early infant diagnosis and immunization and cotrimoxazole prophylaxis as well as breast feeding revised protocols

1. DR NISHANT PRABHAKAR
MD PEDIATRICS

2.  Infant and child born to HIV infected woman,
are reliably excluded or confimed with HIV
status and the infant or child is no longer
exposed to HIV through breast feeding.

3.  Immediate Care at Birth
 Infant feeding
 ARV prophylaxis
 Cotrimoxazole prophylaxis (CPT)
 Immunization and Vitamin A
Supplementation
 Growth and Development
 Early infant diagnosis
 Follow up

4.  Follow universal precautions.
 Do not milk the cord.
 The cord should be clamped soon after birth.
 Cover the cord with gloved hand and gauze
before cutting to avoid blood splattering.
 Initiate breast feeding within the first hour of
birth in accordance with the preferred and
informed choice of the mother.

5. 1. Either maternal or infant ARV prophylaxis
during the duration of breast feeding.
2. Exclusive breast feeding is the
recommended infant feeding choice in the
first 6 months, irrespective of whether
mother or infant is provided with ARV drugs
for the duration of breastfeeding.
3. MIXED FEEDING SHOULD NOT BE DONE
AT ANY COST WITHIN THE FIRST 6
MONTHS.

6. 4 Only in situations where breastfeeding cannot be
done or on individual parents' informed decision,
then replacement feeding may be considered.
 AFASS criteria for Exclusive Replacement Feeding
 A- Acceptability
 F- Feasibility
 A- Affordability- sufficient replacement feeding
 S- Safe water & sanitation
 S- Sustainability= un-interrupted feeding for atleast
6 months.

7. 5 - Exclusive breastfeeding for at least 6 months-
complementary feeding should be introduced
GRADUALLY, irrespective of infant HIV status by EID.
6 - Mother should be receiving ARV prophylaxis or ART
during the whole duration of breastfeeding. ARV
prophylaxis should continue for one week after the
breastfeeding has fully stopped.
7 - For breastfeeding infants diagnosed HIV negative,
breastfeeding should be continued until 12 months of
age irrespective of whether the mother is on ART or
ARV prophylaxis

8. 8 - After 6 weeks of stopping breast feeds, repeat
EID. Confirmation test for HIV has to be done at
18 months irrespective of the EID status.
9- For breastfeeding infants diagnosed HIV
positive, paediatric ART should be started and
breastfeeding should be continued till 2 years of
age.
10 - Breastfeeding should stop once a nutritionally
adequate and safe diet without breast milk can
be provided.

9.  All Infants born to women who are receiving ART /
maternal triple ARV prophylaxis / who present directly-in-
labor and receive intra partum ARV prophylaxis should be
started on daily NVP prophylaxis at birth and continue for
a minimum of 6 weeks, regardless of whether the infant is
exclusively breastfed or receives replacement feeding.
 Infants born to women who present directly-in-labor and
receive intra partum ARV prophylaxis, NVP prophylaxis
should not be stopped at 6 weeks of life but continued
until the mother initiated on ART/ARV prophylaxis and
complete a minimum of six weeks of therapy.

11.  All HIV-exposed infants should receive CPT from the age of 6
weeks until HIV is reliably excluded.
 In all those confirmed to be HIV-infected, it should be
continued till 5 years of age. The recommended dose is 5
mg/kg/day of TMP once daily.
 Children with severe adverse reaction (grade 4 reaction) to
Cotrimoxazole or with G6PD deficiency should not be
initiated on CPT. The alternative drug is Dapsone 2 mg/kg
once daily (max. 100 mg/day) orally.
 Aerolised pentamidine for children > 5 years administered
via respigard II inhaler in the dose of 300 mg once a month is
another alternative.

13.  Dosage: 5mg/kg of TMP/day orally once daily *splitting of tablets into
quarters is not recommended, unless there is no syrup available.

14.  Live vaccines should be avoided in all severely immune compromised infants (CD4 %<
25% or WHO stage 3 and 4).
 Vitamin A supplementation should be as per the national immunization schedule.
 National Immunization schedule is as follows:

15.  If the child’s growth curve is falling down, flattening or
faltering, reinforce nutrition and urgent assessment
for nutrition status, HIV related features and screen
for treatable causes e.g. nutritional deficiency &
chronic infections.
 For the children on ART with growth flattering or
decline, look for treatment failure.
 Delayed development or loss of milestones after
attaining them (Regression of Milestones), may be the
first sign of HIV infection suggesting HIV
encephalopathy

16.  Maternal HIV antibody transferred passively during
pregnancy can persist for as long as 18 months in children
born to HIV-infected mothers. Hence, positive HIV antibody
test does not necessarily indicate HIV infection in the
infant/child. In children who are breastfed, since they have
ongoing risk for HIV transmission, HIV infection can only be
excluded after 6 weeks of complete cessation of
breastfeeding.
 In the current Early Infant Diagnosis (EID) program,
virological tests i.e. HIV-1 DNA PCR by Dried Blood Spot
(DBS) and on Whole Blood Sample (WBS) are being done for
infants and children below 18 months of age. Antibody tests,
using rapid test method can be used for children > 18 months
of age for diagnosis of HIV infection as in adults.

17.  Previous algorithm A & B have been merged.
 Confirmatory whole blood test has been
replaced by a confirmatory second dry blood
spot (DBS) test. First DBS has to be done in
regional reference lab on being HIV-1 reactive
second DBS has to be sampled at ICTC.
 All the exposed children included in EID
algorithm irrespective of HIV status as per
molecular test has to be confirmed at 18
months as per national algorithm.

22.  first follow up visit should be at 2 weeks of
age for babies on ARV prophylaxis to look for
any adverse reaction to NVP.
 Rest follow up visit at the ICTC centre are as
per following table.

24.  Appropriate counselling would include-
 counseling on PPTCT, ARV prophylaxis,
 infant feeding,
 nutrition,
 EID,
 CPT initiation,
 vaccination,
 opportunistic infections,
 ART therapy and adherence