HIV Infection

Routine care

Bactrim prophylaxis

Family care

Eligible to start ART

WHO clinical staging of HIV/AIDS for infants and children

Antiretroviral treatment

HIV testing should be offered to all children admitted to medical wards. If children are known to be exposed antenatally a routine PCR is done at 6 weeks, but this may be done as earlier if clinically indicated. An Elisa test after 18 months is also confirmatory, but prior to 18 months only indicates exposure, not infection: a PCR will be required. If a child is suspected clinically as having HIV, and you are waiting for an HIV test result, don’t forget to treat the child with Bactrim and other routine medications. Stop Bactrim if 6 weeks PCR neg and not breastfeeding. Testing for HIV requires informed consent from the parent/legal caregiver. If the child is the product of a stable parental relationship, it is best to gain consent from BOTH parents. Always document your counselling and the giving of consent in the notes. Post test counselling can be done in the ward if the child is still an inpatient. 

Routine care

Treat all acute illness and opportunistic infections. HIV-infected and HIV-exposed children should be immunised according to the routine national immunisation schedule, including live vaccines. Weight checks and weight monitoring at each visit. If failure to thrive, try to identify a treatable cause; e.g. acute or chronic respiratory, gastrointestinal or urinary tract infections or TB, then introduce food supplementation. Monitor haemoglobin and treat with iron, folate, multivite and zinc sulphate. 6 Monthly Vitamin A supplementation and deworm treatment. Bactrim prophylaxis from 6 weeks of age or if HIV infection is suspected. 

Bactrim Prophylaxis

Family care 

HCT for both parents and siblings. CD4 tests of all infected family members. Parental counselling re condomisation, family planning, care grants, nutrition support, disease information (PTB etc) and f/u at ARV Clinic. Consider the status of siblings of children diagnosed as HIV-infected. Counsel the caregivers about disclosure to spouse/partner and family. 

Eligible to Start ART

• All children less than 5 years of age, irrespective of CD4
  
• Children 5 years to 15 years with WHO clinical stage 3 or 4 or CD4 <350 cells/μl

Require Fast-Track (i.e. start ART within 7 days of being eligible) 

• Children less than 1 year of age
  
• WHO clinical Stage 4
  
• MDR or XDR-TB
  
•  CD4 Count < 200 cells/μl r < 15%

WHO CLINICAL STAGING OF HIV/AIDS FOR INFANTS AND CHILDREN

Clinical stage I

• Asymptomatic
  
• Persistent generalised lymphadenopathy

Clinic al stage II

• Unexplained persistent hepatosplenomegaly
  
• Popular pruritic eruptions
  
• Fungal nail infection
  
• Angular cheilitis
• Lineal gingival erythema
  
• Extensive wart virus infection
  
• Extensive molluscum contagiosum
  
• Recurrent oral ulcerations
  
• Unexplained persistent parotid enlargement
  
• Herpes zoster
  
• Recurrent or chronic upper respiratory tract
  
• Infections (otitis media, otorrhoea, sinusitis or tonsillitis)

Clinical stage III

• Unexplained moderate malnutrition or wasting not adequately responding to standard therapy
  
• Unexplained persistent diarrhoea (14 days or more)
  
• Unexplained persistent fever (above 37.5ºC intermittent or constant, for longer than one month)
  
• Persistent oral candidiasis (after first six to eight weeks of life)
  
• Oral hairy leukoplakia
  
• Acute necrotizing ulcerative gingivitis or periodontitis
  
• Lymph node tuberculosis
  
• Pulmonary tuberculosis
  
• Severe recurrent bacterial pneumonia
• Symptomatic lymphoid interstitial pneumonitis
  
• Chronic HIV-associated lung disease including bronchiectasis 
• Unexplained anaemia (< 8 g/dl), neutropaenia (< 0.5 x 109 per litre) and/or chronic thrombocytopaenia

Clinical stage IV

• Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
  
• Pneumocystis pneumonia
  Recurrent severe bacterial infections (such as emphysema, pyomyositis, bone or joint infection or meningitis but excluding pneumonia)
  
• Chronic herpes simplex infection (orolabial or cutaneous of more than one month’s duration or visceral at any site)
  
• Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
  
• Extra-pulmonary tuberculosis
  
• Kaposi sarcoma
  
• Cytomegalovirus infection: retinitis or cytomegalovirus infection affecting another organ, with onset at age older than one month
  
• Central nervous system toxoplasmosis (after one month of life)
  
• Extra-pulmonary cryptococcosis (including meningitis)
  
• HIV encephalopathy
  
• Disseminated endemic mycosis (coccidiomycosis or histoplasmosis)
  
• Disseminated non-tuberculous mycobacterial infection
  
• Chronic cryptosporidiosis (with diarrhoea)
  
• Chronic isosporiasis
  
• Cerebral or B-cell non-Hodgkin lymphoma
  
• Progressive multifocal leukoencephalopathy
  
• Symptomatic HIV-associated nephropathy or
  
• HIV-associated cardiomyopathy

Antiretroviral treatment 

• For further details see National guidelines. 
• See latest drug dosing charts in app
• Refer to TC Newman HIV clinic.