropenia (<0.5 x 109 /l
• chronic thrombocytopenia (<50 x 109 /l)
The Zambia Paediatric ART Training Curriculum
68
Clinical Stage 3
69. WHO CLINICAL STAGING FOR INFANTS
AND CHILDREN (CONT’D)
• Unexplained severe wasting, stunting or
severe malnutrition not responding to
standard therapy
• Pneumocystis jirovecii pneumonia
• Recurrent severe bacterial infections
(e.g. empyema, pyomyositis, bone or
joint infection, meningitis, but excluding
pneumonia)
• Chronic herpes simplex infection;
(orolabial or cutaneous of more than
one month duration or visceral at any
site)
• Extrapulmonary TB
• Kaposi sarcoma
• Oesophageal candidiasis (or Candida of
trachea, bronchi or lungs)
• CNS toxoplasmosis (outside the
neonatal period)
• HIV encephalopathy
The Zambia Paediatric ART Training Curriculum
69
• CMV infection; retinitis or infection
affecting another organ, with onset
at age more than one month.
• Extrapulmonary cryptococcosis
including meningitis
• Disseminated endemic mycosis
(extrapulmonary histoplasmosis,
coccidiomycosis, penicilliosis)
• Chronic Cryptosporidiosis with
diarrhoea
• Chronic Isosporiasis
• Disseminated non-tuberculous
mycobacteria infection
• Cerebral or B cell non-Hodgkin
lymphoma
• Progressive multifocal
leukoencephalopathy
• HIV-associated cardiomyopathy or
nephropathy
Clinical Stage 4
70. IMMUNOLOGICAL THRESHOLDS
Differences in CD4 counts between adults and
children
• Absolute CD4 count varies with age
• Absolute CD4 count is higher in healthy children than
in adults.
• CD4 percentage more constant/reliable indicators of
immunosuppression for children < 5 years
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70
71. APPROACH TO CARE FOR HIV EXPOSED
AND INFECTED INFANTS AND CHILDREN
73. Package for Comprehensive Paediatric Care
1. Confirm HIV status as early as possible.
2. Monitor the child’s growth and development.
3. Ensure that immunisations are started and completed according to the
recommended schedule.
4. Provide prophylaxis for opportunistic infections.
5. Offer ARV prophylaxis according to national PMTCT guidelines
6. Actively look for and treat infections early.
7. Counsel the mother and family on:
a. optimal infant feeding to minimise MTCT, prevent malnutrition and
promote growth and development.
b. good personal and food hygiene to prevent common infections, and
encourage them to seek prompt treatment for any infections or other
health related problems.
c. when the child should be followed-up according to national guidelines.
8. Conduct disease staging for the infected child.
9. Screen for TB if eligible start IPT
10.Offer ART for the infected child
11.Provide psychosocial support for the infected child and mother/care-giver
12.Refer the infected child to higher levels of specialised care if necessary, or to
other social or community based support programmes.
75. APPROACH TO CARE FOR AN HIV
EXPOSED INFANT
Care for the HIV exposed infant
centres around 4 goals:
•Preventing postnatal HIV transmission
•Identifying the HIV infected child
•Preventing opportunistic infections
•Maximizing family health and wellbeing
*Note: approach to care of HIV-exposed
child is applicable to HIV- infected child
76. APPROACH TO AN HIV
EXPOSED INFANT CONT’D
Health systems must:
•Actively identify all exposed children
•Provide appropriate interventions to avert
infections
•Identify Infections early
•Provide treatment early
•Avert complications of HIV
77. PREVENTING POSTNATAL HIV
TRANSMISSION
•Give AZT+ 3TC+ NVP from birth to infants born to HIV positive
mothers
•Infants whose mothers are considered virologically suppressed “Low
Risk”:
•Give AZT+3TC+ NVP for 6 weeks
•Infants whose mothers not considered virologically suppressed: “High
Risk”
• Give AZT+3TC + NVP for 12 weeks
78. PREVENTING POSTNATAL HIV TRANSMISSION
High Risk:
1. Born to women with established HIV infection not on
ART
2. Born to women with established HIV infection and
having received less than 12 weeks of ART at the
time of delivery
3. Born to women with established HIV infection with
viral load >1000 copies/mL within the four weeks
before delivery, if viral load measurement available
Low Risk:
Infants whose mothers are known positive and had at least 12 weeks of
ART prior to delivery
79. CONFIRM DIAGNOSIS
• It is important to confirm diagnosis as soon
as possible using age appropriate tests so
that appropriate interventions can be put in
place
80. MONITOR GROWTH AND DEVELOPMENT
• Growth failure is greater in HIV
infected than in uninfected
children as a result of:
• Low birth weight (prematurity, small
for age)
• HIV infection
• Other underlying disease i.e. TB
• Inadequate macro/micronutrient
intake
• It is important to closely monitor
growth and development in
perinatally exposed children
81. PREVENTION OF INFECTIONS
FOR HEIS
•All exposed infants should receive routine
immunizations like all other children
•All exposed infants should be given CTX
prophylaxis starting at 6 weeks of life until
they are confirmed HIV negative and no
longer breastfeeding
82. PREVENTION OF INFECTIONS FOR HEIS
CONT’D
• Administer childhood immunizations as
recommended by the National EPI program with the
following modification:
• When considering BCG at a later age,
revaccination or no scar, or missed earlier BCG:
do not give to children with symptomatic HIV
infection
• BCG adenitis (IRIS) can occur after vaccine
• Give live measles vaccine even when HIV
symptoms are present
83. PROPHYLAXIS AGAINST
OPPORTUNISTIC INFECTIONS
Definitions:
• Prophylaxis – intervention to prevent a
disease from occurring
• Primary prophylaxis – used to prevent occurrence
in someone who has never had the disease
• Secondary prophylaxis – used to prevent
recurrence in someone who has already had the
disease
84. PROPHYLAXIS AGAINST OI:
PNEUMOCYSTIS
• PCP is a significant cause of morbidity with a
fatality rate of 40-90% and can be prevented by
giving CTX
• Start CTX in all perinatally exposed infants from
age of 6 weeks and continue until HIV infection
has been ruled out using age-appropriate tests
and child is no longer at risk of acquiring HIV
through breastfeeding
85. PROPHYLAXIS AGAINST OI:
PNEUMOCYSTIS
• Generally well tolerated –side effects may be:
Rash
Fever
Bone marrow suppression
If allergic to CTX give Dapsone -
2mg/kg/day (maximum 100mg/day)
86. PROPHYLAXIS AGAINST OI: TB
• All HIV-infected infants and exposed children
should be evaluated for contact with a TB source
case at every visit to a health-care facility.
• Evaluate for TB all those presenting with:
• poor weight gain
• current cough of any duration
• Fever
• Those with active TB disease should be treated
88. PREVENTING TB
• INH prophylaxis against TB should be given:
• HIV infected children (>12 Months)
• Have no TB contact
• If no active TB on symptom based screening
• HIV infected children ( < = 12 months)
• Have TB contact
• Evaluation for TB ( using investigation) shows no TB
• All children living with HIV who have successfully
completed TB treatment should receive INH for an
additional 6 months
