Facts to consider in the care of HIV-exposed infants
Exposed infants who are HIV-infected may not immediately present with signs and symptoms suggestive of HIV infection, but once they get sick they can rapidly deteriorate, even with normal CD4 levels.
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So all HIV infected infants and children <24 months must be immediately started on ART regardless of the clinical or immunological stage
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Clinical care providers should include HIV infection in their differential diagnosis of all infants at risk of, or known to be exposed to, HIV.
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If a mother has died of AIDS, the child's risk of dying is increased 3-4 times, even for children who are not HIV-infected. Therefore, special vigilance and accurate counseling of caregivers is very important at every visit.
HIV-exposed or infected infants and children should be provided with comprehensive care in the broader context of child health strategies. In addition to routine well-baby and under-5's clinic services, the following should be provided to HIV-exposed infants and children:
7.1. Immunizations
As early in life as possible, HIV-exposed infants and children should receive all vaccines under the Expanded Programme for Immunization (EPI), including Haemophilus influenzae type B and pneumococcal vaccine.
This should be done according to recommended national immunization schedules.
Modification to EPI schedules may be required for infants and children who are HIV-infected:
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Measles: Because of the increased risk of early and severe measles infection, infants with HIV should receive a dose of standard measles vaccine at six months of age, with a second dose as soon as possible after nine months of age, unless they are severely immuno-compromised at that time.
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Pneumococcal vaccine: Immunization with pneumococcal conjugate vaccine should be delayed if the child is severely immuno-compromised.
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Haemophilus influenzae:
Haemophilus influenzae type B conjugate vaccine should be delayed if the child is severely immuno-compromised (until when?).
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BCG: New findings indicate a high risk of disseminated bacille Calmette-Guérin (BCG) disease developing in infants who have HIV, and therefore BCG vaccine should not be given to children known to be HIV-infected. However, infants cannot always be identified as HIV-infected at birth, so in areas with high prevalence of TB and of HIV, BCG vaccination should generally be given to all infants at birth.
7.2. Prophylaxis
7.2.1. Co-trimoxazole preventive therapy starting at 4-6 weeks of age
Co-trimoxazole prophylaxis prevents pneumocystis pneumonia (PCP) in infants and reduces morbidity and mortality among infants and children living with, or exposed, to HIV. Co-trimoxazole protects against common bacterial infections, toxoplasmosis, and malaria.
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All children born to HIV-infected mothers should receive co-trimoxazole prophylaxis starting at 4-6 weeks after birth, or at first encounter with the health care system. They should continue until HIV infection has been excluded and the infant is no longer at risk of acquiring HIV through breastmilk.
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In the infected child, co-trimoxazole should be continued until the child is 5 years of age AND ON ART WITH SUSTAINED CD4 ABOVE 25%. Adherence should be discussed at initiation and monitored at each visit.
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Dapsone can be provided for children who cannot tolerate co-trimoxazole.
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Severe adverse reactions to co-trimoxazole in children are uncommon.
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Co-trimoxazole is contraindicated for infants and children with glucose-6-phosphate dehydrogenase deficiency and those with a history of severe adverse reaction to co-trimoxazole or other sulpha drugs.
Table 7.2.1aWho needs co-trimoxazole prophylaxis?
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| Situation |
|---|
| HIV-exposed infants and children | Infants and children confirmed to be living with HIV infection |
|---|
| < 1 year | 1 – 4 years | ≥ 5 years |
|---|
| Co-trimoxazole prophylaxis is universally indicated, starting at 4-6 weeks after birth and maintained until cessation of risk of HIV transmission and exclusion of HIV infection. | Co-trimoxazole prophylaxis is indicated regardless of CD4 percentage or clinical status | WHO clinical stages 2, 3 and 4 regardless of CD4 percentage
OR
Any WHO stage and CD4 <25% | Follow adult recommendations |
| Once a child with HIV infection is started on co-trimoxazole, prophylaxis should continue until five years of age regardless of clinical symptoms or CD4 percentage. |
Adapted from: WHO, 2006. Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults in resource-limited settings. Recommendations for a public health approach.
Table 7.2.1bCo-trimoxazole dosage and formulations for infants and children
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| RECOMMENDED DAILY DOSAGE | SUSPENSION | CHILD TABLET | SINGLE-STRENGTH ADULT TABLET | DOUBLE-STRENGTH ADULT TABLET |
|---|
| (5 ml syrup 200mg/ 40 mg) | (100 mg/ 20 mg) | (400 mg/ 80 mg) | (800 mg/ 160 mg) |
|---|
| <6 months | 100 mg sulfamethoxazole/20 mg trimethoprim | 2.5 ml | One tablet | ¼ tablet, possibly mixed with feedinga | -- |
| 6 months – 5 years | 200 mg sulfamethoxazole/40 mg trimethoprim | 5 mlb | Two tablets | Half tablet | -- |
| 6 – 14 years | 400 mg sulfamethoxazole/80 mg trimethoprim | 10 mlb | Four tablets | One tablet | Half tablet |
| >=15 years | 800 mg sulfamethoxazole/160 mg trimethoprim | -- | -- | Two tablets | One tablet |
- a
Splitting tablets into quarters is not considered best practice and should be done only if syrup is not available.
- b
Children of these ages (6 months -14 years) may swallow crushed tablets.
Adapted from: WHO, 2006. Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults in resource-limited settings. Recommendations for a public health approach.
Circumstances when co-trimoxazole should be discontinued in infants and children
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Co-trimoxazole prophylaxis can be discontinued when HIV infection has been excluded and the infant or child is no longer at risk of acquiring HIV through breastmilk.
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Co-trimoxazole prophylaxis may need to be discontinued in the event of an adverse drug reaction. Although severe reactions to co-trimoxazole are uncommon, these may include:
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Severe cutaneous reaction such as Stevens-Johnson syndrome
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Severe anaemia
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Pancytopaenia
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Renal and/or hepatic insufficiency
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Severe haematological toxicity
As with all long-term medication, everyone starting co-trimoxazole should be provided verbal or written information on the potential adverse effects, and advised to stop the drug and report to the nearest health facility if co-trimoxazole-related adverse events are suspected.
There is insufficient data on co-trimoxazole desensitization among children to make any recommendations on its use in resource-limited settings.
7.2.2. Isoniazid (INH)
TB screening is
strongly recommended
for all infants, children and adults with HIV.
In addition to early ART the WHO recommends the Three I's for HIV/TB to reduce TB morbidity and mortality in people, including children living with HIV.
Decrease the burden of TB in people living with HIV with the Three I's for HIV/TB
Establish Intensified TB case-finding.
Introduce Isoniazid prevention therapy (IPT).
Ensure TB Infection control in health care and congregate settings.
TB screening, infection control for TB, and IPT should be core functions of HIV prevention, treatment and care services for infants, children and adults living with HIV.
The TB status of HIV-infected patients should be monitored at all visits to health providers. Those with symptoms or signs suggestive of TB should undergo further clinical investigation. Screening is essential in order to treat TB, and to determine whether patients are eligible for isoniazid (INH) preventive therapy (WHO 2010 recommendation).
Intensified tuberculosis case finding and prevention in children living with HIV
WHO recommends (refer to the guidelines for intensified tuberculosis case finding and isoniazid preventive therapy for people living with HIV in resource constrained settings):
Strong recommendation
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Children living with HIV who do not have poor weight gain, fever or current cough are unlikely to have active TB.
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Children living with HIV who have any one of poor weight gain, fever, current cough, or contact history with a TB case may have TB and should be evaluated for TB and other conditions. If the evaluation shows no TB, they should be offered IPT regardless of their age.
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Children over 12 months of age who are living with HIV and who are unlikely to have active TB on symptom-based screening, and have no contact with a TB case, should receive 6 months of INH preventive therapy (10mg/kg) as part of a comprehensive package of care.
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Children less than 12 months of age, only those children who have contact with a TB case and who are evaluated for TB (using investigations) should receive 6 months IPT if the evaluation shows no TB disease.
Conditional recommendation
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All children living with HIV after successful completion of treatment for TB disease should receive INH for an additional 6 months.
According to WHO, a tuberculin skin test (TST) may provide important additional information in assessing a child with suspected TB, especially if there is no positive contact history—but it is not required to initiate IPT in children, and should not be routinely used as part of the process to determine eligibility to initiate IPT.
Similarly IGRA (Interferon Gamma Release Assay) cannot discriminate between M. tuberculosis infection and active TB disease. Encouraging data shows that IGRAs are more sensitive than TST in HIV infected children, including those with a low CD4 count and/or malnutrition. In addition, excellent specificity for M tuberculosis infection has been reported and unlike TST, IGRAs are unaffected by prior BCG vaccination or exposure to environmental mycobacteria. However more evidence is needed and implementation issues affecting most HIV/TB endemic settings have to be solved. Therefore the use of IGRAs remains not recommended outside of research settings with lab validation procedures.
WHO recommends the use of a simplified screening algorithm that relies on four clinical symptoms to identify those eligible for either IPT or further diagnostic work-up for TB and other conditions (see page 11).
TB information provided to all patients with HIV, and to caregivers of infants and children with HIV, should include:
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the importance of knowing your HIV and TB status
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the importance of being regularly screened for TB
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risks of acquiring TB
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ways of reducing risks
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clinical manifestations of TB
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the risks of transmitting TB to others
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TB preventive therapy, where appropriate
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the importance of raising awareness in respective communities and community advocacy on paediatric HIV and TB prevention, treatment and care.
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the importance of setting up patient groups and networks to disseminate information on paediatric HIV and TB prevention, treatment and care.
INH should be provided as TB preventive therapy to all people with HIV once active TB disease has been excluded. Criteria are being developed for INH prophylaxis for HIV-exposed or HIV-infected infants and children <5 years of age. However for the time being, existing IMAI recommendations should be considered within the context of national guidelines, and include:
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Specialist advice should be sought for preventive therapy for those with multidrug-resistant or extensively drug-resistant TB.
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Previous TB is not a contraindication to TB-preventive therapy. WHO conditionally recommends that all children who have been successfully treated for TB and living in settings with high TB prevalence and transmission should receive IPT for an additional 6 months, and that IPT can be started immediately following the last doses of anti-TB treatment.
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Intensified TB case finding in people living with HIV is essential since TB is a curable disease. Intensified HIV case finding in people with TB is also essential because cotrimoxazole prophylaxis can prevent complications.
Isoniazid preventive therapy for TB contacts aged less than 5 years
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Children aged less than 5 years are at special risk for TB.
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If a child aged less than 5 years has cough, fever, or weight loss, refer to clinician for assessment of TB
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If child does not have TB, give Isoniazid daily for 6 months to prevent TB.
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Give preventive therapy with Isoniazid ONLY to children who do not have TB or possible TB and are well and thriving. Give 10 mg/kg Isoniazid daily for at least 6 months.
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See child monthly. Give one month supply of Isoniazid at each visit.
7.2.3. Other prophylaxis
Cryptococcus is a significant cause of illness and death in children (and adults) with HIV. Other fungal infections may be important depending on local epidemiological patterns.
In areas where cryptococcal disease is common, antifungal prophylaxis with azoles may be provided for HIV-infected adults if their condition satisfies specific clinical and immunological criteria. Further research is required before azole prophylaxis for HIV-infected children can be recommended.
7.3. Nutrition
A child has increased energy needs associated with HIV infection, which requires a proactive approach to nutritional support:.
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From the time of first infection, energy needs increase by about 10%
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In HIV-infected children with chronic conditions such as LIP, persistent diarrhoea, HIV-related malignancies, and during infections such as TB, energy needs can increase by about 25-30%
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During and following periods of severe malnutrition, energy requirements may increase by 50-100% in order to recover weight
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These increased requirements are over and above normal energy and protein requirements that are needed by all children to support normal growth and development (see Chapter 10, sections 1, 2 and 5 in the Pocketbook of Hospital Care for children).
Nutritional assessment should be conducted for HIV-exposed and infected infants and children, covering:
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current nutritional status (weight and weight change, height, Body Mass Index or mid-upper arm circumference, symptoms)
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diet (access to food, care-giving practices, protein and micronutrient intake, possible drug-food interactions)
Children experiencing growth failure (i.e. failure to gain weight, or weight loss between regular measurements) or feeding difficulties require targeted support, including:
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counselling and education about locally available food choices, how to feed and manage anorexia and, where indicated, referral to food programmes
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Diagnose and treat any underlying illness
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Evaluate child for the need for, or switch of, ART.
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For conditions that interfere with normal ingestion or digestion (e.g. mouth ulcers, oral thrush, diarrhoea), counsel caregivers on how to alleviate symptoms and provide foods that can help ensure sufficient energy intake.
7.3.1. Infant feeding counselling and support
Breastfeeding reduces child mortality and has health benefits that extend into adulthood. For children born to HIV-negative mothers, the WHO recommends exclusive breastfeeding for the first six months of life, followed by continued breastfeeding with appropriate complementary foods for two years or beyond.
For mothers known to be HIV-infected, the WHO recommends that national (or sub-national) health authorities should decide whether health services will principally counsel and support mothers to:
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breastfeed and receive ARV interventions, or
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avoid all breastfeeding, as the strategy that will most likely give infants the greatest chance of HIV-free survival.
This decision should be based on international recommendations and should consider: the socio-economic and cultural contexts of the populations served by Maternal and Child Health services, the availability and quality of health services, and the local epidemiology, including HIV prevalence among pregnant women, the main causes of infant and child mortality, and the status of maternal and child under-nutrition.
Of infants born to HIV-positive women, an estimated 5% to 20% of infants will become infected through breastfeeding if HIV-related interventions are not provided. The risk of HIV transmission through breastfeeding increases with advanced maternal disease, low CD4 cell count, high viral load, mixed feeding, and prolonged duration of breastfeeding.
In resource-limited settings, breastfeeding is still the single most important intervention to prevent deaths in infants with HIV-positive mothers. Additionally, ARV interventions for infants and mothers significantly reduce HIV transmission through breastfeeding. Even when antiretroviral drugs are not (immediately) available, breastfeeding may still provide infants born to HIV-infected mothers with the greatest chance of HIV-free survival.
In countries where breastfeeding is the policy for HIV positive mothers:
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Women who are taking antiretroviral therapy for their health should exclusively breastfeed the infant for 6 months and continue breastfeeding as complementary feeds are added after six months. The baby should be given NVP from birth to 6 weeks of life.
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Women who were given AZT for prophylaxis during pregnancy should continue with AZT through the breastfeeding period. The baby is also given NVP during breastfeeding until one week after all exposure to breast milk has ended.
References for further reading
- 1.
WHO.
Priority interventions: HIV/AIDS prevention, treatment and care in the health sector. Geneva: World Health Organization; 2010. Available at:
http://www.who.int/hiv/data/en/- 2.
- 3.
WHO.
Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults: recommendations for a public health approach. Geneva: World Health Organization; 2006. [
PubMed: 26042326]
- 4.
- 5.
