Initiating ART in Children

Step 1 : Record Patient Details and History

Step 2: Decide if the Child has Confirmed HIV Infection

Step 3: Decide if the Caregiver is Able to Give ART

Step 4: Decide if a IMCI Nurse Should Initiate ART

Step 5: Assess and Record Baseline Information

Step 6: Start ART

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Follow the 6 Steps 

Step 1: Record Patient Details and History

Record the following information in the HIV clinical chart.

• Patient details
• Caregiver details: Details of primary and secondary caregiver
• Past medical history:
  - Allergies
  - Mode of transmission
  - ARVs prior to ART start date including PMTCT prophylaxis
  - ART transfer in details
  - Disclosure status
  - Immunisation status (update from RTHB)
  - Past medical history including surgical history

Step 2: Decide if the Child has Confirmed HIV Infection

Infant/ child <18 months:

The first positive PCR test is confirmed with a second positive HIV PCR

• Proceed to Steps 3 - 6 whilst awaiting second PCR result

Child >18 months:

Under 2 years: A positive rapid HIV antibody test is confirmed with a positive HIV PCR

Over 2 years: A positive rapid HIV antibody tests confirmed with a second positive HIV antibody test(rapid or ELISA)

• If the first rapid HIV test is positive and the second test is negative (discordant), do an ELISA or refer
• Send outstanding tests but proceed to step 3 while awaiting results

Step 3: Decide if the Caregiver is Able to Give ART

• Check that the caregiver is willing and able to administer ART
• Complete psychosocial readiness and social record sections in the HIV clinical chart
• The caregiver should ideally have disclosed the child’s HIV status to another adult who can assist with providing ART (or be part of a support group)
• If caregiver is willing and able to give ART, move to Step 4
• If not, classify as HIV INFECTION not on ART, and provide care as outlined in HIV- follow-up

Step 4: Decide if a IMCI Nurse Should Initiate ART

• Check for the following:
  - General danger signs or any severe classification
  - Infant <1 month of age
  - Child weighs less than 3 kg
  - TB
  - Fast breathing
  - Any WHO stage 4 condition
• If any of these are present, refer to next level of care for ART initiation
• If none present, move to Step 5

Step 5: Assess and Record Baseline Information

• Nutrition assessment
• Weight, height/ length, head circumference (if <2 years), MUAC
• BMI or WFH z-score. Classify based on findings
• Assess and classify for anaemia 
• TB screening and TB contacts
• Developmental screening, school attendance and school performance
• WHO clinical staging
• Baseline laboratory investigations:

Baseline Investigations	Done for
CD4 count and FBC/ Hb	All children starting ART
Creatinine and eGFR	Children/ adolescents starting tenofovir (TDF)
Alanine Aminotransferase (ALT)	On TB treatment or starting nevirapine (NVP)

• If the child has severe acute malnutrition, severe anaemia (Hb < 7g/dl) or TB refer to the next level of care for management and for initiation of ART
• If Hb is 7 g/dl - 11 g/dl, classify as anaemia and treat. Do not delay starting ART
• Send any outstanding laboratory tests. If the child already meets the criteria for starting

Step 6: Start ART

• ART regimens always include 3 drugs
• See ART dosing and instructions
• Remember to counsel the caregiver on how to give the drugs and possible side-effects
• Remember to give cotrimoxazole
• Give other routine treatments
• Follow-up after one week

Weight/ Age	ART regimen
Age >1 month AND Weight 2.5 kg - < 20 kg	Abacavir (ABC) Lamivudine (3TC) Lopinavir/ritonavir (LPV/r)
Weight 20 - < 35 kg OR Age < 10 yrs	Abacavir (ABC) Lamivudine (3TC) Dolutegravir (DTG)
Age ≥10 years AND Weight ≥ 35 kg	Tenofovir (TDF) Lamivudine (3TC) Dolutegravir (DTG)

 

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Integrated Management of Childhood Illness 2022; Anti-Retroviral Therapy; Initiating ART in Children: Follow the 6 Steps

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Last checked for updates: June 2023