HIV in India#2023#Recent updates# diagnosis and management# Dolutegravir# NACP V# Pediatric HIV#

1. 20XX
PITCH DECK 1
UPDATES IN THE DIAGNOSIS
AND MANAGEMENT OF
HIV
Dr Gayathri C V
Senior Resident
Allergy & Immunology Unit
Department of Pediatrics

2. 2
• Master A
• 3 week old infant delivered at home
• Mother is known HIV positive on
ART
•Mrs J
•Term pregnant lady comes in labour
•HIV card test- positive
Miss S, 1 year old
•Has persistent loose stools, failure to thrive
•On screening, Child and parents was
found to be HIV positive.
• Master K, 3 year old boy
• Presents with persistent pneumonia,
oral thrush.Chest Xray- diffuse B/L
interstitial infiltrates.
• HIV serology -positive
Management
challenges in
pediatric HIV
Case 1 Case 2
Case 3
Case 4

3. Learning objectives
 Diagnosis in a HIV exposed child
 Evaluation and management of a child with HIV
 Update on recent changes in Antiretroviral therapy

4. HISTORY: The initial risk groups
identified were men
who have sex with men
(MSM) and injection
drug users (IDU). Field
investigations
demonstrated sexually
linked cases in MSM
and in persons with
hemophilia and
transfusion recipients.
Called as GRID , 4H
disease

5. 14-02-2024 5
In March 1983, the US Public Health Service published
the first recommendations for AIDS prevention, including a
recommendation that members of risk groups limit their
numbers of sex partners and not donate blood or plasma.
In 1983, HIV was discovered, by French Virologists Francoise
Barre Sinoussi and Luc Montagnier. In 1985, a serologic test for
HIV became commercially available.
By August 1982, the disease was being referred to by
its new CDC-coined name: Acquired Immune
Deficiency Syndrome (AIDS).

6. INDIAN SCENARIO
1986 1992
Establishment of National
AIDS Control Organization
(NACO) in 1992 to oversee
the policies for prevention
and control of the HIV
infection
1987
Approximately
135 more cases
came to light, of
which 14 had
already
progressed to
AIDS
The first case of HIV
in the country
detected- female sex
workers screened for
HIV in Chennai, Tamil
Nadu
2006
An estimated 5.6 million cases
of HIV existed in the country,
concentrated mainly in six
states, namely Maharashtra,
Andhra Pradesh, Karnataka,
Tamil Nadu, Manipur and
Nagaland.

7. NACP-I
1992-1999
focussed on
awareness
generation and blood
safety
NACP II
2000-2005
Decentralized to the
states -establishment
of SACS -focus on
targeted
intervention &
management. ART
was introduced in
2004.
2006-2011
Aimed at reversing
the epidemic and
focused on a massive
scale-up of services
Reduction in new
infections by 50% !
2012-2017
Aimed at improving
integration and
mainstreaming HIV
care in the general
health system.
20XX
PITCH DECK 7
NACP III NACP IV
NACP Phase- IV Extension (2017-2020)
Gamechanger initiatives of the HIV/AIDS Prevention and Control Act (2017), Test and Treat Policy,
Universal Viral Load Testing, Mission Sampark.

8. NACO 2021 HIV ESTIMATES.

9. NACO 2021 HIV ESTIMATES.

10.  Mother-to-child-transmission - over 90% of all HIV infections in children
Pediatric HIV
PMTCT coverage and MTCT rates globally, 2010-2022 UNAIDS 2023 ESTIMATES.

11. NACO 2021 HIV ESTIMATES. 14-02-2024 11
European
countries-
65%(59-75)
68
%
48
%
52
%
93
%
38
%
65
%

12. Pediatric HIV
NACO 2021 HIV ESTIMATES.

13. Risk of HIV transmission from Mother to Child
ARV Intervention
Risk of HIV
Transmission
from mother to child
No ARV; breastfeeding 30-45%
No ARV; No breastfeeding 20-25%
3 ARVs (ART) with breastfeeding 2%
3 ARVs (ART) with No breastfeeding 1%
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

14. • Maternal:
 High viral load, advanced clinical stage, malnourishment, uterine manipulation, prolonged
rupture of the membranes, placental disruption, intra-partum haemorrhage, invasive
delivery technique
• Infant:
 Breastfeeding, mouth sores or an inflamed GI tract in baby, mixed feeding
Factors for parent to child transmission

15.  Baby’s mouth and nostrils should be wiped as soon as the head is delivered
 Infants should be handled with gloves
 The cord should be clamped soon after birth and milking should be avoided
 Cover the cord with gloved hand and gauze before cutting to avoid blood splattering
Immediate Care at Birth Care of HIV-exposed
infants
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

16. Infant ARV prophylaxis
16
 Plasma viral load should be done in all pregnant women between 32 and 36 weeks of
pregnancy (regardless of the duration of maternal ART)
Low risk infants
Infants born to mothers
with suppressed plasma
viral load assessed any
time after 32 weeks of
pregnancy up to delivery
High Risk Infants
• Born to HIV positive mother not
on ART
• Maternal Viral load not done after
32 weeks
• Plasma viral load not suppressed
after 32 weeks of pregnancy
• Newly identified HIV positive
mothers (within 6 weeks of
delivery)

18. NEVIRAPINE PROPHYLAXIS
 Dose depends on birth weight
 In low risk infants- 6 weeks, regardless of feeding habits
 In High risk infants, Extended to 12 weeks, if breast feeding.
Birth weight Nevirapine dose (mg) Nevirapine dose (ml) (1ml = 10 mg)
< 2kg 2mg/kg OD 0.2 ml/kg OD
2 – 2.5 kg 10 mg OD 1 ml OD
>2.5 kg 15mg OD 1.5 ml OD
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

19. Cotrimoxazole prophylaxis
How much
to initiate?
5mg/ kg of TMP OD
Whom to
start?
All HIV exposed till 18 months
HIV positive till 5 years of age
When to
start?
At 6 weeks of age
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

20. Breastfeeding
 “With ongoing maternal ART during pregnancy and lactation, there remains no diference
in the feeding guidelines related to feeding of HIV-exposed versus unexposed infants.
 Individual pregnant women should also be informed about alternative infant-feeding options
and their advantages and disadvantages as compared to breastfeeding
 Exclusive Replacement Feeding is not a viable public health strategy in India and other
developing nations for HIV-exposed infants due to increased chances of non–HIV related
morbidity and mortality negating the benefits of reduced HIV transmission
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

21. Diagnosis

22. Whom to test ?
HIV exposed infants (Born to HIV positive mothers)
Clinical suspicion of HIV (mother status unknown)
Since breastfed children have ongoing risk of HIV acquisition, they are retested 3 months
after complete cessation of breast-feeding to reliably exclude HIV-1 infection.

23. Diagnostic tests available
Test Recommendation Reason
HIV antibody No False +ve due to persistent maternal
antibodies
HIV DNA PCR(DBS) Yes 98 % sensitive from 6 weeks of age
HIV p24 Antigen Yes, but Lower sensitivity than PCR (27 % at 6 weeks)
HIV viral culture Yes, but
Costly, result takes 2- 4 weeks, not
readily available

24. How to test? When to test?
<18 months
PCR based test
(DBS)
>18 months
Serology based
test
• All HIV exposed infants are to tested with serology-based test at 18 months of age
• Regardless of ART therapy or HIV undetected on DBS
• Infants who are sick with clinical features suggestive of HIV but with unknown HIV
exposure status

25. How to test ? (<6 months)
> 6 WEEKS
DBS
Positive 2nd DBS
Positive
Negative 3rd DBS
Negative
Repeat testing
after 6
months
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

26. How to test ? (<6 months)
Positive
Negative 3rd DBS
Positive
Negative
Repeat testing
after 6
months
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

27. How to test ? (<6 months)

28. Diagnosis <18 months
HIV
positive
mother
Maternal
IgG
Placental
transfer
• Serology is standard of care
• Over diagnosis and over treatment in
infancy
• No role of Rapid antibody/ ELISA
• PCR based test is recommended

29. 30
Collect blood and test for HIV antibodies, using all three
serological tests.

30. How to test between 6 and 18 months of age ?
 Repeat testing at 6 months ,12 and 18 months of age or 3 months after cessation of
breastfeeding whichever is later
 If signs and symptoms of HIV infection develop at more than 6 months of age, follow the
testing algorithm.
 Continue CPT until proven negative by all three antibody tests at 18 months of age or later
31
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

31. Diagnosis of HIV infection in children >18 months
 Two positive HIV antibody test results (done sequentially) in a clinically symptomatic child
(symptoms suggestive of HIV infection) more than 18 months of age indicate HIV
infection in the child.
 Three positive HIV antibody test results (done sequentially) in a clinically asymptomatic
child aged more than 18 months old indicate HIV infection in the child.
 Two positive HIV antibody test results and one negative result (done sequentially) in an
asymptomatic child more than 18 months of age is indeterminate HIV status.
 Follow-up testing should be done in such a child to resolve the HIV status.
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

32. Diagnosis of HIV infection in children >18 months
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

33. Diagnosis of HIV infection in children- Serology
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021
Three tests done using three
different principles

34. Treatment
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

35. Current NACO guidelines
when/whom to initiate ART
ALL persons diagnosed with HIV infection
are ELIGIBLE for ART initiation
REGARDLESS of
CD4 count or WHO Clinical Staging,
Any age or population
8

36. BASELINE INVESTIGATIONS :
 Screening for CMV retinitis- Fundus examination
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

39. Timing of ART in relation to initiation of TB
treatment
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

41. HAART
Combinatio
n ART
Anti CD4 Monoclonal Ab(Ibalizumab),
Zinc finger nuclease, Latency Reversing
agents(Romidepsin)- under trial

42. Lifecycle of HIV

43. Classes of ARV drugs
Entry Inhibitors NRTIs NNRTIs Protease Inhibitors
Chemokine Co
Receptor
(CCR5 / CXCR4)
Antagonists
NsRTI Nevirapine (NVP)*
Efavirenz (EFV)*
Etravirine
Rilpivirine
Delavirdine (DLV)
Atazanavir (ATV)*
Ritonavir (RTV)*
Lopinavir (LPV)*
Darunavir (DRV)
Saquinavir (SQV)
Indinavir (IDV)
Nelfinavir (NFV)
Amprenavir (APV)
Fosamprenavir, (FPV)
Tipranavir (TPV)
Zidovudine (AZT)*
Stavudine (d4T)*
Lamivudine (3TC)*
Abacavir (ABC)*
Didanosine (ddI)
Emtricitabine (FTC)
Maraviroc
(CCR5 co receptor
antagonist) Integrase Inhibitors
Fusion Inhibitor
Raltegravir (RGV)
Elvitegravir (ELV)
Dolutegravir (DTG)
Enfuviritide (T-20)
NtRTI
Tenofovir (TDF)*
* The highlighted drugs are NOW available in the NACO ART programme

45. RECENT GUIDELINES:
ART regimen in ART naïve CLHIV
The WHO recommends
Dolutegravir as the preferred
first line drug for all the
children in the age of >6yrs.
Because of limitations in
widespread availability of
pediatric formulations in India,
the pediatric ART technical
resource group recommends
these regimens based on
the age and weight of the
children.
47
Weight and age of CLHIV Recommended Regimen
Weight- less than 20kg or
– below 6 years
Abacavir + Lamivudine +
Lopinavir/ritonavir
Weight – between 20-30kg
Age: between 6-10 years
Abacavir + Lamivudine +
Dolutegravir
Weight – above 30 kg and
Age: above 10 years
Tenofovir + Lamivudine +
Dolutegravir
Child’s Weight DTG dose In DTG 10mg
formulation
3-5.9kg 5mg 0.5
6-9.9 kg 15mg 1.5
10-13.9kg 20 mg 2
14-20kg 25mg 2.5
>20kg 50mg Available as 50mg

46. Why Dolutegravir based regimen ?
20XX
PITCH DECK 48
 High genetic barrier: It is highly potent and has high genetic barrier.
 Rapid viral suppression: Reduce the viral copies to <50 copies/ml within 4 weeks and this helps
reduce the chances of transmission.
 Fewer toxicities and side effects: As compared to NNRTI-based regimens, DTG based regimen,
have lesser allergic reactions and chances of neuropsychiatric events compared to NNRTI-based
regimens.
 Minimal drug interactions
 Effective against HIV-2: Prior to the availability of DTG in the programme, those infected with
HIV-2 were being initiated with two NRTIs plus boosted PI regimen.
 No need for substitution of DTG-based ART regimen in PLHIV if co-infected with TB or HBV or
HCV.

47. ART regimen HIV-TB co infection in ART naïve CLHIV
Thus, CLHIV who is on
Rifampicin containing ATT
regimen should receive an
additional dose of
Dolutegravir every day.
49
Weight and age of CLHIV Recommended Regimen in TB co-
infection
Weight- less than 20kg or
Age – below 6 years
Abacavir + Lamivudine +Dolutegravir
weight-based dose with an additional dose
after 12 hours
Weight – between 20-30kg
and
Age: between 6-10 years
Abacavir + Lamivudine + Dolutegravir with
an additional dose of Tab Dolutegravir 50
mg after 12 hours
Weight – above 30 kg and
Age: above 10 years
Tenofovir + Lamivudine + Dolutegravir with
an additional dose of Tab Dolutegravir 50
mg after 12 hours
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

48. Immunization
 HIV-exposed infants and children should be immunized according to the routine national
immunization schedule, as they can be more prone to infections when compared to
general population
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

49. Immunization
 If BCG not given at birth, avoid in symptomatic CLHIV.
 Live vaccines should be avoided in all severely immune compromised and
symptomatic infants and children (CD4 <15 %)
 Rotavirus vaccine is recommended for use in HIV exposed infants due to
their risk for diarrhea except in severe Immunodeficiency.
Possibility of
disease caused
by live vaccines
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

50. Immunization
52
 A 4-dose, double-quantity schedule for hepatitis B has been recommended in view of poor
seroconversion with routine immunization
 It is recommended that PPSV23 should be administered at least 8 weeks after the last dose of
PCV to children with HIV infection aged 2 years or older.
 WHO recommends that an additional dose of measles containing vaccine be administered to HIV-
infected children receiving ART following immune reconstitution (CD4 count 20%–25%).
 A supplemental dose of measles vaccine may be considered in HIV-exposed infants older than 6
months who are not receiving ART and for whom the risk of measles is high, with the aim to provide
partial protection till they are revaccinated.
Inadequacy of
Immune
response
https://naco.gov.in/ National Guidelines for HIV Care and Treatment, 2021

51. 20XX
PITCH DECK 53
HIV exposed child
Prevention of
Parent to Child
transmission
PPTCT
ARV in mother
ARV prophylaxis in
child f/b CPT
Early Infant
diagnosis
EID
ARV prophylaxis
and testing as per
guidelines
Identifying clinically
symptomatic
children/screening
for OI
Initiating ART
+

52. 54
• Master A
• 3 week old infant delivered at home
• Mother is known HIV positive on
ART
•Mrs J
•Term pregnant lady comes in labour
•HIV card test- positive
Miss S, 1 year old
•Has persistent loose stools, failure to thrive
•On screening, Child and parents was
found to be HIV positive.
• Master K, 3 year old boy
• Presents with persistent pneumonia,
oral thrush.Chest Xray- diffuse B/L
interstitial infiltrates.
• HIV serology -positive
Management
challenges in
pediatric HIV
Case 1 Case 2
Case 3
Case 4
• Immediate care during delivery
• Infant ARV prophylaxis f/b Cotrimoxazole
prophylaxis
• DBS testing at 6 weeks
• Check mother’s viral load done between
32-36weeks
• Start ARV prophylaxis
• DBS testing at 6 weeks
• Confirm using DBS
• Screen for and treat opportunistic
infection(TB,CMV,Stool etc), Baseline CD4
• Start DTG based regimen
• Treat Pneumocystis Pneumonia
• Screen for and treat other opportunistic
infection, Baseline CD4
• Start DTG based regimen after
stabilization of acute infections

53. 55
NACP - V Goals
Includes setting-up of Sampoorna Suraksha Kendras (SSK) for providing services through a single
window model for those “at risk” for HIV and STI covering prevention-test-treat-care continuum
NATIONAL AIDS AND STD CONTROL PROGRAMME PHASE V (2021-2026)

54. NATIONAL AIDS AND STD CONTROL PROGRAMME PHASE V (2021-2026) 14-02-2024 56
Goal 3: Eliminate vertical transmission of HIV and Syphilis

55. 14-02-2024 57
The NACP Phase-V will take the
national AIDS and STD response
till Financial Year 2025-26 towards
the attainment of United Nations’
Sustainable Development Goals
3.3 of ending the HIV/AIDS
epidemic as a public health threat
by 2030.
Reduction of the number of people
newly infected with HIV per 1000
uninfected population to 0.05 by 2025,
and to 0.025 by 2030.

56. 14-02-2024 58