HIV infection in children

1. HIV / AIDS IN CHILDREN. AIDS
OPPORTUNISTIC INFECTIONS
Associate Professor Iakovenko N.O.

2. WHAT IS HIV?
 Human immunodeficiency virus (HIV) is the virus
that is responsible for causing acquired immune
deficiency syndrome (AIDS).
 The virus destroys or impairs cells of the immune
system and progressively destroys the body's ability
to fight infections and certain cancers.
 There are two human immunodeficiency viruses:
-HIV-1
-HIV-2
 Infection with HIV-1 is by far more common than
infection with HIV-2 in almost all geographic areas.

3. EPIDEMIOLOGY BY THE DATA OF UNICEF IN
2020
 150,000 children aged 0-9 years were newly infected with HIV,
bringing the total number of children in this age group living
with HIV to 1.03 million.
 150,000 adolescents aged 10-19 were newly infected with
HIV, bringing the total number of adolescents living with HIV to
1.75 million.
 At least 300,000 children were newly infected with HIV in
2020, or one child every two minutes
 120,000 adolescent girls were newly infected with HIV,
compared with 35,000 adolescent boys.
 120,000 children and adolescents died from AIDS-related
causes; 86,000 aged 0-9 years and 32,000 aged 10-19.
 90% of children living with HIV are in sub-Saharan Africa
 In Eastern and Southern Africa, annual new infections among
adolescents decreased by 41 per cent since 2010, while in the
Middle East and North Africa, infections increased by 4 per
cent over the same period.

4. MODES OF TRANSMISSION
 The three principal modes of transmission of HIV
are vertical, parenteral, and sexual.
 90% of children with HIV are infected through
vertical (perinatal) transmission.
 The overall risk of vertical HIV transmission in the
absence of any intervention is between 20% and
45%. The breakdown of risk of maternal-to-child-
transmission (MTCT) by periods of transmission is:
 5-10% is in-utero
 10-20% is intrapartum
 5-20% is through breastfeeding

5. NO KNOWN CASES OF HIV/AIDS HAVE BEEN
SPREAD BY THE FOLLOWING:
 Saliva
 Sweat
 Tears
 Casual contact, such as sharing food utensils,
towels, and bedding
 Swimming pools
 Telephones
 Toilet seats
 Biting insects (such as mosquitoes)

6. TIMING OF MOTHER-TO-CHILD TRANSMISSION

7. RISK OF TRANSMISSION OF HIV FROM MOTHER TO
CHILD

8. IMMUNOLOGY
As children acquire HIV when the immune system is immature,
the immunology is different from adults. This results in:
 High rates of viral replication
 Very high HIV-1 viral load which takes 1-2 years to reach the
viral set-point after primary infection
 High rates of CD4 positive cell destruction ∼ 5% of total per
day
 Very high rates of viral mutation (e.g. Amino acid substitution
due to reverse transcription errors when there are high levels
of replication)
 Faster rate of disease progression
 Good immunologic response to ART
 CD4 cell counts are high and variable in young uninfected
children. CD4% is less variable, and as a result CD4% is used
instead of CD4 cell count as an immunological marker in
young children (<5-6 years)
 High mortality rate in perinatally infected children: >60% die
by the age of 3 years in resource-poor settings

9. KEY DIFFERENCES BETWEEN ADULTS AND
CHILDREN
 Young children have immature immune systems, and if
HIV-infected, are particularly susceptible to common
childhood and opportunistic infections. They may
experience a rapid progression of HIV disease if
treatment is delayed.
 ◦Maternal HIV antibodies can be passed to the child and
last for up to 18 months, so HIV antibody testing does not
reliably indicate HIV infection in children under 18 months
of age. Positive HIV antibody testing in this time period
can indicate exposure to HIV or HIV infection in the child
and, where possible, should be followed up with a viral
test.
 ◦Children are at risk of acquiring HIV by breastfeeding
from HIV-infected mothers. Children of any age are at risk
of acquiring HIV during the entire time they are breastfed.

10. KEY DIFFERENCES BETWEEN ADULTS AND
CHILDREN
 In young children normal CD4 counts are higher, age-
dependent, and more variable than in adults. For
children under 5 years of age, it is best to use %CD4
rather than absolute count.
 ◦ARV drugs are handled differently in children's bodies,
affecting the doses that are needed.
 ◦ARV medicine dosages must be adjusted as the child
grows.
 ◦It can be challenging to communicate effectively with
children about their HIV status, about the care they
need, and to support their adherence to ART. As children
grow, the counselling they receive must evolve as well.
 In a family where one child is HIV-infected, it is possible
that siblings may also be infected. Make sure diagnostic
counselling and testing is offered to all siblings and
parents.

11. IMMUNOLOGICAL CATEGORIES

12. CLINICAL AND IMMUNOLOGICAL
CLASSIFICATION

13. CLINICAL CATEGORIES

14. CLINICAL CATEGORIES

15. DIAGNOSIS OF HIV INFECTION IN CHILDREN
 Prenatal screening
 Blood tests
 After diagnosis, frequent monitoring
 The diagnosis of HIV infection in children begins
with the identification of HIV infection in pregnant
women through routine prenatal screening of blood.
Rapid tests for HIV can be done while women are
in labor and delivery suites at the hospital.

16. DIAGNOSIS OF HIV INFECTION IN INFANTS AND
CHILDREN (LAST UPDATED DECEMBER 24, 2019;)
 Virologic assays (i.e., HIV RNA or HIV DNA nucleic acid tests [NATs]) that directly detect HIV must
be used to diagnose HIV in infants and children aged <18 months with perinatal and postnatal HIV
exposure;
 HIV antibody tests should not be used
 HIV RNA or HIV DNA NATs are generally equally recommended
 An assay that detects HIV non-B subtype viruses or Group O infections (e.g., an HIV RNA NAT or
a dual-target total DNA/RNA test) is recommended for use in infants and children who were born
to mothers with known or suspected non-B subtype virus or Group O infections
 Virologic diagnostic testing is recommended for all infants with perinatal HIV exposure at the
following ages: • 14 to 21 days • 1 to 2 months • 4 to 6 months
 For infants who are at higher risk of perinatal HIV transmission, additional virologic diagnostic
testing is recommended at birth and at 2 to 6 weeks after cessation of antiretroviral prophylaxis.
 A positive virologic test should be confirmed as soon as possible by repeat virologic testing
 Definitive exclusion of HIV infection in nonbreastfed infants is based on two or more negative
virologic tests, with one obtained at age> 1 month and one at age< 4 months, or two negative HIV
antibody tests from separate specimens that were obtained at age > 6 months
 Some experts confirm the absence of HIV at age 12 to 18 months in children with prior negative
virologic tests by performing an HIV antibody test to document loss of maternal HIV antibodies
 Since children aged 18 to 24 months with perinatal HIV exposure occasionally have residual
maternal HIV antibodies, definitive exclusion or confirmation of HIV infection in children in this age
group who remain HIV antibody-positive should be based on an HIV NAT and antibody retesting
at 24 months
 Diagnostic testing in children with nonperinatal exposure only or in children with perinatal
exposure aged> 24 months relies primarily on the use of HIV antibody (or antigen/antibody) tests.
 When acute HIV infection is suspected, additional testing with an HIV NAT may be necessary to
diagnose HIV infection

17. SIMPLIFIED INFANT DIAGNOSIS ALGORITHM

18. DIAGNOSING OF HIV IN CHILDREN > 18M

19. TREATMENT OF HIV INFECTION IN CHILDREN
 Drugs
 Ongoing monitoring
 Encouraging adherence to treatment

20. WHEN TO INITIATE THERAPY IN ANTIRETROVIRAL-
NAIVE CHILDREN (LAST UPDATED APRIL 14, 2020;)
 Antiretroviral therapy (ART) should be initiated in all
infants and children with HIV infection (as for
children aged< 3 months,so and for older children).
 Rapid ART initiation (defined as initiating ART
immediately or within days of diagnosis),
accompanied by a discussion of the importance of
adherence and provision of subsequent adherence
support, is recommended for all children with HIV.
 If a child with HIV has not initiated ART, health care
providers should closely monitor the virologic,
immunologic, and clinical status at least every 3 to
4 months

21. REGIMENS RECOMMENDED FOR INITIAL THERAPY
OF ANTIRETROVIRAL-NAIVE CHILDREN (LAST
UPDATED APRIL 14, 2020;)
 The selection of an initial regimen should be
individualized based on several factors, including
the characteristics of the proposed regimen, the
patient’s characteristics, drug efficacy, potential
adverse effects, patient and family preferences, and
the results of viral resistance testing
 For treatment-naive children, the Panel on
Antiretroviral Therapy and Medical Management of
Children Living with HIV recommends initiating
antiretroviral therapy with three drugs: a dual-
nucleoside/nucleotide reverse transcriptase
inhibitor backbone plus an integrase strand transfer
inhibitor, a non-nucleoside reverse transcriptase
inhibitor, or a boosted protease inhibitor.

22. PREFERRED REGIMEN BY AGE, WEIGHT AND
DRUG CLASS HIV IN CHILDREN

23. AIDS
OPPORTUNISTIC INFECTIONS

24. PRIMARY PREVENTION OF HIV

25. VACCINATION
 Nearly all HIV-infected children should receive the routine childhood vaccinations,
including Diphtheria, tetanus, and pertussis (DTaP), Inactivated polio vaccine,
Influenza (inactivated, not live vaccine), Haemophilus influenzae, Streptococcus
pneumoniae, Hepatitis A and hepatitis B
 Recently, the meningococcal conjugate vaccine has been recommended for
routine and catch-up use in HIV-infected children, adolescents, and adults.
 Some vaccines containing live bacteria, such as bacille Calmette-Guérin (which is
used to prevent tuberculosis in some countries outside the United States), or live
viruses, such as the oral polio virus, varicella, and measles-mumps-rubella, can
cause a severe or fatal illness in children with HIV whose immune system is very
impaired. However, the live measles-mumps-rubella vaccine and live varicella
vaccine are recommended for children with HIV infection whose immune system
is not severely impaired.
 The live rotavirus vaccine may be given according to the routine schedule to
infants exposed to or infected with HIV.
 Yearly inactivated (not live) influenza immunization is also recommended for all
HIV-infected children over 6 months of age, and inactivated or live immunization is
recommended for household members.
 However, the effectiveness of any vaccination is less in children with HIV infection.
HIV-infected children with very low CD4+ cell counts are considered susceptible to
vaccine-preventable diseases when they are exposed to one (such as measles,
tetanus, or varicella) regardless of whether they have received the vaccine for that
disease and may be given immune globulin by vein (intravenously).
Intravenous immune globulin or immediate vaccination with measles-mumps-
rubella vaccine also should be considered for any nonimmunized household
member who is exposed to measles.