2. Learning Objectives
• Understand the distinction between HIV-exposed and HIV-
infected infants
• Recognize the goals of care for HIV-exposed infants and HIV-
infected children
• Understand routine care procedures for HIV-exposed infants and
HIV-infected children
– Conduct age appropriate assessment
– Prevent opportunistic infections
– Identify the HIV-infected child
– Maximize family health and well being
3. Why provide HEI care
• Ensure follow-up and monitoring of all HIV-
exposed infants and all HIV-infected children
• Prevent opportunistic infections by
providing prophylaxis
• Identify HIV-exposed infants who are HIV
infected as early as possible
• Treat all eligible HIV infected infants and
children with ART
4. Challenges to Care - 1
• HIV Exposed infants can be infected with HIV
during pregnancy, labor and delivery, and through
breast feeding
• All HIV exposed infants (infected and non-infected)
will test antibody positive during the first year of life
• Need special Virologic test ( RNA or DNA PCR) to
confirm HIV-infection in an infant < 18 months of
age
• In the absence of Virologic test, a presumptive
diagnosis can be made in infants < 18 months of
age.
5. Challenges to Care - 2
• Pediatric HIV disease can progress very rapidly
and often requires ARV treatment before the
diagnosis can be confirmed
• HIV-infected infants and children are
susceptible to many opportunistic infections
(OIs) including PCP, TB, and bacterial infections
that are associated with high rates of mortality
6. Who is a HEI
• HEI are children less than 18 months of age whose HIV
status is yet to be fully determined but who
– Are born to HIV+ mothers
– Test positive on a rapid antibody test even if the mother’s status is
unknown
• A positive rapid test in either the mother or the infant
indicates that the infant has been exposed to HIV.
• All HEI are exposed from their mother during pregnancy,
labour and delivery.
• All children aged less than 18 months whose mothers are
newly identified as positive must be enrolled into HEI care
regardless of their HIV antibody status
7. • The care for a HEI infant and for an HIV
infected infant less than 18 months are actually
very similar.
• The major difference is the ART given to a HIV
infected child and the necessary follow up
provided because of the ART given.
• The next few slides apply to both HIV infected
and HIV exposed infants. Any differences shall
be emphasized
9. Determining Infection Status
• Goal- To identify the HIV infected infant who
needs care and treatment rather than to confirm
the absence of disease
– Definitive diagnosis before 1 year of age is very
difficult, but many children get sick earlier than this.
– Always be suspicious of HIV disease when examining
a sick infant.
10. Determination of Infant Infection Status
• All HIV exposed infants (infected and non-
infected) will test antibody positive during the first
year of life
– Special virologic tests are required to definitively
diagnose an infant with HIV infection
– However, clinical signs and symptoms can help identify
if an infant has HIV infection
• HIV infection often cannot be excluded until after
1 year of age particularly in breast feeding babies.
11. Determining Infection Status
• Antibody test can be used in infants older than 12-18
months of age to exclude infection if they are no longer
breast feeding.
• Any antibody positive test in a childe less than 18 months
must be confirmed by virologic test (DNA-PCR)
• A positive antibody test at 12 months of age should be
confirmed ASAP with virologic test or at 18 months of
age or after the child is no longer breast feeding (if
virologic test is not available)
• Breastfeeding infants continue to be at risk for infection
until after they are completely weaned.
• An antibody test should be performed 3 months after
complete cessation of breastfeeding.
12. Presumptive diagnosis of HIV
infection in infants
• In the absence of DNA PCR for early infant diagnosis, a
presumptive diagnosis of HIV can be made if the child is
confirmed HIV antibody positive AND
• Has any AIDS-indicator (stage IV) condition
• OR
• Has two or more of the following:
• Oral thrush;
• Severe pneumonia;
• Severe sepsis.
13. Referral Criteria for Exposed Infants
• The child has any of the following signs and symptoms:
• Chronic diarrhea
• Poor growth or Weight Loss
• Loss of developmental milestones
• Recurrent bacterial infections
• PCP
• TB, especially extrapulmonary
• Severe pneumonia
• The child should be referred for assessment, CD4 count, and
possible ART
15. Background: Pediatric HIV Disease
• Infancy and early childhood is a time of rapid HIV
disease progression:
– Growth failure/failure-to-thrive
– Tuberculosis
– HIV encephalopathy
– Bacterial Infections/pneumonia
– Pneumocystis pneumonia (PCP)
– Diarrhea
• If untreated, greater than 50% of HIV-infected
children will die by two years of age
16. Components of Clinical Care for HIV
infected and Exposed Infants
Maternal and Birth History
Interim history and parental concerns
Nutrition assessment and growth monitoring
Physical exam and developmental assessment
Evaluation of Infection Status
Infant prophylaxis
Counseling and caregiver support
TB contact questionnaire and TB symptom assessment
OI prophylaxis
Follow-Up Plan
18. Clinical Care: Physical Exam
• Infected infants generally grow more slowly than
uninfected infants and differences can be seen
within the first few months of life.
– A GROWTH CURVE for weight, height, and head
circumference plotted EVERY VISIT is the best way
to monitor growth rate. MUAC should also be
documented and is useful in identifying SAM
• Infected infants have a high frequency of HIV
related morbidities that indicate disease
progression
– fever, oral thrush, skin rashes, hepatomegaly,
splenomegaly, lymphadenopathy, weakness, muscle
wasting, etc.
19. Clinical Care: Growth Monitoring
• Growth can be the most sensitive clinical
indication of HIV infection in an infant/young
child
– Children with HIV infection are at high risk for poor
growth
– Growth should be monitored closely for all exposed
infants and all HIV infected children
20. Measuring & Weighing Children
• To enhance accuracy of measurements:
– Use same scale at each visit
– Measure length of babies supine
– Measure head circumference to obtain greatest
volume
• Place tape at midforehead and extend circumferentially to
include most prominent portion of occiput
21. How do we monitor growth?
Step 1: Accurate measurement
• weight, length and head circumference
Step 2: Use growth charts to plot measurements
• That the child has gained weight since the last visit is not
enough, growth charts assess the rate of growth
Step 3: Evaluate growth
• Is the child growing well, growing slowly, or
experiencing failure-to-thrive?
• Should we intervene?
22. Step 1: Accurate measurement -
Weight
• Birth measurements are the basis for
assessing further progress
• To enhance accuracy of measurements:
– Use same scale at each visit (calibrated if possible)
– Infants should be completely undressed and older
children should be wearing only underwear
– Weight infants lying, older children sitting or
standing
• Document weight to the nearest 0.1kg
in the Child Health Card and or the
Medical Record
23. Measure length of children < 2 years
supine
• One person holds the head
against the headboard with the
head facing upwards and
positioned in an imaginary line
from the centre of the ear
hole to the lower boarder of
the eye (Frankfurt plane)
• 2nd person measures the length
by bringing the footboard into
contact with the heels whilst
applying downward pressure
on the knees
•Measure an infant’s length on
his/ her back (supine) by 2 people
with appropriate equipment
featuring both a headboard /
footboard
24. Head Circumference
• Should always be taken
from midway between the
eyebrows and the hairline
at the front of the head
and the occipital
prominence at the back
• Appropriate thin metal or
plastic measuring tape
should be used
• Record measurement to
the nearest 0.1cm
25. Why Use Growth Curves?
• Growth curves allow providers to plot the weight
and height of a child in order to make sure the
child is growing at the correct rate
• Easy and systematic way to follow changes in
growth over time for an individual child
– Height, weight and head circumference should be
plotted at regular intervals
• Monthly for all infants
• Quarterly for older HIV-infected children
26. How to Use and Interpret
a Growth Curve
• Measure and weigh child using same
methodology at each visit
• Using age and sex appropriate charts, plot
measurement (weight, height, head
circumference) on the vertical against age on the
horizontal axis.
• Compare growth point with previous points
• Assess growth percentile
27. Weight for Age
The child is in the 15th percentile of weight for age
Wt- 5.1
kg
Age-
3 mos.
28. Girls Growth Chart Weight-for-Age
Normal growth on 50th percentile
Poor growth/failure-to-thrive
97%
85%
50%
15%
3%
29. Boys Growth Chart Height-for-Age
Good growth on 85th percentile
Good growth on 50th percentile then
failure to thrive at 6 months
97%
85%
50%
15%
3%
31. Nutrition Assessment
• Caretakers should be asked about child’s feeding and
nutrition
• It is crucial to ensure adequate nutrition for HIV exposed
infants and HIV infected children
• An assessment of nutrition is essential at each visit:
– Mode of feeding
– Frequency, duration or ounces
– Adequacy of supply
– Bowel habits
– Reported problems
32. Infant Feeding for HIV Exposed Infants
• All providers should counsel HIV-infected women on
infant feeding
• HIV infection can be passed through breast milk,
however this risk is substantially reduced if the mother
is on ART and adherent
• Ensure mother is taking her ART and adherent
• Encourage exclusive breastfeeding for the first 6 months
• Thereafter introduction of complimentary feeds in
addition to breastfeeding from 6 months to 24 months
33. Recommendations on Infant feeding and HIV
• ART lowers the risk of HIV transmission through breast milk.
• Breastfeeding women who follow national guidelines on infant
feeding and who are taking ART every day as recommended by
their healthcare providers, have a very low risk of transmitting
HIV to their infants through breast milk.
• For women with HIV, the risks associated with not
breastfeeding (i.e., diarrhea, pneumonia and malnutrition) are
much greater than the risks associated with breastfeeding (i.e.,
risk of HIV transmission from mother to baby).
• Infants who are HIV infected will benefit from extended
breastfeeding and should continue breastfeeding for as long as
feasible and desired, 12-24 months or longer.
34. Exclusive Breastfeeding
• Exclusive breastfeeding means that the baby only
consumes breast milk (no formula, water or other food)
• There are many challenges associated with this and
mothers will need support to exclusively breastfeed
• However, benefits outweigh the risks if the mother is on
ART and adherent
• Mothers with HIV should continue breastfeeding for at
least 12 months and can continue breastfeeding for up to
24 months or longer while being fully supported for ART
adherence.
• Breastfeeding should stop only once a nutritionally
adequate and safe diet without breast-milk can be
provided.
36. Clinical Care: OI Prophylaxis
• HIV infected infants are at high risk for
acquiring pneumocystis jiroveci pneumonia (PCP), a
rapidly progressive pneumonia
– Peak incidence is between 3-6 months
– Most exposed infants become infected with PCP
before their HIV status is determine
– PCP has a very high rate of death
37. • Severe and rapidly progressive pneumonia
– Tachypnea
– Hypoxia
– Diffuse interstitial pneumonitis
– High risk of death
• Diagnosis difficult and invasive measures are
often necessary (tracheal aspirate, induced
sputum, Broncho-alveolar lavage (BAL))
• Risk can be reduced with routine use of
cotrimoxazole
Pneumocystis jiroveci Pneumonia (PCP) (cont.)
39. Clinical Care: OI Prophylaxis
• Use pediatric cotrimoxazole in ALL EXPOSED
INFANTS
– significantly reduces the rate of both PCP and other
bacterial infections and
– in turn reduces infant mortality rates
• Treat all infants with cotrimoxazole from 4-6
weeks of age through first year of life or
until HIV infection is DEFINITIVELY
excluded
40. Implementing OI Prophylaxis
• Who will identify exposed babies and make sure they
receive CTX?
• Where will babies receive CTX?
• Who will explain to care takers about the importance of
CTX and of need to take it every day?
• Who will follow-up and monitor these babies?
41. Giving CTX to Infants
• Caretakers should be instructed to
– Use a spoon or syringe to administer the dose
– Always use the same clean utensil to administer dose
– For breastfeeding babies, CTX should be mixed with a small amount of
water or breast milk
• Tabs can be crushed and mixed with liquid, jelly
or jam
• CTX can be given with food.
42. CTX Dosing Guidelines
Age Suspension
(5 ml syrup
200 mg/40
mg)
Pediatric
Tablet
(100 mg/ 20
mg)
Single
Strength
Adult Tablet
( 400 mg/80
mg)
Double
Strength
Adult Tablet
(800 mg/160
mg)
< 6 months 2.5 ml One tablet ¼ tablet
(mixed with
feeding)
_________
6 months- 5
years
5 ml Two Tablets Half tablet _________
6-14 years 10 ml Four tablets One tablet Half Tablet
> 15 years _____ _____ Two tablets One tablet
Cotrimoxazole (TMP/SMX): Given ONCE Daily
44. Clinical Care: Assessment and Plan
• What is the child’s HIV status and health status?
• Does the child have any new problems? If so,
do these problems put the child in a WHO
stage?
• Does the child require any laboratory studies?
• Has the child received proper vaccinations?
Medications? OI Prophylaxis?
• When should the child return to clinic?
45. Follow-up Plan
• Basic principles:
– Early identification of infants who are sick or failing
to thrive is critical
– Careful and frequent clinical monitoring is required
– CTX prophylaxis is crucial in preventing
opportunistic infections
– Systematic follow up is vital
• Appointment systems
• Medical records
• Family education and support
46. Follow-Up of the Exposed Infant
• Monthly visits for the first six months of life, then every 3
months until infection status is determined
• Each visit should include
– Interim History and Parental Concerns
– Physical Exam
– Growth and Nutrition
– Developmental assessment
– Caretaker counseling and support
– WHO staging
– OI prophylaxis (CTX monitoring and refill)
– Evaluation of Infection status
– Assessment and Plan for follow-up and care
47. Family Health and Well Being
• Families benefit from open and
honest exchange of information
about the child
• Use simple language to explain the
difference between exposure to
HIV and HIV infection
• Make sure to repeat the
information at each visit
• All family members (infected and
non-infected) can benefit from
psychosocial support
48. Role of the Multi-Disciplinary Team
• Ongoing communication between the members
of the MDT is crucial for supporting the family
and caring for the exposed infant.
• Each member of the team will have a different
perspective and different pieces of information
about the family and infant.
• Engaging parents in care and treatment can help
to decrease the burden of disease, prevent
orphanage, and keep families healthy
