2. A 14 year old girl brought with c/o
P/C: cough – 2 weeks
fever – 2weeks
white patches in the mouth – 2 weeks
HOPI:
Cough :
insidious onset
productive - yellow colored sputum,
blood stained +
more in recumbent posture
Fever : intermittent high grade
no chills or rigors
Oral lesions : white in color
not associated with pain
gradually increasing in nature
3. PAST HISTORY :
Scaly skin lesions over both legs : 3 years
Recurrent respiratory infections : 1 ½ years.
Similar oral lesions : 1 year.
Loose mucoid stools , on & off : 1 year
P/H/O febrile seizures was on regular AED`S till 3 years
of age.
4. BIRTH HISTORY : uneventful
DIET HISTORY :Loss of appetite - 1 year
IMMUNISATION HISTORY : Immunised .
FAMILY HISTORY :
5. O/E : Afebrile, cachexic, Wt: 35 kg Grade III PEM
Pallor + Ht : 142cm GradeII stunting
Generalised lymphadenopathy +
Grade III clubbing +
Oral thrush
Dystrophic nail changes,
Hypopigmented macules over forehead
Scaly plaques over both legs
S/E: CVS : s1 s2 normal, No murmur
RS : B/L coarse crepitations,
bronchial breathing right infrascapular region
P/A : soft, no hepatosplenomegaly
CNS: No focal neurological deficits
11. DISCUSSION
HIV MODES OF TRASMISSION :
Unprotected sex with an infected person
Blood – to- blood contact
Pregnancy
Childbirth
Breast feeding by HIV positive mothers
12. Babies can acquire HIV infection during:
Gestation
Labor & delivery
Breastfeeding
13. CLINICAL STAGING OF HIV INFECTION
WHO CLASSIFICATION :
Stage 1
Asymptomatic
Persistent generalized lymphadenopathy
15. Stage 3
Unexplained moderate malnutrition not adequately
responding to standard therapy
Unexplained persistent diarrhoea (14 days or more )
Unexplained persistent fever (> 37.5oC intermittent or
constant, > one month)
Persistent oral candidiasis (after first 6-8 weeks of life)
Oral hairy leukoplakia
Pulmonary TB
Severe recurrent bacterial pneumonia
Symptomatic lymphoid interstitial pneumonitis
Chronic HIV-associated lung disease including
bronchiectasis
Unexplained anemia (<8g/dl )
Neutropenia (<0.5X 109/L3) or
Chronic thrombocytopenia (<50 x 109/L3)
16. Stage 4
Unexplained severe wasting, stunting or severe malnutrition
not responding to standard therapy
Pneumocystis 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’s duration or visceral at any site)
Extrapulmonary TB
Kaposi sarcoma
Oesophageal candidiasis (or candidiasis of trachea, bronchi or
lungs)
Central nervous system toxoplasmosis (after one month of life)
17. Contd..
HIV encephalopathy
Cytomegalovirus infection: meningitis)
Disseminated endemic mycosis (extrapulmonary
histoplasmosis renitis or CMV infection affecting another
organ, with onset at age over 1 month.
Extrapulmonary cryptococcosis
(including, coccidiomycosis)
cryptosporidiosis
Chronic isosporiasis
Disseminated non-tuberculous mycobacteria infection
Cerebral or B cell non-Hodgkin lymphoma
Progressive multifocal leukoencephalopathy
Symptomatic HIV-associated nephropathy or HIV-
associated cardiomyopathy
18. Classification of HIV associated
immunodeficiency - CD 4 COUNTS
Classification of ≤ 11 12 -35 36 -59 ≥5 years
hiv assoc. (%)months months(%) months (cells/mm3)
immunodeficiency (%)
Not significant >35 >30 >25 >500
Mild 30 - 35 25 - 30 20 - 25 350 - 499
Advanced 25 - 29 20 - 24 15 - 19 200 - 349
Severe <25 <20 <15 <200 or <15%
19. HIV is difficult to diagnose in infants
Routine HIV antibody tests cannot be used
Specialised virological tests are necessary
Clinical diagnosis requires clinical and close follow up
of infant
20. Common diagnostic tests
Antibody tests:
HIV rapid test
ELISA
Western blot
These tests detect antibodies that are produced during
immune response to HIV.
False negative tests may occur when infected individuals do
not produce detectable antibodies, such as during
early acute phase of infection (window period)
Very late stages of infection ( immune suppression)
21. All infants born to HIV+ mothers will test HIV
antibody positive in the first several months of life
Maternal HIV antibody (IgG) is transferred across the
placenta during pregnancy
A positive HIV antibody test in infants <18 months of
age will not distinguish whether or not the infant is
HIV-infected; rather it shows that:
Mother is HIV-infected
Infant is at risk for HIV infection (exposed to HIV)
If the child is not infected the HIV antibody fades
during first 6 - 18 months of life
Most uninfected infants test negative by 12 months of age
All uninfected infants test negative by 18 months of age
22. Virological tests:
Specialized virologic tests must be used
HIV DNA PCR
HIV RNA PCR
p24 Antigen
Viral Culture
Two positive virologic tests = HIV infection
One positive virologic test = Presumed HIV infection
23. HIV DNA PCR
HIV DNA PCR is a special laboratory test that detects
pieces of the viral gene that are incorporated in the human
blood cell
By comparison, HIV Antibody testing detects the antibody
that the body makes in response to the HIV virus
Sensitivity of HIV DNA PCR increases with time during the
first month of life
The infant may have HIV infection but there may not be
enough virus in the blood to detect it at birth. It becomes
easier to find/detect as the infant gets a little older
24. MANAGEMENT OF<6 MONTHS OLD INFANTS BORN TO
HIV POSITIVE MOTHER
ADVISORY 1:
Start cotrimoxazole if not already started.
Asses and encourage breast feeding if replacement feeding
not started.
Collect and send dried blood spot sample(DBS) of babies
b/w 6wk to 6 months for DNA PCR
25. HIV DNA DETECTED
collect and send whole blood for DNA PCR
HIV DNA DETECTED IF NOT DETECTED
HIV INFECTED
Repeat with another sample
ADVISORY 2
Continue cotrimoxazole IF DNA DETECTED
Manage OI if any
Start ARV as per protocol
Continue breast feeeding
Avoid mixed feeding
26. If DNA DETECTED WITH INITIAL DBS SAMPLE BUT
NOT WITH 2 REPEAT WHOLE BLOOD SAMPLES:
ADVISORY 3:
Infant probably not infected but at risk.
Repeat DNA PCR by DBS test at 6mon , or 6wk at last
breast feeding or child develops symptoms of HIV
infection.
Continue cotrimoxazole until definitely negative.
Discourage weaning too early - use local guidelines
and AFASS criteria met before weaning .
6months is often good time to discuss possibility of
weaning
27. IF DBS SAMPLE AT 6 WKS HIV DNA NOT DETECTED
If child develops signs or symptoms of infection
at <6mon age repeat DNA PCR by DBS
If asymptomatic repeat DNA PCR at 6months
HIV DNA DETECTED HIV DNA NOT DETECTED
Follow advisory 1
Confirm by rpt DNA PCR by BREAST FED NOT FED
whole blood IN 6wk IN 6Wk
BEFORE TEST before
FOLLOW ADVISORY3
HIV DNA DETECTED HIV NOT DETECTED NOT INFECTED
INFANT INFECTED WITH STOP
HIV COTRIMOXAZOLE
FOLLOW ADVISORY2 AVOID BREASTFEEDING
28. HIV EXPOSED CHILD > 18MONTHS OF AGE
Child > 18 months of
age* HIV Antibody
NEGATIVE
Rapid HIV Antibody
Test
Breast feeding child
Non-breast feeding child remains at risk of infection
UNINFECTED
HIV Antibody
POSITIVE
Repeat HIV Rapid Antibody
HIV-INFECTED
>6-12 weeks after weaning
HIV Antibody POSITIVE (after 6months of EBF)
HIV-INFECTED
Refer for HIV care
& HIV Antibody
Refer for HIV NEGATIVE
treatment
care & UNINFECTED
treatment
29. HIV DIAGNOSIS IN CHILDREN <18 MONTHS WITH
DNA -PCR
Delivery
HIV + PREGNANT HIV exposed infant
Symptomatic HIV-
WOMEN (breastfed and non-
exposed
breastfed
infant <18 months
6 – 8 weeks age age (not previously
1st HIV DNA 1st HIV DNA PCR
+
PCR
_ diagnosed
Repeat HIV NEGATIVE
DNA PCR PCR test
To confirm
Breastfed Not breast fed
+
REPORT _ 2nd PCR after 6–8 2nd PCR at 6 months
HIV Positive weeks of stopping to confirm status
breast-feeding
+
Repeat test and
+ _ _ Repeat test
refer for REPORT & refer for
follow-up HIV negative follow -up
30. What if the Initial DNA PCR is Negative
but the child is ILL?
If the HIV DNA result is negative, but the child
develops HIV symptoms
Oral thrush
Pneumonia
Poor growth
Developmental delay
Chronic diarrhea
Repeat HIV DNA PCR testing
31. Post exposure prophylaxis
Health care personnel are at risk of blood borne infection
Percutaneous injury( needle stick, sharps)
Contact - mucous membrane of eye & mouth of an infected person
-non intact skin or blood
-potentially infected body fluids .
What is infectious and what is not ?
Infectious :
blood
semen
vaginal secretions,
peritoneal
pericardial,
amniotic fluid
contaminated with visible blood can lead to infection.
Non infectious:
sweat
saliva
urine
feces
unless these contain blood .
32. First Aid in management of exposure
Immediately wash the wound and surrounding skin
with soap and water.
Don’ts
Don’t squeeze the wound to bleed
Don’t put pricked finger in mouth
Don’t use bleach or antiseptic or alcohol
33. Establish eligibility for PEP
Risk of transmission proportional to amount of HIV
transmitted.
A baseline rapid HIV test of exposed and source
person must be done before PEP.
Informed consent must be obtained.
A designated person or trained doctor must asses the
risk of transmission following an AEB. Assessment
must be quick to start treatment without delay ideally
within 2 hrs but certainly within 72 hrs after
exposure.
34. Assessing risk of transmission:
Mild
Moderate
Severe
Counsel for PEP
Psychological support
Document exposure
35. Deciding on PEP regimen
Exposure Status of source
HIV+ and HIV + and HIV status unknown
asymptomatic clinically
symptomatic
Mild Consider 2 Start 2 drug PEP Usually no pep or consider 2
drug PEP drug PEP
Moderate Start 2 drug Start 3drug PEP -DO -
Severe Start 3 drug Start 3drug PEP -DO-
36. Drug regimen for PEP
There are 2 types of regimens:
Basic regimen : 2 drug combination
Zidovudine(AZT)+ Lamivudine (3TC)
or
Stavudine(d4T) + Lamivudine
Expanded regimen: 3 drug combination
above either combo’s of 2 drugs with protease inhibitors
( Lopinavir or Indinavir or Nelfinavir)_
37. MANAGEMENT OF CHILDREN WITH HIV
INFECTION
Attention to growth, nutrition and immunization of
child.
Treatment and prevention of opportunistic infections.
Antiretroviral therapy.
38. Prophylactic therapy
Cotrimoxazole prophylactic therapy:
For prevention of pneumocystis jiroveci , toxoplasma , malaria
and other bacterial infections.
When to start?
1 – 5 yrs : WHO clinical stage 2,3 or 4
regardless CD4 counts.
If CD4 count <25% irrespective of
stage.
>5 yrs : WHO stage 2,3, or 4 if CD4 counts not available
WHO stage 3 or 4 irrespective of CD4 counts.
CD4 count <350 cells/mm3 irrespective of stage.
39. Dose : 5mg/kg/day
Duration : To be continued till 5 years of age.
After 5 yrs, consider stopping, if
CD4 count >350 cells/mm3 on 2
occasions at least 3 months apart.
40. ISONIAZID PROPHYLACTIC THERAPY (IPT)
Screening for TB strongly recommended for all
Children living with HIV OR AIDS(CLHA)
> 1 YR : 6 Months IPT who have no contact
with a TB case and are unlikely to have
active symptoms.
<1 YR : IPT recommended for only those who
have contact with TB case and who
are unlikely to have active TB.
Dose : 10 mg/kg/day.
41. ANTIRETROVIRAL THERAPY
ART decreases mortality in CLHA.
However ART is not a cure for infection.
Pre ART workup:
CLINICAL:
Weight, height, head circumference, and other measures
of growth.
Nutritional status, assessment of dietary intake
Developmental assessment.
Concomitant medical conditions.
WHO clinical staging.
Details of drugs child receiving including CPT
42. LABORATORY:
Hemoglobin , complete blood counts.
Biochemical tests: LFT, RFT, Blood glucose, serum
electrolytes, serum lipids, amylase, lipase levels.
Pregnancy test in adolescent girls.
CD4 counts and percentage.
Viral load if available.
43. PRE ART COUNSELING
Identification of primary care giver who understands
implications of ART.
Identify secondary care giver in absence of primary
care giver.
Adequate counseling of care giver regarding dose
,duration, timing and side effects of drug is mandatory
before initiating ART.
44. Time of initiation of ART
All infected children <24 months of age.
All children < 18 months of age with presumptive
clinical diagnosis of HIV.
In 24 – 59 months of age:
WHO stage 3 and 4
CD4 < 25% or CD4 count <750
cells/mm3
For >60 months age:
WHO clinical stage 3 or 4 disease.
CD4 count < 350 mm3
45. When to start ART in children, guided by CD4
< 11 month infants : if CD4 < 1500 cells/mm3
(< 25%)
12–35 months : if CD4 < 750 cells/mm3
(<20%)
36–59 months : if CD4 <350 cells/mm3
(15%)
> 5 years old : follow adult guidelines ie
start ART if < 350 cells/mm3
especially if symptomatic.
Initiate ART before CD4 drops below 200 cells/mm
48. CURRENT ART REGIMENS FOR USE
IN CHILDREN
Standard first line regimen :
2NRTI + 1 NNRTI
commonly used NRTI are AZT, d4T, 3TC, ABC.
commonly used NNRTI are EFV, NVP.
49. Choice of first line ART
CHILDREN NOT EXPOSED TO NNRTI:
AZT+ 3TC+ NVP
CHILDREN EXPOSED INFANT OR MATERNAL
NVP OR OTHER NNRTI`S USED FOR
MATERNAL TREATMENT:
AZT+3TC+LPV
IF EXPOSURE TO ARV IS UNKNOWN:
2NRTI+ 1NNRTI.
50. FOLLOW –UP
Followed up once every month for initial 6 months
Evaluation at every visit should include evaluation for
efficacy of treatment which include clinical
improvement and weight gain.
Monitoring for adverse drug reactions.
51. Role of the Parent/caregiver
Parent needs to understand:
That infant diagnosis is an ongoing process
The importance of early testing, frequent
monitoring, and adherence to care
Often the first to notice signs and symptoms.
Often has multiple complex roles and needs, including
self-care, caretaker role for other family
members, feelings about transmission of HIV to the
infant.
Parent needs understanding and support.
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