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Pediatric HIV Infection

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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Learning Objectives

By the end of this session, participants should be able to:

Explain how to diagnose children with HIV

Describe WHO clinical staging for children

Explain when and how to initiate cotrimoxazole prophylaxis in children

List the 6 vaccines that are contraindicated in children with AIDS

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Overview of Pediatric HIV

>90% of global pediatric HIV due to mother-to-child transmission (MTCT)• During pregnancy• During delivery

Most common time for infection

• After delivery Breastfeeding increases transmission risk by

5-20%

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Overview of MTCT

What is the risk of transmission without intervention?

The overall MTCT rate is approximately 25-40% without intervention

However, with current prophylactic strategies, the risk of transmission can be reduced to less than 2%

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Pregnancy 5-10%

Delivery 10-15%

Breastfeeding 5-20%

When Does MTCT Occur?

In an untreated breastfeeding population, the total transmission rate is 25-40%

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Management of HIV-Exposed Infants and Children

Make diagnosis as soon as possible Give appropriate vaccines and

prophylaxis Start antiretroviral therapy when

indicated (for HIV-infected infants) Recognize and treat opportunistic

infections Support growth and development

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Diagnosis of HIV Infection: > 18 Months

Confirmed by the same HIV antibody test used for adults

HIV infection is diagnosed when the serum gives 3 positive results in 3 tests with 3 different bioproducts

Only laboratories certified by MoH are authorized to confirm HIV positive test results before reporting

the result to patients

Guidelines for the Diagnosis and Treatment of HIV/AIDS. Ministry of Health, 2009.

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Diagnosis of HIV Infection: < 18 months (1)

Because an infant up to 18 months of age may carry maternal HIV antibodies, regular HIV antibody test will be positive whether baby has HIV or not• Test will either be detecting baby’s

antibodies or mother’s• This leads to difficulties interpreting an

HIV antibody positive test result in children < 18 months

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Diagnosis of HIV Infection: < 18 months (2)

Diagnosis is based on PCR for viral DNA or RNA• < 9 months: 2 positive PCR (performed

after 4-6 weeks of life)• 9 to 18 months: if HIV antibody test is

positive then need PCR to confirm (as for < 9 month old)

If breastfeeding, stop for 6-8 weeks before testing

Guidelines for the Diagnosis and Treatment of HIV/AIDS. Ministry of Health, 2009.

MOH 2009HIV exposed children(<9 months old)

PCR testingPCR testing not

available

PCR positive

PCR negative

No HIV infection

Breastfed within 6 weeks of PCR test?

Repeat PCR 6 weeks after last breastfeeding

Continued Care at HIV outpatient

clinic

2nd PCR

HIV infection confirmed

HIV antibody test at 18 months

NO

YES

POS

NEG

POS

NEG

HIV Diagnosis for HIV Exposed

Children <9 months

AntibodyAntibody

testingtesting

Antibody Antibody testing (+)testing (+)

AntibodyAntibody

testingtesting (-)(-)

PCRPCR testingtesting(as < 9 months (as < 9 months

old) old)

HIV exposed children(9-18 months old)

MOH 2009

NoNo HIVHIV infectioninfection

HIV Diagnosis for HIV

Exposed Children 9-18 months old

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Clinical Diagnosis of Severe HIV/AIDS Disease in < 18 months

Stage 4 clinical disease • PCP• Toxoplasmosis• Cryptococcus• Wasting syndrome• Esophageal

candidiasis• EPTB (excluding

axillary LN – BCG disease)

At least 2 of the 3 findings:• Oral thrush (if >

1 month of age)• Severe bacterial

pneumonia• Severe sepsis

HIV Antibody test positive, plus:

OR

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Staging of Pediatric HIV Infection

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WHO Pediatric Clinical Staging

Clinical staging should be performed for infants and children with confirmed HIV infection

If HIV infection cannot be confirmed in infants <18 months, a presumptive diagnosis may be made in those with severe disease

Accurate staging is important for deciding when to start ART

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WHO Pediatric Stages (1)

Stage 1 Child is asymptomatic May have persistent

generalized lymphadenopathy

Stage 2

Characterized by: Hepatosplenomegaly Recurrent or chronic

upper respiratory tract infections

Papular pruritic eruption

Herpes zoster

Linear gingival erythema

Stage 2 Diseases (1)

Zona

PPE: lower arms and legs, leaves scarring

after resolution

Stage 2 Diseases (2)

Bilateral parotid enlargement

Stage 2 Diseases (3)

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WHO Pediatric Stages (2)

Stage 3

Characterized by: Unexplained moderate

malnutrition Unexplained diarrhea

>14 days Unexplained fever for

>1 month Pulmonary, lymph

node TB

Stage 4

Characterized by: Unexplained severe

wasting/malnutrition PCP Recurrent severe

bacterial infection Extrapulmonary TB HIV encephalopathy

Oral hairy leukoplakia:Side of tongue, can’t scrape off

Stage 3 Diseases (1)

Oral candidiasis

Stage 3 Diseases (2)

Pulmonary TB TB Lymphadenitis

22Lymphocytic interstitial pneumonitis:

Typical nodular infiltrates in mid and lower lungs

Stage 3 Diseases (3)

Stage 4 Diseases (1)

Herpes Simplex chronic infection (>1 month)

Penicillium Marneffei skin lesions:Flesh-color, umbilicated papules concentrating mainly on face

Stage 4 Diseases (2)

Quiz: Which stage?

Scenarios Stage ?

A 5 year old boy who has:•had an unexplained fever for over a month now•and also has a skin rash consistent with papular pruritic eruption (PPE)

A 1 year old girl who has TB meningitis

A 7 year old boy who with generalized lymphadenopathy but otherwise appears well with no other symptoms

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4

1

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Immunological Staging (1)

The degree of immunosuppression in HIV infected children is assessed by the percentage (%) of CD4 cells

CD4 percentage is used for children under 5 years of age, whereas CD4 number is used for children 5 years and older

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Immunological Staging (2)

<11 months

12-35 months

36-59 months

≥ 5 yrs

Not significant

> 35% > 30% > 25% > 500 cells

Mild 30 – 35%

25 – 30%

20 – 25% 350−499 cells

Advanced 25 – 29%

20−24% 15−20% 200−349 cells

Severe <25%<1500 cells

<20%<750 cells

<15%<350 cells

<15% <200 cells

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Overview on Care and Treatment of Children

with HIV/AIDS

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Cotrimoxazole Prophylaxis for HIV-Exposed and -Infected Children

HIV-exposed children

Confirmed HIV-infected children

•Start 4–6 weeks after birth•Continue until exclusion of HIV infection

< 24 months

24 – 60 months > 60 months

All

Clinical stages 2, 3 and 4 regardless of CD4 count orCD4 < 25% or ≤ 750 cells/mm3 regardless of clinical stage

Clinical stage 3 or 4 regardless of CD4 count or CD4 ≤ 350 regardless of clinical stage

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Immunization Children with HIV and C.S 4 should not be given live vaccines

Vaccine HIV-exposed infants, before diagnosis is known

HIV + with clinical stages I, II, III

HIV + with clinical stage IV

• Nationally-supported vaccines

BCG As scheduled DO NOT GIVE DO NOT GIVE

DPT As scheduled As scheduled As scheduled

Poliomyelitis oral

As scheduled As scheduled IM vaccine only

Hepatitis B As scheduled As scheduled As scheduled

Measles As scheduled As scheduled DO NOT GIVE

JE As scheduled As scheduled As scheduled

• Optional vaccines

HIB As scheduled As scheduled As scheduled

Varicella As scheduled As scheduled DO NOT GIVE

Mumps As scheduled As scheduled DO NOT GIVE

Rubella As scheduled As scheduled DO NOT GIVE

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ARV Indications

Children with confirmed HIV infection:

Age Starting ART

< 24 monthsStart ART as soon as possible

(regardless of clinical stage or CD4)

24 - 60 months

Clinical stage 3 or 4 regardless of CD4 count

CD4% ≤ 25% or CD4 ≤ 750 cells/mm3 regardless of clinical stage

> 60 months Indications as per HIV-infected adults

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Common Opportunistic Infections in HIV-infected

Children

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Pneumocystis carinii Pneumonia (PCP)

Most common OI in young children

Interstitial, diffuse pneumonia

Characterized by:• Fever• Cough• Progressive dyspnea• Tachypnea• Hypoxia

Peaks at 2-8 months of age

Infant mortality after treatment up to 40%

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AIDS-Defining Conditions by Age at Diagnosis for Perinatally-Acquired AIDS Cases

Reported through 1999, United States

Age in Months

Nu

mb

er

of

Cases

0

0

50

100

150

200

250

300

350

400

450

2 4 6 8 10 12 14 16 18 20 22 24

Other AIDS-defining

conditions

Pneumocystis jiroveci pneumonia

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Tuberculosis

Diagnosis of TB in children in VN• High index of suspicion needed• Suspect in any child with prolonged cough,

low grade fevers, failure to thrive• BK smear, PPD (tuberculin skin test), CXR• Gastric aspirates used in small infants• Look for LN, peripheral and mediastinal• FNA to evaluate for lymph node infection

Differential Diagnosis: Lymphoid interstitial pneumonia, PCP, bacterial pneumonia

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Support for Growth and Development

Growth High rates of growth

failure due to decreased intake and/or increased nutrient demands• Give multivitamins

containing Vitamin A• Treat iron-deficiency

anemia• Maximize caloric intake

Development Watch for spastic

limbs and gait, encephalopathy, other neurological deficits

Review developmental milestones

Delay or loss of developmental milestones indicate HIV encephalopathy

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Key Points

Most children get HIV through mother-to child transmission• Children > 18 months are tested with

antibody test• Younger children may still carry mother’s

antibodies, need different testing strategy Use clinical and immunological staging

to determine ART eligibility Important to look closely at child’s

growth and development markers for clues about health

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Thank you!

Questions?