81 Clinical Presentation and Management of HIV in Children
Jacquie Oliwa DD/MM/YY
Absolute risk of HIV MTCT:
- Pregnancy up to 10%
- Labour and deliery up to 20%
- Breast feeding up to 20%
When can kids present with HIV? Classifications pre ART
- Category 1 - 1/3 - most die befroe first birthday (these have acquired in pregnancy)
- Category 2 - 1/2 - most die by 3-5 yr (these have acquired maybe at birth)
- Category 3 - 1/4 - long term survivors, live beyond 8 (these have acquired later, maybe BF)
Why do kids get way sicker than adults when they get HIV? They’re worse at clearing the viral load, and can’t do it as effectively as adults.
You can’t use absolute CD4 counts in children, the numbers vary too much). So you need to use the CD4 percentage (out of total WCC). You can use abolute CD4 when older than five.
| . | Less than one year | less than 35 months | less than 60 month |
|---|---|---|---|
| Mild Disease | CD4 30-35% | ||
| Advacnced Disease | < 40 | ||
| Severe Disease | < 25 | < 20 | < 15 |
Test at birth or at 6 weeks with PCR (Antibody tests can be false positive due to maternal abs)
81.1 Diagnosing
Immunological:
- Ab
- CD4 Assay
Virological:
- DNA PCR
- RNA PCR
Virologic testing is gold standard in kids less than 18 months.
Older than 18 months it’s ok to do the antibody serological tests. You want to do a secondary confirmatory test.
How do you do a dried blood spot test? Heel prick sent away, takes ages to get results, so treat empiracally rather than waiting
If you get a child with no idea what status is. Do rapid HIV antibody tests on mum or baby. Important to repeat just incase mum seroconverting.
How to test in breastfed infant: Do a PCR test one month after weaning, then 6 weeks after weaning?
Sometimes you need to make a presumptive diagnosis in kids < 18 months. You can do this in
- HIV antibody test positive plus two of oral Candidiasis, severe Pneumonia, severe Sepsis
- WHO Stage 4 condition
- Maternal death/advanced death
- CD4 <20%
What about older kids and adolescents? Serial testing with consent! Counsel on risk reduction behaviours
Question: Lymphoid Interstitial Pneumonia Versus Miliary TB
Question: WHO Clinical Staging of HIV
81.2 Treating
Anyone with confirmed HIV infection, treat with ART within 2 weeks of diagnosis
Do not start someone on therapy without good adherence training
Treatment should be from the same care provider/team of care providers every time
All patients need counselling, with a good system to understand why patients are failing therapy/missing appts. Don’t change from drug to drug until clear on adherence.
As well as HIV drugs kids need: Cotrimoxazole and Isoniazid and Vitamin A and Deworm
They need all vaccines. Except delay BCG if stage 3/4 disease, as BCG adenitis. With measles vaccine, get extra doses for more protection.
Cotrimoxazole prophylaxis: Malaria, PCP, Bacterial infection - saves lives from all of these things
All older kids (>5) with CD4 < 200 should be screened for cryptococcal meningitis. Treat them if you find it, delay ART for 5 weeks to minimise IRIS. Kids less than 5 do get CM< but it’s less common. Kids who are negative on CrAG but symptomatic should get fluconazole as prophylaxis.
HIV treatment for children is the same WHO guidleines as for adults and adolescents. Only Protease Inhibitor comes into first line options. 2 NRTIs and Doltegravir are first line options for kids/adolescents/adults
81.2.1 Treatment Failure
Not quite as same as adults. Kids are less likely to suppress to undectable levels so you have to track over time.
81.2.1.1 TB
Testing for TB in Kids:
In general in TB, kids are less likely to be positive smear than adults
In kids who are HIV, they are less likely to have a positive skin test. Reasonable chance of false negatives
81.3 Adolescents
Sabrina Bakeera-Kitaka
Around 2 million adolescents with HIV worldwide.
Difficulties with teenagers with meds: don’t retain in treatment, they don’t want to disclose it, they dont adhere it, they get stock-out of commodities