7. Febrile Illnesses

7.6. HIV

Impact of Pediatric HIV

In 2013, 3.2 million children were estimated to be living with HIV, 90% of them in sub-Saharan Africa.1 Despite substantial progress in preventing mother to child transmission, 240,000 children less than 15 years of age are HIV infected every year.1 Only 1 out of 4 children living with HIV have access to life-saving anti-retroviral treatment (ART). Amongst children born with HIV, 50% will die by 2 years of age without treatment.2 Keys to caring for children with HIV include 1) recognizing children and risk for HIV infection and diagnosing them early, 2) treating all children under 5 years with HIV and all those eligible for treatment >5 years, 3) managing co-infections and opportunistic infections, and 4) ensuring excellent adherence by avoiding missed doses and treatment interruptions.

Recognition and Diagnosis of HIV

Key concepts:

  • Child is under 18 months: HIV infection is confirmed if virological test (PCR) is positive
  • Child is over 18 months: HIV infection is confirmed if two diff erent serological (antibody) tests are positive

Recognition of children at risk for HIV infection is key to identifying these children early and initiating life-saving therapy rapidly. The majority of children are infected through mother to child transmission. Therefore, diagnosing HIV in women of childbearing age is critical to not only caring for women with HIV but preventing new pediatric infections. ALL pregnant women should undergo voluntary HIV testing and receive prophylaxis and treatment as recommended by in-country guidelines. Currently, WHO recommends combination anti-retroviral therapy for all pregnant and breastfeeding women in areas with high HIV burden and suggests ART be continued throughout life. \( ^{3} \)

Children born to women with known HIV infection or unknown status must be prioritized for HIV testing. Children under 18 months of age may carry maternal HIV antibodies in their blood indicating HIV exposure but not confirming HIV infection. Therefore, regular HIV antibody testing (such as rapid tests) may be used to confirm HIV exposure in those <18 months of age and HIV infection in those >18 months of age. If a child is HIV exposed (positive antibody test or mother with known HIV infection) virological testing using polymerase chain reaction (PCR) is required through a specialized laboratory.

Treatment of HIV

Key concepts:

  • All children less than 5 years who are HIV infected should be initiated on ART irrespective of CD4 count or clinical stage.
  • If a child has any general danger sign or a severe classification, he or she needs URGENT REFERRAL. ART initiation is not urgent, and the child should be stabilized first.
  • Early infant diagnosis in high prevalence areas must be a priority
  • PMTCT should be reinforced

WHO eligibility criteria for ART initiation in children\( ^{3} \)

  • ART should be initiated in all children infected with HIV below five years of age, regardless of WHO clinical stage or CD4 cell count
  • ART should be initiated in all HIV infected children five years of age and older with CD4 cell count ≤500 cells/mm3 , regardless of WHO clinical stage
  • ART should be initiated in all children infected with HIV with severe or advanced symptomatic disease (WHO clinical stage 3 or 4) regardless of age and CD4 cell count
  • ART should be initiated in any child younger than 18 months of age who has been given a presumptive clinical diagnosis of HIV infection

Below are IMCI simplified approach for starting ART in children. Whenever possible, also refer to in-country guidelines. \( ^{4} \)

Steps in initiating ART for children

  1. Step 1 DECIDE IF THE CHILD HAS CONFIRMED HIV INFECTION
    • If HIV is confirmed (see abo ve) and child is in stable condition, go to STEP 2.
    • If HIV is confirmed (see abo ve) and child is in stable condition, go to STEP 2.
  2. Step 2 DECIDE IF CAREGIVER IS ABLE TO GIVE ART
    • Check that the caregiver is willing and able to give ART. Support caregiver to disclose child’s HIV status to another adult who can assist in giving ART.
    • Caregiver able to give ART: GO TO STEP 3
    • Caregiver not able: classify as CONFIRMED HIV INFECTION but NOT ON ART. Counsel and support the caregiver. Follow-up regularly. Move to the step 3 once the caregiver is willing and able to give ART
  3. Step 3 DECIDE IF ART CAN BE INITIATED IN YOUR FACILITY
    • If child is less than 3 kg or has TB, Refer for ART initiation.
    • If child weighs 3 kg or more and does not have TB, GO TO STEP 4
  4. Step 4 RECORD BASELINE INFORMATION ON THE CHILD’S HIV TREATMENT CARD
    • Record the following information:
    • Weight and height
    • Pallor if present
    • Feeding problem if present
    • Laboratory results (if available): Hb, viral load, CD4 count and percentage. Send for any laboratory tests that are required. Do not wait for results.
    • GO TO STEP 5
  5. Step 5 START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS
    • Child up to 3 years: ABC or AZT +3TC+ LPV/R or recommended firstline regimen
    • Child 3 years or older: ABC + 3TC + EFV, or recommended first-line r egimen.
    • Give co-trimoxazole prophylaxis
    • Give other routine treatments, including Vitamin A and immunizations
    • Follow-up regularly as per national guidelines

  1. Step 1 Decide if the Child has Confirmed HIV Infection
  2. Step 2 Decide if Caregiver is able to Give ART
  3. Step 3 Decide if ART can be Initiated in YourFacility/Location

Treatment of Co-Infections and Opportunistic Infections

Children exposed to and living with HIV are generally at higher risk of the common childhood illnesses including diarrhea, pneumonia, malnutrition, and TB. Early recognition and treatment as per IMCI and National guidelines are critical. Prevention is equally important—all HIV exposed and infected children should receive routine immunizations on schedule including live vaccines unless they are severely immunosuppressed. Additionally, in most developing country settings, prophylaxis of PCP is recommended for all exposed and infected children using co-trimaxozole. More recently, prophylaxis for TB has been recommended in countries with high TB burden using isoniazid. Refer to in-country guidelines.

HIV Management in Disaster or Displacement Scenarios

Initial management of HIV-infected children should include documentation of last CD4 and viral load if known and ART regimen if child taking ART. Children who had their antiretroviral therapy and/or prophylaxis or treatment for OIs interrupted by disaster-related displacement should restart these medications as soon as possible. There is no need to start antiretroviral therapy immediately in those HIV-infected patients who were not receiving antiretroviral medications before the disaster.\( ^{5} \)\( ^{,} \)\( ^{6} \)

It is important to determine the current antiretroviral drugs the child is taking. If this is unknown and records are unavailable, consider consultation with an HIV specialist or starting first line treatment as recommended by WHO or national guidelines. All antiretroviral drugs should be restarted at the same time except if the child was receiving nevirapine as part of a regimen and has not taken nevirapine for more than 7 days. If this occurs, nevirapine should be restarted with a 2-week “lead-in” period, giving half the daily dose once daily for 14 days and then standard twice-daily dosing. Of note, some children may be taking liquid formulations, some of which may need to be refrigerated. Pay special attention to ensure proper dosing based on weight-based dosing recommendations.

Treatment of acute infections

HIV-exposed and infected children may be more vulnerable to the usual acute infections seen in disasters such as diarrhea, acute respiratory infections, measles etc. Treatment for acute illnesses remains the same in children with and without HIV.

Prevention of OIs

Prevention of opportunistic infections is very important amongst HIV-infected and exposed children. Routine prophylaxis for OIs with co-trimoxazole as recommended above should be maintained if at all possible following a disaster. Of note, cotrimoxazole is commonly used for routine treatment of ARI’s which may lead to drug shortages and difficulty maintaining drug stock for both acute treatment of illness and prophylaxis. Additional precautions to prevent TB should be emphasized for individuals with HIV, especially children under 5.

Immunizations

HIV-exposed and infected children should receive all routine immunizations on schedule including live vaccines unless they have symptoms of severe immunosuppression or are severely ill. HIV-infected children are particularly susceptible to complications of measles and receive measles vaccines during should disaster situations or displacement conditions unless severely immunosuppressed.