This document discusses HIV in pediatrics. It describes the two types of HIV, HIV-1 being most common worldwide. It outlines the WHO clinical staging of HIV in adolescents and children from Stage 1 (asymptomatic) to Stage 4 (severe manifestations). It discusses diagnosis of HIV infection in infants and children, including early infant diagnosis using viral RNA or antigen detection. It covers ART goals, considerations before initiation, groups and classes of drugs used, monitoring after initiation and management of treatment failure in children living with HIV. Key counseling issues for child clients and their parents/caregivers are also summarized.

1. HIV IN PEDIATRICS
DR LAKSHIT BHALALA
GUIDE BY : DR HARDIK SHAH

2.  There are 2 types of Human Immunodeficiency Virus (HIV) viz. HIV type I
(HIV-1) and HIV type2 (HIV-2).
 The most common cause of HIV infection throughout the world is HIV-1
that comprises of several subtypes with different geographic distributions.

4. WHO Clinical Staging in
Adolescents and Children
STAGE 1
 Asymptomatic
 Persistent generalized lymphadenopathy (PGL)

5. STAGE-2
 Unexplained persistent hepatosplenomegaly
 Recurrent or chronic upper respiratory tract
 infections (Otitis Media, Otorrhoea, Sinusitis,
Tonsillitis)
 Recurrent oral ulceration
 Papular Pruritic Eruption
 Fungal nail infections
 Extensive wart virus infection
 Extensive Molluscum Contagiosum

6. STAGE-3
 Unexplained moderate malnutrition,persistent diarrhoea
 Unexplained persistent fever
 persistent Oral Candidiasis,Oral Hairy Leucoplakia
 Lymph node Tuberculosis ,Pulmonary tuberculosis
 Severe recurrent bacterial Pneumonia
 Acute necrotizing ulcerative gingivitis or Periodontitis
 Unexplained anaemia or neutropenia or chronic
thrombocytopaenia
 Chronic HIV-associated lung disease, including Bronchiectasis

7. STAGE-4
 Unexplained severe wasting, stunting or severe malnutrition
 Pneumocystis (jiroveci) Pneumonia
 Recurrent severe bacterial infectection
 Chronic Herpes Simplex infection
 Oesophageal Candidiasis
 Kaposi’s sarcoma, Cytomegalovirus infection
 Central nervous system Toxoplasmosis
 HIV encephalopathy, Extra pulmonary Cryptococcosis
 Disseminated nontuberculous mycobacterial infection
 Progressive Multifocal Leukoencephalopathy

8.  Chronic Cryptosporidiosis (with diarrhoea)
 Chronic Isosporiasis
 Disseminated endemic mycosis
(extra pulmonary Histoplasmosis,
Coccidioidomycosis, Penicilliosis)
 Cerebral or B-cell non-Hodgkin’s Lymphoma
 HIV-associated nephropathy

9.  DIAGNOSIS
 TREATMENT
 MONITORING

10. Diagnosis of HIV
infection in infants and
children

11. Early infant diagnosis
 Maternal HIV antibodies transferred passively to the infant during
pregnancy usually persist for nearly 9-12 months in the infant.
 In some children, they may persist for as long as 18 months.
 Thus, during this period, children born to HIV-infected mothers will test
positive for HIV antibodies regardless of their own infection status.
 A positive ELISA/Rapid test that detects antibodies to HIV, therefore,
does not necessarily indicate the presence of HIV infection in the
infant/child.
 Rather, a positive ELISA/Rapid test indicates exposure to HIV.
 More reliable indicators of the HIV infection status of the infant are tests
that detect HIV viral RNA or antigens.

13. Tests for diagnosis of HIV
infection:
Anti- HIV antibody
tests:
Antigen detection Virus isolation/
detection of viral
nucleic acids
Screening tests
(micro well ELISA test,
Rapid tests)
P24 antigen assay Viral culture
Supplemental tests
(western blot, line
immunoassay,
recombinant
immunoblotting assay)
PCR tests
(DNA/RNA)

17. Less than 6 month old child with
symptoms
Symptomatic infant
Mother status
not known
Mother is not
available
Serological test
of mother
If postive :sent
HIV TNA PCR
Of Child
Serological test
of child
If postive :sent
HIV TNA PCR Of
Child

21. ADDITIONAL TESTS:
 Depending on clinical presentation:
• Sputum / gastric aspirate / other body fluids as applicable for
AFB / CBNAAT
• USG Abdomen / CT scan chest / CT scan Brain
• CSF Analysis
 Tests for special situations:
• For patients with Hepatitis B or C co-infection: further tests may
be required to assess for chronic active hepatitis.
• For patients started on PI based regimen: Baseline investigations
including blood Sugar, LFT and lipid profile to be done.

22. ART:
 WHEN TO START
 CONSIDERATION BEFORE INITIATION OF ART
 GOALS
 GROUPS AND CLASSES OF DRUGS

23. When to start ART for infants and
children?
 ART should be initiated in all children and adolescents living with HIV,
regardless of the age.

24. Considerations before Initiation of
ART
 Treatment should be started based on a parent’s/guardian’s informed
decision and preparedness to initiate ART with an understanding of the
benefits of the treatment, lifelong medication, issues related to adherence
and positive prevention.
 A caregiver should be identified for each person to provide adequate
support. Caregivers must be counselled and trained to support treatment
adherence, follow-up visits, and shared decision-making.

25.  Co-trimoxazole Preventive Therapy (CPT) should be started in children as
per the paediatric guidelines.
 All patients should be screened for TB, using the 4-symptom tool (recurrent
cough, fever, weight loss and history of contact with TB) and those who do
not have TB should be started on Isoniazid Preventive Therapy (IPT) in
addition to ART.
 ART should not be started in the presence of an active OI.

27. GOALS:

28. GROUPS AND CLASSES OF DRUGS
 Fusion Inhibitors and CCR 5 co
receptor blockers
 Reverse transcriptase inhibitors
 Integrase inhibitors
 Protease inhibitors

32. REGIMENS:

38. Advanced Disease Management in
CLHIV less than 5 Years of Age
 WHO defines advanced HIV disease for adults and
adolescents (and children 5 years and older) as having
a CD4 cell count of less than 200 cells/mm3 or WHO
clinical stage 3 or 4.

39. Advanced HIV disease includes
 Newly diagnosed CLHIV aged less than 5 years
 Severe immune suppression following treatment
failure
 Re-engaging with the care after treatment
interruption

41. Care of CLHIV: Post ART
Initiation
 Monitoring after initiation of ART
 Adverse events of ARVs – identification and
substitution
 Identification of treatment failure
 Adherence counselling

42. What happens to CLHIV in first six
months of therapy
 Viral suppression
 Clinical and immunological improvement
 Improvement in quality of life and decrease in morbidity and mortality
 Certain opportunistic infections may appear
 Immune reconstitution inflammatory syndrome (IRIS) may develop
 Early adverse drug reactions, such as drug hypersensitivity may occur

43. 1.Monitoring:

45. Adverse events of ARVs – identification
and substitution

50. ART FAILURE:

60. Child centred counseling:
 Child-centred counseling includes:
• Development of rapport between the child, caregiver and
counsellor.
• Focusing on the child’s needs and is tailored to the child’s physical
and psychological development.
• Striving to promote the child’s potential and abilities.
• Building self-esteem and respects the child’s identity and emotions.

61. Barriers for the communication
with the children:
 These barriers can be classified into:
• Language – language barrier is when there is no common language (e.g. when
an adult uses non-age appropriate language with the child)
• Cultural barriers
• Due to poor skills – lack of active listening, recipient problem
• Knowledge – wrong message or wrong information
• Age – adult’s failure to come to the child’s level
 The assumption that parents/ guardian will handle communication with the child
and therefore there is no need to communicate with the child.
 The assumption that the child is too young to understand.
 The assumption that certain medical information might harm the child or that the
child is too weak to receive the information.

62. Key Counseling Issues for Child
Clients:
 Adherence - taking medicine regularly.
 Disclosure - Learning about being infected.
 Coping - Learning to live with a chronic illness.

63. Key Counselling Issues for Parents
/ Caregivers:
 Acceptance of Infection in Child.
 Disclosure Issues.
 Preparing for Treatment.
 Supporting treatment.
 Immunization Advisory.
 Planning for the future.

64. THANK YOU